Every finding on record at Jeffersontown Rehabilitation

Based on observation, interview and review of facility policy, the facility failed to ensure resident foods in nourishment refrigerators were stored in accordance with policy and accepted standards. Foods were not labeled with resident's name, name of food item, and date/time or use by date in three of three nourishment refrigerators located on the resident units. The findings include: Review of the Foods Brought by Family/Visitors policy, undated, revealed that a liberalized diet would be permitted as much as possible, and that staff must be aware of, and approve, food(s) brought to a resident by family/visitors. Further review revealed perishable foods must be stored in re-sealable containers with tightly fitting lids in the refrigerator and that containers would be labeled with the resident's name, the items, the current date/time and the 'use by' date. Observation of Hall A nutrition room on 07/31/2024 on 11:43 AM revealed the refrigerator freezer compartment contained a full quart size clear storage bag of green beans inside a plastic shopping bag, unlabeled and undated. Additionally, the freezer contained two sandwich sized clear storage bags containing microwaveable burritos, two each, unlabeled and undated, and four pack of two each prepared sausage biscuits, labeled only with manufacturer name of Old Folks brand, with no dates or names on either. Continued observation of the refrigerator section revealed a quart carton of thickened orange juice marked opened on 07/21/2024 with instructions indicating to discard seven days after opening and refrigerating. Additional observation revealed one 236 milliliter (ml) carton of milk with expiration date of 07/28/2024. Further observation revealed the Director of Nursing (DON) entered the nourishment room during the above observation and discarded all the above unlabeled food items before the surveyor and DON exited the room. Observation of Hall B nutrition room refrigerator on 07/31/2024 at 12:10 PM revealed a plastic grocery bag containing a small box of prepared roast beef lunch meat, a prepackaged bag containing a salad kit and two packs of sandwich size cheese slices, with neither labeled with the resident's name, date/time, or use by date. Observation of freezer revealed one carton of cookies and cream ice cream and one small carton of Snickers ice cream that were unlabeled with the resident's name. Observation of C&D Hall nutrition room on 07/31/2024 at 2:10 PM revealed the refrigerator contained a tray of nine sandwiches, covered but unlabeled and undated. Further review revealed an open sandwich with meat and cheese, uncovered on a paper plate with no label or date. Continued review revealed one 12 ounce can of Red Bull, one 12 ounce can of Coca-Cola, one 20 ounce bottle of Pepsi, one 12 ounce can of Big Red, and one bottle which was half full of Pure Life water. None of the items were labeled with a resident name. During interview with the Director of Nursing (DON) on 07/31/24 at 12:29 PM, she stated she did not know whose items those were in the B Hall nourishment refrigerator but that staff were expected to store lunch items in the breakroom and if it belonged to a resident, it should be dated and labeled with the resident's name. She discarded the items observed above from the B Hall nourishment refrigerator. During interview with Certified Nursing Assistant (CNA) 2 on 07/31/2024 at 2:25 PM, she stated all items in the nutrition refrigerators have to be labeled. She stated if Dietary Service brings the mini cans of soda, those were not labeled because they were for anybody. Otherwise, she stated any item should be labeled with the resident's name, or the sandwiches delivered by Dietary Service were labeled with content, such as peanut butter or chicken salad, and dated. She further stated this was important so that if somebody needs a snack, they do not receive something they are allergic to, or that was going bad, or that belongs to somebody else. In an interview with Registered Nurse (RN) 3 on 08/02/2024 at 8:34 AM she stated she made rounds every morning around the facility and that included checking each temperature log for the refrigerators on each unit and ensuring they were checked and the temperatures were recorded by the night shift nurse. In further interview with RN3, she stated a morning meeting with the administrative team followed her rounding and any issues she found were discussed. During interview with RN12 on 08/02/24 at 3:05 PM, she stated when food was brought to nutrition refrigerators for a resident, it must be labeled with the resident's name, room number and date. She stated this was important so that residents do not get food that could be spoiled. During interview with Licensed Practical Nurse (LPN) 7 on 08/02/2024 at 3:10 PM, she stated for food stored in nourishment refrigerators, staff were responsible to label items with the resident's name and date. She stated this was important so that anyone getting an item out for a resident gets what is actually theirs. During interview with RN8 on 08/02/2024 at 3:15 PM, he stated food items in the residents' nourishment refrigerators must be labeled for safety with the resident's name, room number and date. During interview with LPN6 on 08/02/2024 at 3:20 PM, she stated for individual residents' food in the nourishment refrigerators, staff were expected to label and date each item. She stated this was important so that residents get what is actually theirs. During interview with Certified Dietary Manager (CDM) on 08/02/2024 at 3:39 PM, he stated if dietary staff place snack items in nourishment refrigerators, they were expected to label with date made and use by date. He stated, for example, when he would instruct dietary aides to make sandwiches for snacks, they were expected to individually wrap and label each item with date made and the use by date. In further interview, he stated the sandwiches were in individual baggies so the type of meat could be seen. He stated if they had an items like chicken salad that had been on the menu that day, the baggie would already be labeled with the type of sandwich. Regarding the sandwich tray, he stated those should not have been in the refrigerator to begin with because they were not individually wrapped and had no label or date. He also stated those sandwiches were discarded and remade. He stated the dietary aide who was tasked with making snacks was responsible for labeling and dating. During continued interview, the CDM stated if a snack was commercially prepared, the dietary aide who delivered the food item to the nourishment room was expected to label with the date it was received from the vendor. Dietary staff were also responsible for delivering thickened drinks to nourishment refrigerators, and those were expected to be dated with the date delivered, as the cartons were individually dated. He stated dietary staff were expected to review items in the nourishment refrigerators for use by dates. He also stated if there is no date on an item, the dietary staff member was expected to throw the item away. Per the CDM, whoever received a food item for a resident from outside was responsible for labeling and dating the item. He stated he has educated staff to throw away items if there is no date on the food item. During interview with DON on 08/02/2024 at 04:07 PM, she stated staff were expected to label and date food items brought in for residents, and the label should include the resident's name and could include the room number if it goes in the refrigerator or if there are residents with the same name. She stated labeling was important in order to be sure the intended resident gets the item. She stated if the food item was not labeled there was a risk for a resident getting the wrong food which could be a food item not on the resident's diet or the resident could be allergy to the food. An interview with the Administrator on 08/02/2024 at 3:21 PM, revealed he was unaware prior to the survey of a concern regarding nourishment refrigerators. He stated the scheduler was responsible for monitoring nourishment refrigerators and also monitored temperatures. In further interview, he stated the nurses on the hall should be ensuring refrigerated items were labeled and dated. He also stated anything brought from kitchen should be labeled and dated by dietary manager. The Administrator stated it was important to do so in order to prevent someone getting spoiled food.

Based on interview, record review, and facility policy review, it was determined the facility failed to implement the comprehensive care plan for one (1) of twenty-two (22) sampled residents, (Residents #18). Resident #18 was care planned to be up in wheelchair (w/c) with supervision; however, the facility failed ensure the resident was supervised when in wheelchair and the resident sustained [REDACTED]. In addition, the resident was care planned for staff to establish a voiding pattern for the resident; however, further review of the record revealed there was no documented evidence staff attempted to determine the resident's voiding pattern. The findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, last revised (MONTH) (YEAR), revealed the comprehensive, person centered care plan will describe services to be furnished to attain or maintain the resident's highest practicable physical, mental, psychosocial, and functional needs is developed and implemented for each resident. Assessments of the residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Record review revealed the facility admitted Resident #18 on 11/19/18 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident 18's cognition was severely impaired with a Brief Interview of Mental Status (BIMS) score of four (4) which indicated the resident was not interviewable. Review of the Comprehensive Care Plan revealed an intervention dated 02/07/19 for Resident #18 may be up in w/c while being supervised by staff. However, review of Resident #18's Interdisciplinary Post Fall Review revealed, on 04/16/19 at 3:15 PM, the resident was in w/c and in an attempt to ambulate, the resident had an unwitnessed fall and was found on the floor in front of the doorway to his/her room. The resident had no supervision at time of fall. Resident #18 was sent to the ER for evaluation and admitted for Fracture of Right Femur and Displaced Fracture of Right Ulna (right elbow) which required surgical intervention. Resident #18 was hospitalized [DATE] through 04/22/19. Review of Resident #18's Comprehensive Care Plan for Resident has Bladder and Bowel Incontinence, dated 02/21/19, revealed an interventions to establish voiding patterns and provide incontinence care every shift and whenever necessary (prn). However, further record review revealed there was no documented evidence the facility tried to establish a voiding pattern for the resident. Interview with the Unit Manager, on 05/10/19 at 2:30 PM, revealed the facility failed to record Resident #18's toileting pattern and staff were expected to implement the care plan. Interview with the Director of Nursing (DON), on 05/10/19 at 12:45 PM, revealed Resident #18 was not implemented on toileting schedule to establish voiding pattern due to his/her cognition and she expected staff to implement the care plan.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to update and revise the care plan for three (3) of twenty-two (22) sampled residents, related to falls, wound care, and incontinent care (Residents #18, #58, and #31). Resident #18 had a fall on 01/03/19 due to getting up without assistance and not calling for assistance as care planned; however, the facility failed to revise the care plan to address the resident getting up without assistance and not using call light. On 01/30/19, Resident #18 sustained another fall due to not using call light and getting up without assistance again which resulted in the resident sustaining a [MEDICAL CONDITION] hip which required surgery. Resident #58 had a fall on 12/14/19 and 01/09/19, however, the facility failed to revise the care plan with appropriate interventions to address the root cause of the fall per facility policy. Resident #58 was getting up and ambulating with asking for assistance. Resident #31 was identified to have a pressure ulcer to the buttock on 05/07/19; however, the licensed staff failed to revise the care plan to address the care and treatment of [REDACTED]. The findings included: Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, last revised (MONTH) (YEAR) revealed a comprehensive centered, person centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident. Assessments of the residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Review of the facility's policy titled, Falls Management Program Guidelines, dated 12/01/18, should a resident experience a fall, the attending nurse shall put interventions in place to reduce risk of repeat episode. The Interdisciplinary Team (IDT) should evaluate the appropriateness of the interventions. The resident care plan should be updated to reflect, any new or change in interventions. 1. Record review revealed the facility admitted Resident #18 on 11/19/18 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 02/24/19, revealed the facility assessed Resident #18's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of four (4) which indicated the resident was not interviewable. Review of the Resident #18 Interdisciplinary Post Fall Review revealed on 01/03/19 at 7:30 AM, Resident #18 had an unwitnessed fall in his/her room while getting dressed and sustained a laceration to back of the head. Resident #18 was sent to the emergency room (ER) and returned to the facility with sutures to the laceration. Review of Resident #18's Comprehensive Care Plan for Resident at Risk for Falls, dated 11/19/18, revealed an intervention dated 01/03/19 to keep resident's walker within reach to provide visual prompts; however, the intervention was not appropriate per facility policy as it did not address the root cause of the fall which was the resident getting up without supervision and not using the call light to call for assistance. Review of the Interdisciplinary Post Fall Review revealed on 01/30/19 at 8:30 PM, Resident #18 had been in the bed and was found on the floor by staff lying next to his/her bed due to the resident attempting to get up without assistance. The resident complained of hip pain and was sent to the ER for evaluation and treatment and admitted to the hospital due to a Left Femur Fracture which required surgical intervention. Interview with Licensed Practical Nurse (LPN) #2, on 05/09/19 at 5:00 PM, revealed Resident #18 had multiple falls since admission. LPN #2 stated the resident ambulated with a walker on admission; however, he/she had no safety awareness of his/her capabilities. She revealed Resident #18's falls were not witnessed by staff and the Interdisciplinary Team (IDT) was responsible to update the resident's care plan. 2. Record review revealed the facility admitted Resident #58 on 06/15/1916 with [DIAGNOSES REDACTED]. Review of Quarterly Minimum Data Set (MDS) assessment, dated 04/12/19, revealed the facility assessed this resident's Brief Interview for Mental Status (BIMS) score as a five (5), which indicated this resident was not cognitively intact and not interviewable. Review of Facility Fall Incident Report revealed Resident #58 had a fall on 12/14/18 in which the resident was observed by staff ambulating in the hallway next to another resident's doorway before stumbling and falling hitting his/her head on the doorway. Review of the Comprehensive Care Plan dated 06/02/17 for falls revealed an intervention was put in place on 12/14/18 to encourage resident to allow staff to assist with mobility; however, the intervention was not appropriate per facility policy due to Resident #58 not being cognitively intact, impaired thought process, forgetful, confusion and short attention. Review of Interdisciplinary Post Fall Review revealed Resident #58 had a fall on 01/09/19 as staff found the resident on the floor in the dining room when another resident yelled out. Review of a Hospital Discharge Summary, dated 01/09/19 revealed Resident #58 was diagnosed with [REDACTED]. Further review of the Comprehensive Care Plan for falls dated 06/02/17 revealed an intervention was put in place to encourage resident to sit in common area when awake to provide increased supervision. However, the intervention was not appropriate as observation of the facility Common's area on multiple occasions on 05/09/10 and 05/10/19 revealed there were no staff present and the nurses' station did not face the common's area directly which created several blind spots that would prevent staff from having direct oversight of resident's in that area. Interview with Registered Nurse (RN) #1 on 05/10/19 at 10:05 AM, revealed Resident #58 sustained a fall on 01/09/19 when he/she attempted to get up from his/her wheelchair and ambulate in the dining room. RN #1 stated Resident #1 should have had increased supervision after the fall on 12/14/18. She revealed the resident should not have been in the independent dining room due to there being only one staff member to assist. Interview with the Unit Manager, on 05/10/19 at 2:30 PM, revealed care plan interventions were reviewed after each fall during the facility's morning meeting and interventions not appropriate were revised. She stated she was responsible to ensure interventions were added to Resident #18's care plan after each fall. Interview the Director of Nursing (DON), on 05/10/19 at 12:45 PM, revealed the nurse caring for residents after each fall was responsible to review and revise care plan interventions. She stated each fall was also reviewed in morning meeting by the IDT which consists of the DON, Assistant DON, Unit Manager, MDS Coordinator, and Therapy Director. She revealed Care Plan interventions were reviewed for the resident, and if decided interventions needed to be more specific for that resident, then revised at that time. 2. Record review the facility readmitted Resident #31 on 09/10/18 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 03/11/19, revealed the facility assessed Resident #31 as cognitively intact with a BIMS score of fifteen (15) which indicated the resident was interviewable. Further review of the MDS assessment revealed the facility assessed the resident at risk for developing pressure ulcer/injury. Observation during Resident #31's incontinent care on 05/09/19 at 10:25 AM, and interview with Certified Nurse Aide (CNA) #8, on 05/10/19 at 2:00 PM revealed the resident had a Stage II pressure ulcer to upper right buttock and it was identified on 05/07/19. However, review of Resident #31's Comprehensive Care Plan titled, Potential Impairment to Skin Integrity dated 05/24/18, revealed there was no documented evidence the care plan was revised to include the Stage II pressure ulcer and with interventions to address the care of the pressure ulcer. Interview with the Unit Manager (UM), on 05/10/19 at 2:30 PM, revealed she expected the nurse who identified pressure ulcer to review and revise the care plan with interventions to minimize potential of any further pressure ulcer and/or skin breakdown.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure each resident received adequate supervision and assistance devices to prevent avoidable accidents for two (2) of five (5) sampled residents who were reviewed for falls (Residents #18 and #58). Resident #18 was assessed and care planned at risk for falls on admission. Resident #18 sustained three (3) falls with major injuries on 01/03/19, 01/30/19 and 04/16/19 while in his/her bedroom; however, the facility failed to identify the resident was getting up without supervision and not using the call light to call for assistance and no interventions were put in place to address the resident getting up/ambulating without assistance per facility policy. In addition, the facility failed to conduct a post fall assessment after each fall per the facility policy. The resident sustained [REDACTED]. The findings included: Review of the facility's policy titled, Falls Management Program Guidelines, dated 12/01/18, revealed the facility strives to maintain a hazard free environment, mitigate fall risk factors, and implement preventive measures. The fall risk assessment is included as part of the admission, quarterly, and when a fall occurs. Identified risk factors should be evaluated for the contribution they may have to the resident's likelihood of falling. Care plan interventions should be implemented that address the resident's risk factors. Should a resident experience a fall, the attending nurse shall complete a fall assessment to include an investigation of the circumstances surrounding the fall to determine the cause of the episode, a reassessment to identify possible contributing factors, interventions to reduce risk of repeat episode, and a review by the Interdisciplinary Team (IDT) to evaluate thoroughness of the investigation and appropriateness of the interventions. The resident care plan should be updated to reflect, any new or change in interventions. Record review revealed the facility admitted Resident #18 on 11/19/18 with [DIAGNOSES REDACTED]. Review of the Admission Fall Risk Assessment, dated 11/26/18, revealed Resident #18 scored seventy (70) on the assessment indicating he/she was at high risk for falls. Further review of the assessment revealed a score of forty-five (45) or greater, meant the resident was at high risk for falls. Review of Resident #18's Admission MDS assessment, dated 11/26/18, revealed the facility assessed Resident #18's cognition as moderately impaired with a Brief Interview of Mental Status (BIMS) score of ten (10) which indicated the resident was interviewable. Further review of the MDS assessment revealed the resident required encouragement and supervision for transfer and ambulation. Review of Resident #18's Comprehensive Care Plan for Resident at Risk for Falls, related to history of falling and dementia, dated 11/19/18, revealed interventions to be sure call light was within reach and to encourage the resident to use it for assistance as needed. Review of the Resident #18 Interdisciplinary Post Fall Review revealed on 01/03/19 at 7:30 AM, Resident #18 had an unwitnessed fall in his/her room while getting dressed and sustained a laceration to back of the head. Resident #18 was sent to the emergency room (ER) and returned to the facility with sutures to the laceration. The facility determined the root cause of the fall was the resident lost his/her balance while standing without walker. However, further review revealed there was no documented evidence the facility identified the resident fell due to being up without supervision and failed to use the call light to call for assistance per assessment/care plan. Further review of the Comprehensive Care Plan revealed an intervention was put in place to keep resident's walker within reach to provide visual prompts; however, the intervention did not address the root cause of the fall per facility policy. In addition, the facility failed to complete a falls risk assessment after the fall per facility policy. Review of the Interdisciplinary Post Fall Review revealed on 01/30/19 at 8:30 PM, Resident #18 had been in the bed and was found on the floor by staff lying next to his/her bed with complaint of hip pain. The facility determined the root cause of the fall was the resident had poor recall and judgement; however, there was no documented evidence the facility identified the resident was attempting to transfer/ambulate without supervision or calling for assistance per assessment/care plan. In addition, further review of the record revealed there was no documented evidence a Fall Risk assessment was completed after the fall per facility policy. Resident #18 was sent to the ER for evaluation and treatment and admitted to the hospital due to a Left Femur Fracture which required surgical intervention. Resident #18 was in the hospital from 01/30/19 through 02/02/19. Further review revealed the IDT determined the resident would be reassessed upon reentry to facility. Review of the Comprehensive Care Plan revealed an intervention dated 02/07/19 (five (5) days after return from hospital) that resident may be up in wheelchair (w/c) while being supervised by staff. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 02/24/19, revealed the facility assessed Resident #18's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of four (4) which indicated the resident was not interviewable. Further review of the Quarterly MDS revealed Resident #18 was totally dependent for bathing, required extensive assistance of one (1) person with bed mobility and hygiene, extensive assistance of two (2) with transfers, and ambulation did not occur. Review of Resident #18's Interdisciplinary Post Fall Review revealed, on 04/16/19 at 3:15 PM, Resident #18 was in w/c and in an attempt to ambulate, the resident had an unwitnessed fall and was found on the floor in front of the doorway to his/her room. Resident #18 was sent to the ER for evaluation and admitted for Fracture of Right Femur and Displaced Fracture of Right Ulna (right elbow) which required surgical intervention. Resident #18 was hospitalized [DATE] through 04/22/19. Further review of the record revealed there was no documented evidence a fall assessment was completed after the fall and there was no evidence the facility identified the resident was up in wheelchair without supervision at the time of the fall instead of with supervision per care plan. The IDT recommendations related to fall revealed was for Resident #18 to have a medication review and to move him/her in to room closer to nursing station; however, observations during facility survey (05/07/19 through 05/10/19) revealed the resident remained in the same room (8-B) he/she was in at the time of the fall. Interview with Resident #18's Daughter/Responsible Party, on 05/08/19 at 10:16 AM, revealed resident had several falls over past five (5) months while at the facility. She stated she chose to send the resident to the facility due to repeated falls at home because the resident failed to use his/her walker. She revealed due Resident #18's Dementia [DIAGNOSES REDACTED]. She further stated her parent's falls in the facility had resulted in a laceration to head that required sutures, a fracture to left hip, and fractured right elbow and right hip on last fall. She further revealed she felt the falls caused a decline in resident's condition, in addition to the dementia. and she was not aware of anything the facility had done to keep the resident from falling. Interview with Certified Nursing Assistant (CNA) #1, on 05/09/19 at 11:35 AM, revealed Resident #18 was a fall risk however, he/she would forget to use his/her walker and fail to use the call light at times. She stated Resident #18's supervision was not increased related to frequent fall history and the resident failing to use walker and/or call light when needed. Interview with Licensed Practical Nurse (LPN) #2, on 05/09/19 at 5:00 PM, revealed Resident #18 had multiple falls since admission. LPN #2 stated the resident ambulated with a walker on admission; however, he/she had no safety awareness of his/her capabilities. She revealed Resident #18's falls were not witnessed by staff and she was unable to recall if a Fall Assessment was conducted with each fall and stated the IDT was responsible to update the resident's care plan. 2. Record review revealed the facility admitted Resident #58 on 06/15/16 with [DIAGNOSES REDACTED]. Review of Discharge MDS assessment dated [DATE] revealed the facility assessed Resident #58's cognition as severely Impaired with a BIMS score of five (5) which indicated the resident was not interviewable. Further review of the MDS assessment revealed the facility assessed the resident required supervision with transfers and and was able to ambulate independently with the use of a walker. There were no falls indicated for that review period. Review of the Comprehensive Care Plan for Falls Risk, dated 06/02/17, revealed Resident #58 was at risk for injury related to confusion, high risk medications, balance and cognitive deficit, a history of multiple falls, and at risk for future falls. Further review revealed interventions to encourage participation and plan diversional activities that are of resident's interest. Review of the ADL care plan revealed Resident #58 was care planned for assist of one (1) or two (2) staff for transfers. Further review of the Comprehensive Care Plan revealed Resident #58 was also care planned for impaired cognition, impaired thought process, forgetfulness, confusion and short attention span. Review of Interdisciplinary Post Fall Review revealed Resident #58 had a fall on 01/09/19 as staff found the resident on the floor in the dining room when another resident yelled out. Review of a Hospital Discharge Summary, dated 01/09/19 revealed Resident #58 was diagnosed with [REDACTED]. Further review of the Interdisciplinary Post Fall Review revealed there was no documented evidence the facility determined the root cause of the fall per facility policy. The facility put an intervention in place to encourage resident to sit in common area when awake to provide increased supervision. However, observation of the facility Common's area on multiple occasions on 05/09/10 and 05/10/19 revealed there were no staff present and the nurses' station did not face the common's area directly which created several blindspots that would prevent staff from having direct oversight of resident's in that area. Interview with Registered Nurse (RN) #1 on 05/10/19 at 10:05 AM, revealed Resident #58 was observed walking in the hallway on 12/14/18 with the assistance of a walker when he/she lost lost his/her balance and fell down hitting head. RN #1 stated Resident #58 sustained another fall on 01/09/19 when he/she attempted to get up from his/her wheelchair and ambulate in the dining room. RN #1 revealed another resident yelled out that Resident #58 was falling and staff ran towards Resident #58 but was unable to reach Resident #58 before he/she fell on to the ground hitting head. RN #1 stated Resident #1 should have had increased supervision after the fall on 12/14/18. She revealed the resident should not have been in the independent dining room due to there being only one staff member to assist than in the other dining room in which there are several staff members and one would have most likely been closer to resident to stop any unassisted transfers and most likely prevented the fall. Interview (Post Survey) with Unit Manager, on 06/14/19 at 10:50 AM, revealed following a resident's fall, a fall investigation begins, and the clinical staff member on call is notified. She stated the information is obtained post fall, and the attending nurse and clinical staff member collaborate to determine root cause of fall and interventions are put in place. She further revealed the attending nurses failed to initiate a Interdisciplinary Post Fall Review, Fall Risk Assessment, and document the root cause and interventions for each of Resident #18's falls as indicated per facility policy. Interview the Director of Nursing (DON), on 05/10/19 at 12:45 PM, revealed the nurse caring for Resident #18 at each fall was responsible to initiate a Fall Investigation, Fall Risk Assessment, and review and revise care plan interventions. She stated each fall is was reviewed in morning meeting by the IDT which consists of the DON, Assistant DON, Unit Manager, MDS Coordinator, and Therapy Director. She revealed Care Plan interventions were reviewed for the resident, and if decided interventions needed to be more specific for that resident, then revised at that time. The DON stated I would expect the nurses to assess for reason of fall, interventions to decrease fall, and revise interventions at that time. The DON stated she felt the interventions were appropriate for Resident #18 because the resident's cognition was moderately intact at the time.

Based on observation, interview and review of facility policy, it was determined the facility failed to store and serve food in accordance with professional standards for food service safety. Observations in the kitchen on 05/07/19 revealed staff failed to ensure heads of cabbage were covered while stored in the refrigerator. In addition, observation on 05/07/19 during a supper meal revealed staff failed to wash or sanitize their hands. Review of the facility Census and Condition, dated 05/07/19, revealed sixty-eight (68) of sixty-eight (68) residents received their meals from the kitchen. The findings include: 1. Review of facility policy titled, Food Receiving and Storage, last revised , revealed all foods stored in the refrigerator or freezer will be covered, labeled and dated with a use by date. Observation of the walk-in refrigerator in the kitchen on 05/07/19 at 2:03 PM, revealed three (3) heads of cabbage on top of a box, uncovered and open to air. Interview with the Dietary Manager on 05/07/19 at 2:40 PM, revealed she expected all foods being stored in the freezers and refrigerators to be covered or stored in the appropriate box to avoid contamination. Interview with Dietary Cook #1 on 05/09/19 at 3:15 PM, revealed all foods stored in the walk-in refrigerator should be covered to avoid contamination. 2. Review of the facility's policy titled Handwashing/Hand Hygiene, last revised (MONTH) 2019, revealed the facility considers hand hygiene the primary means to prevent the spread of infections. Staff soul use an alcohol-based hand rub containing at least 62% alcohol and/or concentrated foam hand sanitizer; or alternatively, soap (anti-microbial or non-antimicrobial) and water before or after assisting a resident with meals. Observation during supper meal in the main dining room, on 05/07/19 at 4:52 PM, revealed eight (8) staff members providing meal service. Dietary Aide #2 was observed to serve a cart of desserts to residents without wearing gloves and she failed to wash or sanitize hands between each resident. She also cupped her hands over top of the dessert cups after she touched the outside of the dining cart to open and close the door. Then her left index fingernail extended downward into a dessert bowl and she served it to a resident. Further observation revealed Dietary Aide #2 left the dining room carrying a meal tray to the unit; however, when she returned to the dining room, she failed to wash/sanitize her hands and continued to pass desserts from food cart. Interview with Dietary Aide #2, on 05/07/19 at 4:59 PM, revealed when staff provide meal service, staff should wash and/or sanitize hands after each tray given to a resident, when leaving and upon return to the dining area, and before serving meals. Dietary Aide #2 stated, I was not serving the resident's meal tray or handling the food, I was passing out the dessert cups. She revealed she failed to wash or sanitize her hands at intervals while handling food during supper meal. Interview with the Dietary Manager, on 05/09/19 at 2:57 PM, revealed staff was required to wash or sanitize their hands in between each meal tray pass. She stated staff should not place bare hands over food containers without lids but were expected to place hands at side of the food containers. She revealed if hands cover the top of a food container and/or go inside of any open container, that food should be discarded and a new dish obtained. She further stated staff that leave the dining room during meal tray pass should wash and/or sanitize hands upon return to dining area and before providing meal service.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure gloving procedures were followed related to a medication pass. Observation on 05/08/19 revealed licensed staff handled a resident's medication with her bare hands. The findings include: Review of the facility's policy titled, Administering Medications, last revised (MONTH) 2012, revealed staff shall follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. Observation of a medication administration pass on 05/08/19 at 8:07 AM, revealed Licensed Practical Nurse (LPN) #4, removed a tablet from the resident's medication cup with her bare hand, and in the process touched other medications, prior to administering the remaining medications to the resident. Interview with LPN #4 on 05/08/19 at 8:12 AM, revealed she should not have removed the medication from the cup with her bare hand because she touched other medications in the process. LPN #4 stated this was not good practice but she was nervous and should have caught herself. Interview with the Director of Nursing (DON) on 05/10/19 at 6:00 PM, revealed she would expect nurses to be more aware and not use their bare hands to touch medications. The DON stated LPN #4 should have wasted the other medications because they would be considered unclean. She stated the facility did not have a policy specifically regarding handling medications with bare hands; however, the facility follows state and federal regulations related to infection control and medication administration.

Based on observation, interview, record review, and review of the facility policy, it was determined the facility failed to treat one (1) of twenty-two (22) sampled residents with dignity and respect (Resident #18). Staff failed to close the privacy curtains and window blinds prior to giving Resident #18 a bed bath to ensure privacy while providing perineal care. The findings include: Review of the facility's policy titled, Resident Rights , not dated, revealed the facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. Record review revealed the facility admitted Resident #18 on 11/19/18 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 02/24/19, revealed the facility assessed Resident #18's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of four (4) which indicated the resident was not interviewable. Observation on 05/09/19 at 10:00 AM revealed Certified Nursing Assistant (CNA) #4 failed to close the privacy curtains and window blinds prior to giving Resident #18 a bed bath which left his/her pubic area and upper thighs exposed when staff was providing perineal care. Interview with CNA #4, on 05/09/19 at 10:00 AM, revealed she stated, if the roommate was in here I would have pulled the curtain. I should have closed the window blinds because there were people walking around outside. CNA #4 further stated she failed to provide privacy for the resident and should not have left the resident exposed during perineal care. Interview with Licensed Practical Nurse (LPN) #1, on 05/10/19 at 2:30 PM, revealed she expected staff to provide privacy for each resident when providing care. Interview the Director of Nursing (DON), on 05/10/19 at 6:30 PM, revealed she expected CNA #4 to close the privacy curtain and the blinds when providing care to Resident #18. The DON stated she expected all residents to be provided privacy and dignity with care.

Based on interview, record review and review of facility policy, it was determined the facility failed to ensure each resident who experiences a significant change in status is comprehensively assessed using the CMS-specified Resident Assessment Instrument (RAI) process for one (1) of twenty-two (22) sampled residents (Resident #58). Resident #58 had a decline in three (3) care areas, however, the facility failed to complete a significant change assessment. The findings include: Review of the facility policy titled, MDS Assessment Completion, last revised (MONTH) (YEAR), revealed the facility will conduct and submit resident assessments in accordance with the RAI Manual including deferral and state submission timeframes. Further review revealed significant change in status assessment will be completed on the 14th calendar day after determination of significant change in status. Record review revealed the facility admitted Resident #58 on 06/15/16 with [DIAGNOSES REDACTED]. Review of Resident 58's Quarterly Minimum Data Set (MDS) assessment, dated 10/10/18, revealed Resident #58's Activities of Daily Living (ADL's) were coded as Bed: 2/2 (limited assistance of one (1) staff); Transfer: 1/2 (supervision of one (1) staff), and Toileting: 2/2 (limited assistance of one (1) staff). Review of Resident #58's quarterly MDS assessment, dated 01/10/19 revealed Resident #58's ADL's for bed, transfer, and toileting were coded at 3/2 (extensive assistance of one (1) staff). Resident #58 declined from only requiring supervision and limited assistance to requiring extensive assistance by staff in the three (3) care areas. However, further review revealed there was no significant change MDS assessment completed. Interview with the MDS Coordinator on 05/09/19 at 4:15 PM revealed she started with facility on 01/09/19. The MDS Coordinator stated she expected Resident #58 to return back to his/her baseline in ADL function; however, there was no documentation to show that the facility expected the return in function or that the resident did in fact return back to her/his baseline. The MDS Coordinator stated a Significant Change Assessment was not completed but one should have been completed after there was no reverse in function after a fourteen day (14) time period. Interview with the Director of Nursing (DON) on 05/10/19 at approximately 6:30 PM revealed she expected a significant change MDS assessment to have been completed for Resident #58 when the most recent MDS showed three (3) areas of ADL decline. She stated the IDT should have been made aware of the change/decline so interventions could be put in place to prevent further decline and attempt to restore resident back to baseline.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to provide quality of care and treatment in accordance with professional standards of practice for one (1) of twenty-two (22) sampled residents (Resident #24). Observation on 05/10/19 revealed staff failed to change Resident #24's transparent occlusive dressing every seven (7) days per facility policy. Resident #24's dressing was dated 04/24/19, which indicated the dressing had not been changed in sixteen (16) days. The findings include: Review of the facility policy titled, Central Venous Catheter Dressing Changes, dated (MONTH) (YEAR), revealed the purpose of this procedure is to prevent catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings. Apply and maintain sterile dressing on intravenous access devices. Dressings must stay clean, dry, and intact. Change transparent semi-permeable membrane (TSM) dressings at least every seven (7) days and as needed (when wet, soiled, or not intact). Record review revealed the facility admitted Resident #24 on 11/13/18 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #24's cognition as intact with a Brief Interview for Mental Status (BIMS) score of thirteen (13) which indicated the resident was interviewable. Review of Resident #24's Urinalysis Laboratory report, dated 04/19/19, revealed the resident had a Urinary Tract Infection and a urine culture was performed. The urine culture results indicated Pseudomonas Aeruginosa and [MEDICAL CONDITION] Resistant Staphyloccus Aureus (MRSA). Review of Physician Orders revealed Resident #24 had a midline PICC inserted on 04/24/19 for intravenous antibiotic therapy related [MEDICAL CONDITION] in the urine. Further review of the orders revealed there was no documented evidence an order was received for dressing changes to the site. Observations on 05/08/19 at 8:54 AM, 05/09/19 at 10:15 AM, and 05/10/19 at 8:55 AM, revealed Resident #24's PICC line occlusive transparent dressing to upper left forearm was loose, with upper right corner rolled down and dressing dated 04/24/19 which indicated the dressing had not been changed for sixteen (16) days instead of at least every seven (7) days per facility policy. Interview with Licensed Practical Nurse (LPN) #3, on 05/10/19 at 2:18 PM, revealed she was not familiar with the facility's policy on central venous catheter dressing change. Interview with the Unit Manager (UM), on 05/10/19 at 2:30 PM, revealed Resident #24 had finished intravenous antibiotic and the resident's PICC line dressing should have been changed and dressing integrity maintained. Interview with the Director of Nursing (DON), on 05/10/19 at 6:30 PM, revealed she would expect Resident #24's PICC line dressing to be changed as indicated per facility policy.

Based on observation, interview, record review, and review of facility's policy, it was determined the failed to ensure a resident with pressure ulcer received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (1) of three (3) sampled residents, (Resident #31). Staff identified Resident #31 had a Stage II pressure ulcer to his/her right buttock on 05/07/19; however, licensed staff failed to notify the physician/practitioner of the ulcer and resident's condition to obtain orders for treatment; and, document the type of wound, the degree of tissue damage, location of the area, measurements, and ulcer characteristics per facility policy. The findings include: Review of the facility policy titled Pressure Ulcers: Skin Assessment and Prevention dated (MONTH) 2012, revealed the purpose is to systematically assess residents with regard to risk of skin breakdown, to accurately document observations and assessments of residents, and to appropriately use prevention techniques and pressure redistribution surfaces on those residents at risk for pressure ulcers. If a pressure ulcer is identified, cleanse the area prior to observations being made to the wound bed and depth to be accurately assessed. The licensed nurse should record the type of wound and the degree of tissue damage. The licensed nurse records the location of the area, the measurements, and the ulcer/wound characteristics. Notify the physician/practitioner of the ulcer and resident's condition to obtain orders for treatment. Record review the facility readmitted Resident #31 on 09/10/18 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #31 as cognitively intact with a Brief Inventory of Mental Status (BIMS) score of fifteen (15) which indicated the resident was interviewable. Further review of the MDS revealed the facility assessed the resident at risk for developing pressure ulcer/injury. Review of the Resident #31's Weekly Skin Review, dated 05/02/19, revealed the resident had redness to groin and buttocks that appeared as moisture associated skin damage (MASD) with treatment of [REDACTED]. Observation during Resident #31's incontinent care on 05/09/19 at 10:25 AM revealed bilateral buttocks were red and blanchable as staff member provided incontinent care. Further observation revealed the resident had an open area to upper right buttock with a scant amount of serous drainage to area. Interview with Certified Nurse Aide (CNA) #8, on 05/10/19 at 2:00 PM, revealed an open area was noted on Resident #31's right (R) buttock on 05/07/19. CNA #8 stated she informed the nurse (Licensed Practical Nurse {LPN} #6) who was working the unit and the nurse was aware the resident had an open area to (R) buttock. Review of Resident #1's record to include Nursing Notes, Physician Orders and (MONTH) 2019 Treatment Administration Record (TAR) revealed there was no documented evidence the nurse assessed and documented the type of wound, the degree of tissue damage, location of the area, the measurements, and the ulcer/wound characteristics; and, notified the physician/practitioner of the ulcer to obtain orders for treatment. Interview with the Unit Manager (UM) on 05/10/19 at 5:55 PM revealed a wound assessment on 05/10/19 at 3:30 PM by the Advanced Practice Registered Nurse (APRN) indicated Resident #31 had acquired a Stage ll pressure ulcer on right (R) upper buttock (sacral) region. Review of a Wound assessment dated [DATE] revealed Resident #31 had a Stage II pressure ulcer to the upper right buttock proximal to gluteal crevice which measured 0.5 centimeters (cm) in length by 0.4 cm in width. Further review revealed the wound bed was pink, was not blanchable, and had a scant amount of serous drainage to area. An attempt was made to interview LPN 6 by phone on 05/10/19 at 2:10 PM; however, it was unsuccessful. Interview with Resident #31, on 05/09/19 at 10:25 AM, revealed he/she was not aware there was a pressure ulcer to right buttock. He/she stated staff applied cream to his/her buttocks whenever incontinent care provided. Interview with Certified Nursing Assistant (CNA) #1, on 05/09/19 at 11:35 AM, revealed Resident #31 had MASD to buttocks and the CNA's used barrier cream for redness. CNA #1 stated she was not aware the resident had an open area to right buttock. Interview with LPN #3, on 05/10/19 at 8:45 AM, revealed she was the nurse assigned care of Resident #31 and she was not aware the resident had a pressure ulcer/injury to the (R) buttock. Further interview with the UM on 05/10/19 at 5:55 PM revealed she expected the nurse who identified the pressure ulcer to put interventions in place to prevent infection, prevent pressure ulcer from worsening, and minimize the potential of any further pressure ulcers developing. Interview with the Director of Nursing (DON), on 05/10/19 at 6:30 PM, revealed she expected Resident #31's skin to be assessed thoroughly and interventions implemented to prevent further pressure ulcer breakdown.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure each resident receives necessary respiratory care and services that is in accordance with professional standards of practice, the resident's care plan, and the resident's choice for two (2) of two sampled residents reviewed for respiratory care (Residents #12 and #62). Observations on 05/07/19, 05/08/19, and 05/09/19 revealed Resident #12's oxygen (O2) tubing was not being stored in a plastic bag when not in use according to facility policy. In addition, Resident #62 was care planned and had Physician Orders for O2 at two (2) liters per minute (LPM) per nasal cannula; however, observations on 05/07/19, 05/08/19 and 05/10/19 revealed the resident was not receiving O2 at two (2) LPM. The findings include: Review of the facility policy titled, Departmental (Respiratory Therapy) - Prevention of Infection, last revised (MONTH) 2019, revealed the purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment among residents and staff. Infection control considerations related to oxygen administration include keeping the oxygen cannula and tubing in a plastic bag when not in use. 1. Record review revealed the facility admitted Resident #12 on 02/15/19 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 02/22/19, revealed the facility assessed Resident #12 's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of three (3), which indicated the resident was not interviewable. Review of Resident #12's Physician's Order Summary for (MONTH) 2019, revealed an order for [REDACTED]. Observation on 05/07/19 at 3:20 PM revealed Resident #12 was up in the broda chair and was receiving O2 through a nasal cannula from a portable O2 tank. Further observation revealed an O2 concentrator was noted at the bedside with tubing draped over the machine and the nasal cannula was resting on the floor, not stored in a plastic bag per facility policy. Observations on 05/08/19 at 9:08 AM and on 05/09/19 at 8:45 AM revealed Resident #12 was in bed and was receiving O2 through a nasal cannula from a bedside O2 concentrator. Further observations revealed the resident's broda chair was stored in the bathroom with a portable O2 tank on the chair with the attached O2 tubing draped over the arm of the chair and the nasal cannula resting in the seat of the chair, not stored in a plastic bag per facility policy. Interview with Certified Nurse Assistant (CNA) #2 on 05/09/19 at 8:58 AM revealed the nasal cannula, when not in use, should be stored in a plastic bag. The CNA stated if she found the cannula not in use and not in a plastic bag, she would let the nurse know so the tubing could be replaced. She revealed she had not noticed the tubing not being stored appropriately. Interview with Licensed Practical Nurse (LPN) #5 on 05/09/19 at 11:30 AM revealed when O2 tubing/ nasal cannula was not in use, it should be in a plastic bag. She stated nursing was responsible for ensuring the tubing was stored appropriately. Interview with LPN #1, Unit Manager on 05/09/19 at 9:02 AM, revealed the CNA or the nurse removing the nasal cannula from the resident should place it in a plastic bag. She stated she expected the tubing to be placed in a plastic bag when it was not in use and if found not in use and not in a plastic bag, the tubing should be changed out with new tubing. Interview with the Director of Nursing (DON) on 05/10/19 at 2:02 PM, revealed she expected the CNA, on resident transfer, to place the unused nasal cannula in a protective bag. She stated if a bag was not present, she would expect the CNA to notify the nurse and get a bag to store the unused cannula in. Additionally, the DON stated she expected the unused cannula to be stored in a plastic protective bag. 2. Review of the facility's policy titled, Oxygen Administration, dated (MONTH) 2010, revealed the purpose of the policy is to provide guidelines for safe oxygen administration. Preparation; Verify there is a physician's order for this procedure. Review the physician's order or facility protocol for oxygen administration. Review the resident's care Plan to assess for any special needs for the resident. Record review revealed the facility admitted Resident #62 on 04/13/19 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment, dated 04/27/19, revealed the facility assessed Resident #62's cognition as intact with a Brief Interview for Mental Status (BIMS) Score of fifteen (15), which indicated the resident was interviewable. Review of Comprehensive Care Plan dated 04/15/19 revealed the resident has altered respiratory status/difficulty breathing related to Shortness of Air. Further review of the care plan revealed an intervention for staff to administer resident's oxygen therapy as ordered. Review of Resident #62's Physician Orders, dated 05/08/19, revealed staff was to administer the resident oxygen at two (2) LPM per nasal cannula via 02 concentrator or tank continuous Observations of Resident #62, on 05/07/19 at 3:18 PM and 05/08/19 at 8:56 AM revealed the resident was being administered oxygen at two and a half (2.5) LPM per nasal cannula; and, on observation on 05/10/19 at 9:02 AM revealed the resident was being administered oxygen at one and a half (1.5) LPM per nasal cannula; instead of the ordered two (2) LPM. Interview with Licensed Practical Nurse (LPN) #6 on 05/10/19 at 9:05 AM revealed she believed Resident #62's oxygen setting should be on three (3) LPM and the Surveyor observed LPN #6 change Resident #62's oxygen setting to three (3) LPM which was not the correct LPM. Interview with the Director of Nursing (DON) on 05/10/19 at approximately 6:30 PM revealed nursing staff were expected to ensure that O2 settings were set on the correct settings and that nursing staff were following physician's orders. The DON was very disappointed to hear that a nurse actually changed a resident's O2 setting to the wrong setting that was not ordered/prescribed by the physician.

Based on interview, record review, and review of facility policy, it was determined the facility failed to ensure the pharmacy review reports included any irregularities related to appropriate [DIAGNOSES REDACTED].#15). Resident #15 was administered [MEDICATION NAME] ([MEDICATION NAME]-an antipsychotic) and Quetiapine ([MEDICATION NAME]-an antipsychotic) with a [DIAGNOSES REDACTED]. The findings include: Review of the facility policy, Medication Regimen Review, last revised 11/28/16, revealed the Consultant Pharmacist will conduct medication regimen reviews (MRR's) if required under a Pharmacy Consultant Agreement and will make recommendations based on the information available in the residents' health record. Record review revealed the facility admitted Resident #15 on 11/12/18 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 02/19/19, revealed the facility assessed Resident #15 was unable to complete the Brief Interview for Mental Status (BIMS) due to poor memory, which indicated the resident was not interviewable. Review of Resident #15's Physician's Order Summary for (MONTH) 2019 revealed orders were initiated on 11/12/18 for [MEDICATION NAME] tablet 0.5 milligram (mg), give one (1) tablet by mouth two (2) times a day; and, [MEDICATION NAME] 12.5 mg, give one (1) tablet by mouth at bedtime; for Dementia with behavioral disturbance. However, review of the Pharmacy Consultation Report , dated 04/15/19 revealed no documented evidence the pharmacy had identified Resident #15 was receiving antipyschotic medications without an appropriate diagnosis. Interview with the Pharmacist on 05/10/19 at 8:42 AM, revealed he thought Dementia was a proper [DIAGNOSES REDACTED]. He stated he reviews residents medications monthly and makes recommendations for the gradual dose reductions and it is up to the physician on whether to do so. The Pharmacist stated he did not document any irregularities related to Resident #15's [DIAGNOSES REDACTED]. Post-interview with the Physician on 05/28/19 at 9:28 AM, revealed she expected pharmacy or nursing to follow up with her or the appropriate physician for the proper [DIAGNOSES REDACTED]. Interview with the Director of Nursing (DON) on 05/10/19 at 8:44 AM, revealed Resident #15 was prescribed [MEDICATION NAME] on admission and stated she was aware that Dementia with behavioral disturbance was not an appropriate [DIAGNOSES REDACTED].

Based on interview, record review, and review of facility policy, it was determined the facility failed ensure one (1) of five (5) residents on [MEDICAL CONDITION] medications was administered a [MEDICAL CONDITION] medication without an appropriate diagnosis (Resident #15). Resident #15 was administered [MEDICATION NAME] ([MEDICATION NAME]-an antipsychotic) and Quetiapine ([MEDICATION NAME]-an antipsychotic) with a [DIAGNOSES REDACTED]. The findings include: Review of the facility policy, Antipsychotic Medication Use, last revised (MONTH) (YEAR), revealed antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed. Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. [DIAGNOSES REDACTED]. Antipsychotic medications shall generally be used only for the following conditions/[DIAGNOSES REDACTED]. a. [MEDICAL CONDITION]; b. Schizo-affective disorder; c. Schizophreniform disorder; d. Delusional Disorder e. Mood Disorders (e.g. [MEDICAL CONDITION] disorder, depression with psychotic features, and treatment refractory [MEDICAL CONDITION]); f. [MEDICAL CONDITION] g. Medical illnesses with psychotic symptoms and/or treatment-related [MEDICAL CONDITIONS](e.g. high-dose steroids); h. [MEDICAL CONDITION]'s Disorder i. [MEDICAL CONDITION]'s Disease j. Hiccups (not induced by other medications); or k. Nausea and vomiting associated [MEDICAL CONDITION] or [MEDICAL CONDITION]. Review of a Nursing Drug Handbook by Lipponcott, dated 2014, revealed [MEDICATION NAME] was used for the following: [MEDICAL CONDITION], Aggression, Irritability, Temper Tantrums, and Self-Injury associated with Autism, and [MEDICAL CONDITION]. Review of the Black Box Warning revealed fatal Cardiovascular or Infectious adverse events may occur in elderly patients with dementia and is not safe or effective in these patients. Record review revealed the facility admitted Resident #15 on 11/12/18 with [DIAGNOSES REDACTED].#15 was unable to complete the Brief Interview for Mental Status (BIMS) due to poor memory, which indicated the resident was not interviewable. Further review of the MDS assessment revealed the resident did not have hallucinations, delusions, rejection of care, wandering, there were no other behaviors exhibited, and there were no mood indicators coded on the MDS. Review of the Comprehensive Care Plans for Resident #15 revealed the resident has impaired cognitive function, impaired thought processes, related to Dementia with behavioral disturbance, forgetfulness, confusion, tendency to misinterpret his/her environment, care procedures, etc, with difficulty understanding/reorienting, dated 11/19/18; with interventions to administer medications as ordered; monitor/document side effects, and effectiveness; and ask yes/no questions in order to determine the resident's needs. Review of Resident #15's Physician's Order Summary for (MONTH) 2019 revealed an order were initiated on 11/12/18 for [MEDICATION NAME] tablet 0.5 milligram (mg), give one (1) tablet by mouth two (2) times a days for dementia with behavioral disturbance. Further review of the orders revealed an order initiated 11/12/18 for [MEDICATION NAME] 12.5 mg, give one (1) tablet by mouth at bedtime for dementia with behavioral disturbance. Review of the Pharmacy Consultation Report, revealed Resident #15's medications were most recently reviewed on 04/15/19 with no irregularities identified to include the resident receiving a medication without an appropriate diagnosis. Further review of the document revealed recommendations to attempt a gradual dose reduction on [MEDICATION NAME] 12.5 mg at bedtime by discontinuing this order and continue [MEDICATION NAME] 0.5 mg twice a day, while monitoring for reemergence of target behaviors. Continued review, revealed they physician documented will need to assess, no changes at this time. Interview with the Pharmacist on 05/10/19 at 8:42 AM, revealed he thought Dementia was a proper [DIAGNOSES REDACTED]. He stated he reviews residents medications monthly and makes recommendations for the gradual dose reductions and it is up to the physician on whether to do so. The Pharmacist stated he did not document any irregularities related to Resident #15's [DIAGNOSES REDACTED]. Post-interview with the Physician on 05/28/19 at 9:28 AM, revealed she knew the [DIAGNOSES REDACTED]. The Physician stated she had completed a consultation on Resident #15 on 05/16/19 and had discontinued the [MEDICATION NAME]. She further stated she would have expected pharmacy or nursing to follow up with her or the appropriate physician for the proper [DIAGNOSES REDACTED]. Interview with the Director of Nursing (DON) on 05/10/19 at 8:44 AM, revealed Resident #15 was prescribed [MEDICATION NAME] on admission and stated she was aware that Dementia with Behavioral Disturbance was not an appropriate [DIAGNOSES REDACTED].

Based on observation, interview, and review of the facility's policy and procedure, it was determined the facility failed to ensure drugs used in the facility were labeled in accordance with currently accepted professional principles. On 05/08/19, observation of medication room refrigerator revealed a medication vial dated 03/29/19 and still available for use. The findings include: Review of the facility's policy titled, Storage of Medications, last revised (MONTH) 2007, revealed the facility shall not use outdated drugs or biological's and all such drugs shall be returned to the dispensing pharmacy or destroyed. Observation of the refrigerator in the B hall medication room, on 05/08/19 at 11:17 AM, revealed one (1) vial of [MEDICATION NAME] ([MEDICATION NAME] protein derivative) solution opened and expired. Interview with Licensed Practical Nurse (LPN) #4, on 05/08/19 at 11:20 AM, revealed the vial of [MEDICATION NAME] should have been discarded because it expired after thirty (30) days. She stated all nursing staff were taught during their orientation to date multi-dose medications and to dispose of expired medications. Interview with the Director of Nursing (DON), on 05/10/19 at 4:30 PM, revealed she expected the nurses to discard expired medications such as [MEDICATION NAME] because the solution expires thirty days after opening. She stated nursing staff are educated on expiration dates of medications during their orientation upon hire.

Based on interview, record review, and review the facility's policy, it was determined the facility failed to ensure an allegation of verbal abuse was reported immediately to the Administrator to prevent the potential for further abuse for one (1) of four (4) sampled residents, Resident #1. The findings include: Review of the facility's policy, Abuse Prevention Program, revised (MONTH) (YEAR), and Abuse and Neglect Training, revealed the facility would investigate and report any allegation of abuse within the timeframe required by federal regulatory requirements and protect residents during the abuse investigation. The facility defined verbal abuse as any use of oral, written, or gestured communication or sounds to residents within hearing distance regardless of the resident's ability to comprehend, or disability. The facility established they required staff to immediately report alleged or suspected abuse to the Administrator, Director of Nursing Services, and the Charge Nurse. Review of a facility Investigation, not dated, revealed on 07/01/18, Certified Nurse Assistant (CNA) #1 and #2 witnessed Registered Nurse (RN) #1 flick Resident #1's knee and state something about him/her in a demeaning manner. Both CNAs reported RN #1 raised her tone of voice, used obscene language, and stated she did not have to put up with this and wanted to quit. The Administrator documented a telephone conversation he had with RN #1 on 07/02/18, which revealed RN #1 told the Administrator after she took a smoke break; she returned and finished her shift. Review of the facility's clinical record for Resident #1 revealed the facility admitted the resident on 06/21/18, with multiple diagnoses, which included Paranoid Personality Disorder with Delusions and [MEDICAL CONDITION]. Review of Resident #1's Nursing Note, dated 07/01/18 at 5:43 PM, revealed RN #1 documented Resident #1 was out of control, yelling and screaming. Since the resident returned from the hospital, his/her behavior had been demanding and disturbing to other residents. The physician would not approve [MEDICATION NAME] for agitation. Interview with CNA #2, on 09/03/18 at 11:41 AM, revealed she witnessed RN #1 verbally abuse Resident #1 on 07/01/18 at approximately 5:00 PM. She stated the resident was yelling, cursing, and throwing items and RN #1 stood over the resident and cursed at him/her. She stated RN #1 and Resident #1 were arguing back and forth with each other until CNA #1 asked RN #1 to take a break. According to CNA #2, she told Licensed Practical Nurse (LPN) #1 about the altercation and requested LPN #1 to assist her with Resident #1, but RN #1 returned to the resident's room and LPN #1 left. CNA #2 stated RN #1 was at the nurses' station when her shift ended at 6:30 PM. She stated she was trained to report abuse to the nurse and she had never heard a nurse speak that way towards a resident and stated it was awful. Interview with CNA #1, on 09/03/18 at 11:28 AM, revealed she told RN #1 to take a smoke break because the RN was cursing and threatening to quit her job in the hall outside Resident #1's room on 07/01/18. She stated other residents and their family members were sitting outside Resident #1's room. CNA #1 stated when LPN #1 came to help with Resident #1, she told her RN #1 was frustrated with the resident and was over-reacting, and used curse words. Interview with LPN #1, on 09/03/18 at 2:27 PM, revealed she assisted staff with Resident #1 and CNA #1 was standing outside Resident #1's room and told her RN #1 was spazzing out (lose emotional control). She stated when she entered the resident's room, CNA #2 was standing beside the resident's bed straightening the covers, and the resident appeared calm. LPN #1 stated she asked CNA #2 if everything was okay, but she could not recall her answer and RN #1 returned to the room. According to LPN #1, she called RN #2 (the on-call manager), but she could not recall exactly what she told her about the incident. Interview with RN #2, on 09/04/18 at 4:45 PM, revealed she relieved RN #1 at the end of shift on 07/01/18 and when she first arrived, LPN #1 told her the CNAs asked her to assist RN #1 with Resident #1 earlier that evening because RN #1 was very upset. RN #2 stated when she entered Resident #1's room; she heard RN #1 speak to Resident #1 inappropriately by mocking him/her. According to RN #2, she did not receive a phone call from LPN #1, but if LPN #1 had reported the incident to her, she would have arrived earlier and immediately sent RN #1 home. Interview with RN #1, on 09/04/18 at 3:20 PM, revealed the CNAs called her multiple times to assist with Resident #1 because the resident was hitting, kicking, and thrashing. She stated Resident #1 frustrated her because the resident put his/her finger on her nose and pushed her head backwards. The RN stated she took a short break to calm herself, and then returned to the resident's room, and finished her shift. RN #1 stated yelling at a resident was considered abuse and she would never abuse a resident. RN #1 stated at times, she got stressed and her heavy workload made her snippy and [MEDICATION NAME]. She stated that was just her personality and she tried to be nice, but it was not working. Interview with CNA #3, on 09/04/18 at 2:08 PM, revealed the facility educated her on the types of abuse and yelling and cursing at a resident was considered abuse. She stated if she witnessed abuse, she would immediately report it to the nurse and if the nurse did not act upon her report, she would report it to the Director of Nursing (DON). CNA #3 stated the alleged abuser could continue abusing the resident if the facility did not immediately remove them. Interview with LPN #2, on 09/04/18 at 1:34 PM, revealed the Staff Development Coordinator trained staff on the types of abuse and on reporting alleged abuse. She stated if a resident and/or staff person reported abuse to her, she would ensure the resident was safe by immediately removing the alleged abuser and contacting the DON and/or the Administrator. According to LPN #2, if the alleged abuser was not immediately removed from resident care, it could cause further abuse to continue, which could harm the resident physically or emotionally. Interview with LPN #4 (Unit Manager), on 09/04/18 at 2:15 PM, revealed staff was trained to immediately report abuse to the nurse on duty. LPN #4 stated when staff reported alleged abuse of a resident; she would first ensure the safety of the resident and immediately pull the alleged abuser from providing direct resident care. She stated the resident and/or other residents could suffer further abuse if the alleged abuser was not immediately removed from providing direct resident care, and she would not take that chance. Interview with the DON, on 09/04/18 at 4:25 PM, revealed staff did not meet the facility's reporting obligation because she was not informed of Resident #1's alleged verbal abuse until the day after the incident occurred. She stated CNA #2 came to her office on 07/02/18 and told her about the incident that occurred on 07/01/18 at approximately 3:30 PM-5:00 PM. According to the DON, to ensure Resident #1's safety, RN #1 should have been immediately removed from the facility until the investigation was completed. Interview with the Administrator, on 09/04/18 at 6:30 PM, revealed his employment at the facility began after the incident occurred, but staff should immediately report any suspected abuse and remove the alleged abuser to ensure residents remained safe. According to the facility's policy, if there were an allegation of employee to resident abuse, the employee should be immediately removed from providing direct care to all residents. The Administrator stated verbal abuse was any use of foul language and he considered mocking and cursing at a resident as abuse, which should be reported immediately.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure drugs were safely stored in one (1) of the four (4) units of the facility. Observation of the refrigerator utilized for medication storage in the Unit A medication room revealed the facility failed to maintain the temperature of the refrigerator as required by facility policy and in accordance with medication storage requirements. The findings include: Review of the facility policy titled Acquisition, Receiving, Dispensing and Storage of Medications, last revised (MONTH) (YEAR), revealed the temperature of refrigerators that contained medications (such as insulin, etc.) would be between 36 and 46 degrees Fahrenheit (F). Further review of the policy revealed refrigerator temperatures would be checked daily. However, a review of the facility's Refrigerator Temperature Log, dated (MONTH) (YEAR), revealed that on 03/15/18 through 03/18/18 (four days) and 03/24/18 through 03/29/18 (five days) there was no documented evidence that staff monitored the temperature of the Unit A medication refrigerator. On 03/29/18 at 4:04 PM, an observation of the Unit A medication room revealed there was an excessive buildup of ice in the freezer and condensation was observed on medications stored in the lower portion of the refrigerator. Further observation revealed there was not a thermometer in the refrigerator. However, at approximately 4:14 PM, ten minutes later, the facility obtained a thermometer and the temperature of the refrigerator was 52 degrees F. The following medications were being stored in the refrigerator: - one (1) box of [MEDICATION NAME] Purified Protein Derivative (PPD) (an injectable medication to aid in the [DIAGNOSES REDACTED]. A review of the directions from the box revealed the medication should be stored between 36 and 46 degrees F. - [MEDICATION NAME] suppository (a laxative used to treat constipation). Observation of the medication box revealed no temperature guidance for storage. - Toujeo (insulin used to treat diabetes). Observation of the medication box revealed no temperature guidance for storage. - Humalog (insulin used to treat diabetes). Observation of the medication box revealed no temperature guidance for storage. - [MEDICATION NAME] R (insulin used to treat diabetes). Observation of the medication box revealed no temperature guidance for storage. Interview with Licensed Practical Nurse (LPN) #1 on 03/29/18 at 4:05 PM revealed third shift nursing staff was responsible for monitoring and documenting refrigerator temperatures daily. Further interview revealed the LPN was last in the refrigerator on 03/29/18, at 12:00 PM, approximately four hours before, and did not identify any concerns with the temperature, condensation, or ice buildup in the refrigerator. Interview with the Unit Coordinator on 03/29/18 at 4:15 PM revealed the temperature of the refrigerator should have been between 36 and 46 degrees F. Further interview revealed staff should monitor the temperature when they take medications out of the refrigerator. Interview with the Director of Nursing (DON) on 03/29/18 at 5:32 PM, revealed third shift staff was responsible for monitoring and documenting refrigerator temperatures; however, after reviewing the temperature logs, the DON stated, obviously someone did not monitor.

Based on interview, record review, and review of the facility's policy/procedure, it was determined the facility failed to ensure an allegation of abuse was reported to the Administrator immediately in order to protect residents from further potential abuse for one (1) of three (3) sampled residents, Resident #2. The findings include: Review of the facility's Abuse and Neglect Policy/Procedure, revised (MONTH) (YEAR), revealed alleged or suspected violations involving any mistreatment, neglect, exploitation, or abuse would be reported immediately to the Administrator and to other officials in accordance with state law. According to the policy, if there were an allegation of employee to resident abuse, the employee would be removed from providing direct care to all residents. Review of a facility investigation involving Resident #2, dated 02/09/18, revealed Resident #2 reported to Certified Nurse Assistant (CNA) #1 that a big black man was rough with him/her and stuck his fingers in the resident's buttock. According to CNA #1's written statement, dated 02/09/18, the information was reported to a nurse on 02/08/18; however, the investigation did not begin until 02/09/18. Review of a facility investigation involving Resident #1, dated 02/09/18, revealed Resident #1 reported to CNA #1 a big black man tried to rape him/her last night. Interview with CNA #1, on 02/28/18 at 1:35 PM, revealed she received an allegation from Resident #2 that a big black man put his fingers in the resident's buttock. She stated she reported the allegation to Licensed Practical Nurse (LPN) #1 on 02/08/18; however, administration never questioned her that day. She stated Resident #1 made an allegation the following day (02/09/18) by stating a black man tried to rape him/her last night (02/08/18), but he/she got away from him. She revealed the allegation was reported immediately to the Unit Manager, the Director of Nursing (DON), and the Administrator, and the allegation involving Resident #2 was discussed at that time. Interview with LPN #1, on 02/28/18 at 1:15 PM, revealed CNA #1 reported to her on 02/08/18, that Resident #2 stated a big black man was wiping the resident and it felt like a finger was in his/her buttock. She stated she did not perceive it as an allegation of abuse; therefore, it slipped her mind and she did not report it to administration. Interview with the DON, on 03/01/18 at 9:36 AM, revealed both allegations, for Resident #2 and #1, were reported on the same day and the facility did not identify concerns related to the delayed reporting. Interview with the Administrator, on 03/01/18 at 11:05 AM, revealed the facility identified some miscommunication related to the allegation involving Resident #2, as it was hard to validate what exactly was reported to LPN #1 on 02/08/18.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to develop and implement a comprehensive and person-centered care plan that reflected physicians' orders for daily weights for two (2) of five (5) sampled residents, Resident #1 and #5. Resident #1 had a physician order [REDACTED].#5 had a daily weight order, as of 11/29/17, but the resident's care plan did not reflect the daily weight intervention until 12/12/17. The findings include: Review of the facility's policy, Weight and Height, revised October 2017, revealed the purpose of measuring weight and height was to ensure the resident maintained acceptable parameters of nutritional status regarding weight, to accurately measure weight and height, to monitor a resident's weight loss or gain, and to report changes in a resident's clinical condition (significant weight changes) immediately to the physician, the family, or to the resident. Review of the closed clinical record for Resident #1 revealed the facility admitted the resident on 09/11/17, with [DIAGNOSES REDACTED]. Review of Resident #1's Physician order [REDACTED]. be measured daily with notification to the Cardiologist of a weight gain of two (2) pounds in twenty-four (24) hours or three (3) to five (5) pounds in forty-eight (48) hours. Weights were to be obtained on day shift according to the order. The start date for the daily weights was 09/14/17. The resident was also prescribed a diuretic to be administered daily. Review of Resident #1's weight record revealed he/she was weighed on 09/12/17 at 1:22 AM, with a recorded weight of 272 pounds. The next weight obtained was documented as 281.8 pounds on 09/14/17 at 10:02 AM. Additional weights were obtained on 09/15/17 as 280.6 pounds, on 09/16/17 as 280.2 pounds, on 09/17/17 as 279.8 pounds, and on 09/18/17 as 277.4 pounds. Interview with Family Member #1, via telephone, on 12/13/17 at 11:45 AM, revealed she visited Resident #1 often and stated per her observation, Resident # 1's legs were very swollen looked like they were ready to pop. Family Member #1 further stated staff called the Cardiologist and the Cardiologist gave an order for [REDACTED]. Review of the Plan of Care for Resident #1, dated 09/13/17, revealed the resident had a [DIAGNOSES REDACTED]. (5) pounds in forty-eight (48) hours. Review of the clinical record for Resident #5, revealed the facility admitted the resident on 11/23/17, with [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED]. The resident was also prescribed a diuretic for daily administration related to fluid retention related to Chronic Diastolic Heart Failure. Review of Resident #5's daily weight record revealed the facility recorded weights daily from 11/30/17 to 12/04/17. However, there were no weights documented from 12/05/17 to 12/09/17. The resident's weight was measured on 12/10/17 and 12/12/17. The physician order [REDACTED]. Review of Resident #5's Plan of Care, dated 12/12/17, revealed the resident had Congestion Heart Failure and interventions included daily weight monitoring and reporting of results to the nurse. The intervention had an initiation date of 12/12/17; however, the order for daily weights had a start date of 11/30/17. Review of Resident #5's Visual/Bedside Kardex Report, not dated, utilized by Certified Nursing Assistants (CNA) for care of Resident #5, did not list daily weights as a task for completion. Interview, on 12/12/17 at 11:25 AM, with CNA #1, revealed she received report from the nursing staff at the beginning of her shift, and would learn the care needs and tasks to be completed for her assigned residents. If a resident was to be weighed, she would obtain the weight and report it to the assigned nurse. She stated she did not personally record the weight in any computerized system or on paper. CNA #1 stated she usually saw the nurse write the weight down on a piece of paper once she told them what the resident weighed for that day. She stated if for some reason she were unable to weigh a resident, then she would tell the nurse so CNAs working the next shift would obtain the resident's weight. According to CNA #1, newly admitted residents were typically on daily weights for the first three (3) days after admission, or a weight might be measured daily depending on the resident's diagnosis. Interview, on 12/13/17 at 10:35 AM, with CNA #2, revealed if a resident needed to be weighed daily, the assigned nurse for the shift would give that instruction. He stated the nurse usually gave that information to the CNAs in the morning, early in the shift. CNA #2 stated he was not working in the facility in September 2017 when Resident #1 was at the facility, but he had weighed Resident #5 once about a week ago. He stated he documented residents' weight in the computer and would indicate whether the weight was obtained with the resident standing or seated in a wheelchair. Interview, on 12/13/17 at 1:40 PM, with Registered Nurse (RN) #1, revealed if a resident had a specific physician order [REDACTED]. She stated the electronic record system required the caregiver to enter the time the weight was measured and the method used (standing, wheelchair, etc.). She revealed the system would not save the weight unless all of that data was entered. RN #1 stated if a resident had an order for [REDACTED]. Interview, on 12/14/17 at 9:28 AM, with the Director of Nursing (DON), revealed the Cardiologist's specific directions for notification of weight gain for Resident #1, dated 09/13/17, should have been incorporated into the resident's written plan of care. She stated that nursing care intervention was particularly important because of the resident's post-operative heart surgery status, and close assessment of the resident was of particular importance in relation to his/her overall cardiovascular status. The DON stated Resident #5's daily weight intervention was not added to the written plan of care until 12/12/17, according to her review of the care plan, but the order was dated 11/30/17, and the resident was not weighed for some days during that time period according to the weight monitoring record. The DON stated each resident's care plan should be individualized to meet the specific needs of the resident. According to the DON, nurses were supposed to look at the care plans, as they were tools for communicating a resident's care needs across all shifts. The DON stated she was not sure if daily weights would be assigned to a CNA or should be measured by the nurse. Ultimately, it was the nurses' responsibility to ensure weights were collected and recorded as ordered by the physician. Interview, on 12/14/17 at 11:10 AM, with the Interim Administrator, revealed the DON was ultimately responsible for ensuring nursing staff followed the physician's orders [REDACTED].

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure residents received treatment and care that promoted the highest practicable level of functioning and well-being for three (3) of five (5) sampled residents, Residents #1, #2 and #5. Staff failed to administer medications per physician orders [REDACTED].#2. In addition, staff failed to follow physician orders [REDACTED].#1 and #5. The findings include: Review of the facility's policy, Physician/Practitioner Orders, revised November 2016, revealed the admitting practitioner's orders were intended to provide guidance on appropriate resident care until a comprehensive assessment was conducted and the interdisciplinary care plan developed. The policy further stated admission orders [REDACTED]. The orders must be noted by the licensed nurse who processed the order. Review of the facility's policy, Medication Administration, Including Scheduling and Medication Aides, revised October 2017, revealed the content of the document was to promote resident/family understanding of medication therapy, to administer medications correctly in a timely manner, and to schedule medications effectively. Medications were to be administered to the resident according to the six (6) rights. Review of the closed clinical record for Resident #1 revealed the facility admitted the resident on 09/11/17, with [DIAGNOSES REDACTED]. Interview with Family Member #1, via telephone, on 12/13/17 at 11:45 AM, revealed she visited Resident #1 one evening and Resident #1 had not been given a prescribed diuretic. Family Member #1 stated she pointed it out to the nurse and the nurse stated she did not usually work on the unit. Family Member #1 stated per her observation, Resident # 1's legs were very swollen and looked as if they were ready to pop. Family Member #1 further stated staff called the Cardiologist and the Cardiologist gave an order for [REDACTED].#1's swelling. Review of Resident #1's Physician Orders, dated 09/11/17, revealed [MEDICATION NAME] 20 milligram (mg) was to be administered twice daily for the resident's [DIAGNOSES REDACTED]. Review of the Medication Administration Record (MAR) for Resident #1, for September 2017, revealed [MEDICATION NAME] 20 mg was to be administered twice daily; however, on 09/12/17, only one (1) dose of [MEDICATION NAME] 20 mg was documented as administered. Further review of the physician's orders [REDACTED].#1's Cardiologist ordered the resident's weight be measured daily with notification to the Cardiologist of a weight gain of two (2) pounds in twenty-four (24) hours or three (3) to five (5) pounds in forty-eight (48) hours. Weights were to be obtained on day shift according to the order and the start date was 09/14/17. Review of Resident #1's weight record revealed he/she was weighed on 09/12/17 at 1:22 AM, with a recorded weight of 272 pounds. The next weight obtained was documented as 281.8 pounds on 09/14/17 at 10:02 AM. Additional weights were obtained on 09/15/17 as 280.6 pounds, on 09/16/17 as 280.2 pounds, on 09/17/17 as 279.8 pounds, and on 09/18/17 as 277.4 pounds. Review of the closed clinical record for Resident #2 revealed the facility admitted the resident on 11/26/17, with [DIAGNOSES REDACTED]. Review of a nurse's admission assessment note revealed it was documented on 11/26/17 and timed as entered at 9:38 PM. Further record review revealed the physician orders [REDACTED]. Review of Resident #2's MAR, for November 2017, revealed physician orders [REDACTED]. mg daily, [MEDICATION NAME] 20 mg daily, and Tamsulosin 0.4 mg daily. All the medications had a start date of 11/27/17; however, the medications were not administered to Resident #2 on 11/27/17 as staff documented the medications were not available or were held. Review of Resident #2's nurses' notes revealed no explanation for the medications not administered to the resident on 11/27/17. Interview, on 12/13/17 at 3:03 PM, with Family Member #2, revealed Resident #2 was admitted to the facility on [DATE], and on 11/27/17 at about 1:30 PM, the resident reported the nurse had not administered any of his/her medications. Family Member #2 stated she spoke with the Director of Nurses (DON) and the DON's explanation was that the facility was at the mercy of the pharmacy for receipt of the medications. Family Member #2 stated she inquired about the availability of any of Resident #2's medications in the facility's Emergency Drug Kit (EDK) Supply, as she had some history with long-term care facilities and was aware of the availability of an EDK in long-term care settings. Review of the list of medications in the EDK, dated as expiring 01/2018, revealed the [MEDICATION NAME] ordered for Resident #2 was available in the EDK. Interview, on 12/13/17 at 4:52 PM, with the Director of Pharmacy, revealed the Pharmacy received the physician orders [REDACTED]. She stated the medications would have been filled and delivered on the next routine delivery that day, between 1:55 PM to 4:55 PM. However, the Director of Pharmacy stated the nurse who transmitted the orders could have called the pharmacy and requested the medications be sent stat (immediately) to the facility and the medications would have arrived at the facility within four (4) hours of the request. She stated that would apply to all of the resident's medications. Interview, on 12/12/17 at 11:00 AM, with Licensed Practical Nurse (LPN) #1, revealed once a physician provided orders for a resident, the nurse should enter the orders into the computer and then fax the copy of the order(s) to the pharmacy. She also stated the facility had an EDK supply available, and sometimes medications could be obtained from the EDK and administered to the resident. She stated if the medication was not in the EDK, then the nurse could call the pharmacy and request a stat delivery of the medications, and the pharmacy would deliver the medicine(s) within four (4) hours of the stat request. LPN #1 further stated for newly admitted residents, the nurse should request a stat delivery of the medications ordered by the physician, but stated she personally would also check the EDK to see if any of the ordered medications were available for administration. LPN #1 stated a stat run of the medications should be delivered within four (4) hours of the resident's admission to the facility, if the orders were transmitted right away by the nurse. She stated nursing staff could notify the pharmacy of needed medications regardless of the time of day. Review of the clinical record for Resident #5, revealed the facility admitted the resident on 11/23/17, with [DIAGNOSES REDACTED]. Review of Physician order [REDACTED]. The resident was also prescribed a diuretic for daily administration for prevention of fluid retention related to Chronic Diastolic Heart Failure. Review of Resident #5's daily weight record revealed the facility recorded weights daily from 11/30/17 to 12/04/17. However, there were no weights documented from 12/05/17 to 12/09/17. The resident's weight was obtained on 12/10/17 and 12/12/17. The physician order [REDACTED]. Observation, on 12/12/17 at 9:40 AM, revealed Resident #5 seated in a chair in his/her room and the resident's legs were swollen and discolored with peeling skin. Interview, on 12/12/17 at 11:25 AM, with Certified Nursing Assistant (CNA) #1, revealed she received report from nursing staff at the beginning of her shift and would learn of the care needs and tasks to be completed for her assigned residents. If a resident were to be weighed, she would obtain the weight and report it to the assigned nurse. She stated she did not personally record the weight in any computerized system or on paper. CNA #1 stated she usually saw the nurse write the weight down on a piece of paper once she told them what the resident weighed for that day. She stated if for some reason she were unable to weigh a resident, then she would tell the nurse so CNAs working the next shift could obtain the resident's weight. CNA #1 stated newly admitted residents were typically on daily weights for the first three (3) days after admission, or the weight might be measured daily depending on the resident's diagnosis. Interview, on 12/13/17 at 10:35 AM, with CNA #2, revealed if a resident needed to be weighed daily, the assigned nurse for the shift would give that instruction in the morning, early into the shift. CNA #2 stated he was not working in the facility in September 2017 when Resident #1 was at the facility, but he had weighed Resident #5 once about a week ago. CNA #2 stated he documented the resident's weight in the computer, and would indicate whether the weight was obtained with the resident standing or seated in a wheelchair. Interview, on 12/14/17 at 9:55 AM, with the Director of Nurses (DON), revealed she could not locate a facility policy for an expected time frame for transmittal of physician's orders [REDACTED]. However, she further stated it was always important to have medications available for administration as soon as possible after the resident's admission so the facility could carry out the physician orders [REDACTED]. After reviewing the MAR of 09/12/17 for Resident #1, the DON stated the blank space on the MAR where the nurse should have documented the administration of a second dose of diuretic was left blank and that indicated the medication was not given. She stated the physician order [REDACTED]. In regard to Resident #2, the DON stated she thought it would be reasonable for the admitting nurse to have faxed the orders to the pharmacy within about one (1) hour after the resident's admission. She stated the nurse could have also called the pharmacy to have the medications sent stat, so the medications could have been delivered within four to five (4-5) hours after the call to the pharmacy had been placed. The DON stated the nurse should have acted more quickly. She stated when a nurse documented on the MAR that medication was held, the nurse should make a note to explain the reason for that entry. The DON stated if a nurse had noted the weight change for Resident #1, from 09/12/17 to 09/14/17, and had called the Cardiologist to inform him, there should have been documentation in the nursing progress notes. The DON stated the documentation of daily weights for Resident #5 did not reflect the resident was weighed between 12/05/17 through 12/09/17, and daily weights were ordered during that time period. Interview, on 12/14/17 at 11:10 AM, with the Interim Administrator, revealed the DON was ultimately responsible for ensuring nursing staff followed the physician's orders [REDACTED]. Interview, on 12/14/17 at 11:10 AM, with the Administrator, revealed she had not been informed there was a resident (Resident #1) and his/her family in the facility, during September 2017, that had concerns about delivery of care. In addition, the Administrator stated she did not learn of the concerns of Resident #2 and his/her family until later the next week after the resident was discharged home.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to provide adequate supervision for one (1) of three (3) sampled residents, Resident #1. The facility assessed Resident #1 wandered and failed to lock a conference room door, which allowed Resident #1 access to an exit door not equipped with the roam alert system, and the resident exited the facility without staff knowledge. The findings include: Review of the facility's Elopement Policy, revised April 2016, revealed the facility defined elopement as when a resident who needed supervision left the premises or a safe area without authorization or necessary supervision. The facility assessed and identified residents at risk for elopement, minimized risk for elopement through individualized interventions, and provided protection to residents at risk for elopement. The facility did not provide a policy on supervision. Review of a facility investigation, dated 08/15/17, revealed on 08/11/17, Resident #1 left the facility through the emergency door in the front conference room. The resident was seen by another resident's family member and brought back into the facility. Review of the facility's Security Monitoring Video, dated 08/11/17, revealed at 7:52 PM, Resident #1 walked to the front entrance hallway of the facility. From 7:52 PM to 8:00 PM, Resident #1 wandered around the front entrance lobby and hallway. At 8:00 PM, Resident #1 walked to the conference room door and stepped out of view of the camera. At 8:01:23 PM, Resident #1 stepped into view outside the facility at the front entrance doors. At 8:02:20 PM, a resident family member brought Resident #1 back into the facility. Review of Resident #1's clinical record revealed the facility admitted the resident on 06/13/16, with the [DIAGNOSES REDACTED]. Review of Resident #1's Social Services Assessment, dated 06/14/16, revealed staff identified the resident with wandering behavior. Review of Resident #1's admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of five (5) out of fifteen and determined the resident not interviewable. The facility documented the resident wandered. Review of Resident #1's Care Plan, dated 06/15/16, revealed the potential for elopement with interventions including placing a wander guard on the resident, the resident was added to the elopement binder, and staff was to offer to take the resident for a walk outdoors. The Care Plan was revised on 08/14/17, with interventions to call family when increased pacing was noted, provide diversionary activity, and fifteen (15) minute visual checks. Review of Resident #1's annual MDS, dated [DATE], revealed the facility assessed the resident exhibited wandering behaviors and assessed the resident with a BIMS score of four (4) out of fifteen (15) and determined the resident not interviewable. Review of Resident #1's Nursing Progress Notes, dated 08/05/17 at 4:20 PM, revealed Resident #1 stated to the nurse that he/she knew the signage read that the fire doors could be pushed for fifteen (15) seconds and then he/she could go out of the facility. Observation, on 09/06/17 at 8:21 AM, revealed the conference room, located in the front lobby, contained a door that exited the facility. Interview with Licensed Practical Nurse (LPN) #2, on 09/06/17 at 2:45 PM, revealed she cared for Resident #1 on 08/11/17. She stated the facility placed Resident #1 on close supervision or frequent observation checks for safety when he/she exhibited increased anxiety or wandering; however, the resident had not exhibited increased anxiety or wandering on 08/11/17. LPN #2 stated Resident #1 had been in the dining hall seated at the table eating dinner with her last visual observation, which was between 7:00 PM to 7:30 PM, and staff did not know Resident #1 had left the unit or the facility. Interview with LPN #2, the night shift Supervisor, on 09/06/17 at 2:17 PM, revealed the last time she visually saw Resident #1, he/she was sitting on the sofa watching TV in the activity area, which was approximately 7:30 PM. LPN #2 stated she did not see the resident leave the unit and she did not hear the exit door in the conference room alarm. Interview with the Maintenance Staff, on 09/07/17 at 10:28 AM, revealed the exit door in the conference room was not equipped with a roam alert alarm. He stated the signage on the exit door in the conference room stated if pushed for fifteen (15) seconds, the door would open. He further stated the alarm to the door had a low volume and staff would not have heard the alarm at the nurses' station. According to the Maintenance Staff, after the exit door closed, the alarm stopped because it did not need a code to reset the alarm. He stated the door to the conference room should remain locked as the only way to access the outer door was through the unlocked conference room. Interview with the Administrator, on 09/08/17 at 2:49 PM, revealed the conference room door was not locked on 08/11/17, and when she asked staff why the conference door was not locked; she was told the conference room door was never locked. She revealed the conference room door should have been locked.

Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to have an effective system in place to revise the plan of care for one (1) of seven (7) sampled residents, Resident #1. Resident #1 demonstrated increased confusion and exit seeking behaviors after admission and the facility failed to revise the plan of care to address the resident's change in behaviors. (Refer to F323) The Director of Social Services (DSS) assessed Resident #1 was not at risk for elopement on 02/17/17. Staff interviews revealed around the same date, staff observed Resident #1 had increased confusion and wandering and reported to the DSS and the Administrator. Record review revealed the facility did not review or revise the resident's care plan to address the resident's needs as related to increased confusion and wandering that posed an elopement risk. On 02/21/17, Resident #1 eloped from the facility without staff knowledge. Nursing staff found the resident outside the facility at 4:44 PM, unsupervised, holding on to his/her walker in the parking lot near the facility. The facility's failure to have an effective system in place to ensure the revision of the Plan of Care has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 03/09/17, and determined to exist on 02/21/17. The facility was notified of the Immediate Jeopardy on 03/09/17. The facility provided an acceptable Allegation of Compliance (AOC) on 03/15/17, alleging the removal of Immediate Jeopardy on 03/11/17. The State Survey Agency verified Immediate Jeopardy was removed on 03/11/17 as alleged, prior to exit on 03/17/17. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction and monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy, Care Plan, revised November 2016, revealed the purpose of the policy was to develop a comprehensive care plan using an interdisciplinary team approach. Residents were to receive and be provided the necessary care and services to attain or maintain the highest practicable well-being in accordance with the comprehensive assessment. Each care plan was to be person centered and directed towards achieving and maintaining the resident's optimal medical, nursing, psychosocial, emotional, spiritual, physical, functional, and educational needs. Through use of departmental assessments, the Resident Assessment Instrument, and review of the physician orders, any problems, needs, and concerns were identified and addressed. Review of the facility's policy, Elopement, revised September 2013, revealed the facility was to assess and identify residents at risk for elopement and minimize the risk for elopement through individualized interventions. Residents assessed as not a risk for elopement during the pre-admission process, but begin to exhibit wandering behaviors or attempt to elope, would be assessed and monitored by staff. The physician and legal representative would be notified, and the resident's care plan would be updated. Identification of environmental hazards, evaluating/analyzing hazards and risks, implementing interventions including adequate supervision, monitoring/modifying interventions as needed, were practices the facility staff was expected to follow. Observation of the facility's video of Resident #1, on 03/03/17 at 3:55 PM, in presence of the Administrator, revealed the resident exited the Post-Acute unit through the double doors on 02/21/17 at 4:44 PM. The resident used a rolling walker, pushed the door open with his/her left hand, and exited into a small foyer that led to another set of double doors, and then exited the facility. Licensed Practical Nurse (LPN) #5 exited the facility at 4:47 PM and escorted the resident back into the facility at 4:48 PM. The resident was dressed in a long sleeve shirt, long pants, and shoes. Review of the facility's investigation for Resident #1's elopement, revealed on 02/21/17, Resident #1 was sitting in the rehab dining room and the resident's nurse went to assist another resident. When the nurse looked up, she saw the resident in front of the entrance by the rehab door. The resident did not sustain any injuries and the nurse walked the resident back into the building. The facility moved Resident #1 to the long-term care unit to promote safety and supervision for the remainder of his/her stay. Review of the facility's closed clinical record for Resident #1, revealed the facility admitted the resident on 02/15/17, with [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. The initial nursing assessment for Resident #1 was requested; however, interview with the Administrator on 03/03/17 at 11:00 AM, revealed an initial nursing assessment had not been completed. Review of Resident #1's Progress Notes, dated 02/16/17, revealed the DSS documented the resident was admitted from the acute hospital and was alert and oriented times three (3) (person, place, and time). Review of Resident #1's Social Services Assessment, dated 02/17/17, revealed Resident #1's mental status was assessed by the DSS as alert and oriented to person only and the resident's short and long term memory was impaired. Documentation revealed the resident had no wandering behaviors or elopement attempts. Review of Resident #1's Neurological Check, dated 02/18/17, revealed the nurse assessed the resident was alert and oriented to person only and had periods of confusion. Continued review of Resident #1's clinical record revealed no documentation of exit seeking behaviors from the time of admission on 02/15/17, to the elopement on 02/21/17. Review of the facility's care plan for Resident #1 revealed a focus area for activities, date initiated 02/20/17. There were no other focus areas on the care plan prior to the 02/21/17 elopement. However, staff interviews revealed the resident exhibited increased confusion and exit seeking behaviors. Interview with Certified Nursing Assistant (CNA) #7, on 03/08/17 at 3:30 PM, via telephone, revealed she knew Resident #1 had increased confusion in the evenings. Towards the evening, the resident became more active, talked about his/her spouse, and wandered into other resident's rooms. She stated she did not tell the nurses about the resident's behaviors because they were aware of Resident #1's increased confusion and wandering, as it was common knowledge. Interview with Registered Nurse (RN) #1, on 03/07/17 at 10:50 AM, via telephone revealed Resident #1 had a prior attempt to exit the facility around 02/17/17. He stated Resident #1 was confused and attempted to open the door on the West end of the Post-Acute hall. The door had an egress and the alarm sounded when the resident attempted to open the door. He stated he informed the DSS and she related the information on the exit seeking behavior to the Administrator. RN #1 stated the resident was active and he was sure other nursing staff knew Resident #1 had a tendency to wander. He further stated he was not sure if he was supposed to update the care plan. Interview with the DSS, on 03/08/17 at 1:30 PM, revealed RN #1 informed her of Resident #1's attempt to open the egress door prior to the 02/21/17 elopement. She stated she did not consider pushing on the door as an exit seeking behavior, the resident was still adjusting to the facility, and she did not reassess for elopement. The DSS stated she did not document the exit seeking behavior RN #1 reported to her prior to the elopement nor did she complete a risk management note that would have been reviewed the next morning by the Interdisciplinary Team (IDT). Further interview, on 03/16/17 at 2:05 PM, revealed she was responsible for updating care plans with observations or reports of a resident's increased confusion and/or exit seeking behaviors. She stated progress notes and care plan documentation communicated resident changes to all clinical staff and the Administrator. Interview with the Director of Nursing Services (DNS), on 03/06/17 at 2:40 PM, revealed Resident #1 did not have a care plan for behaviors or an initial nursing assessment. Further interview with the DNS, on 03/08/17 at 12:08 PM, revealed she expected nurses to document in the progress notes when they observed residents having increased confusion or wandering behaviors, but there was no documentation in the clinical record about Resident #1 pushing on doors and wandering into other resident's rooms. She stated the Minimum Data Set (MDS) Nurse was responsible for updating care plans; however, since there was no documentation in the resident's clinical record about the increased confusion and exit seeking behaviors, the MDS Nurse had no way of knowing the care plan needed updating. She stated it was alarming that the nurses did not document exit-seeking behaviors and did not assess Resident #1. Social workers were also responsible for assessing and documenting increased confusion and exit seeking behaviors. Interview with the Administrator, on 03/03/17 at 10:35 AM, revealed Resident #1 had no exit seeking behaviors when admitted to the facility. She stated Social Services and nurses were responsible to assess residents for elopement risks. Continued interview, on 03/07/17 at 4:10 PM, revealed when a resident demonstrated increased confusion, staff should document in the progress notes and place appropriate interventions on the care plan. Further interview, on 03/08/17 at 3:42 PM, revealed after she had found out about Resident #1's attempt to exit the facility by pushing on an egress door, they moved the resident to a different room. The Administrator stated she made the decision jointly with the DSS; however, she did not communicate the resident's exit seeking behavior to the DNS and took no other action after Resident #1's exit seeking behavior was reported to her. The facility implemented the following actions to remove the Immediate Jeopardy: 1. The Medical Director was notified of the Immediate Jeopardy on 03/10/17. 2. The facility transferred Resident #1 after the elopement from the Post-Acute unit to the Long Term Care C-unit of the facility and fitted Resident #1 with a Wander Guard bracelet. Notifications were made according to policy. The facility discharged Resident #1 on 03/01/17. 3. The facility reassessed Resident #2, #3, and #4 for their elopement risk and verified that Wander Guard bracelets were in place and functioning. The facility reviewed Resident #2, #3, and 4's care plans, updated the Wander Guard on the Kardex for staff to check and verify function every shift. The Director of Nursing Services (DNS) completed the review and revision of the care plan and Kardex's on 03/09/17. 4. The facility's DNS, Case Manager (CM) and Director of Social Services (DSS), screened eighty-three (83) current residents at the facility for elopement risk. Ten (10) of the eighty-three (83) residents were identified to have a cognitive deficit, as determined by the facility's assessment of a Brief Interview for Mental Status (BIMS) score of twelve (12) or below, and also ambulated independently or by wheel chair. The ten (10) residents were reassessed for elopement risk by the DNS and the care plans for these residents were reviewed and updated by the DNS on 03/10/17. 5. The facility had Wander Guard technicians present installing a new Wander Guard system that was expanded to cover all exit doors when the installation was completed. The installation of the new Wander Guard system began on 02/26/17. The Post-Acute unit was not utilized for any exit seeking residents until the exit door was Wander Guard equipped. The Administrator oversaw the Wander Guard system installation. 6. The facility will screen all new residents by the nurse for elopement risk at the time of admission and care plan interventions as indicated. Any current resident developing exit seeking behaviors was to be assessed immediately. Their care plan was updated with interventions as indicated by Social Services. The care team of the facility includes the Administrator, DSS, the DNS, the Minimum Data Set (MDS) Coordinator, and the CM. The care team reviewed new behavior alerts at the daily clinical meeting and updated resident's care plan as indicated. Clinical meetings were held on 03/10/17 and were continued daily for five (5) business days. 7. Social Services and Licensed Nurses will be responsible to document behaviors. 8. The facility re-educated all facility and agency staff present in the building regarding Elopement Policy and Procedures on 03/08/17. The Staff Development Coordinator (SDC) and the DNS conducted the training. The education included a post-test derived from the Good Samaritan policy and procedures. Fifty-seven (57) staff members were present and educated. Twenty-three (23) of the fifty-seven (57) were agency staff members. The nursing department was to be educated on the completion of the assessment and care plan process by the SDC and the DNS. Twelve (12) staff members that worked as needed schedules remained untrained on 03/08/17. The training took place prior to the start of staff members shift and prior to providing direct resident care. All new facility employees and agency staff received training on Policy and Procedures prior to providing direct care. Completion for the planned training occurred on 03/11/17. 9. The DNS or DSS of the facility audited residents with Wander Guards and verified proper placement and function of the device. Audits were started on 03/10/17 and completed daily for seven (7) days, then weekly for three (3) weeks, proceeding with a monthly audit for two (2) months and then quarterly for three (3) quarters. 10. The DNS or DSS of the facility rounded the facility, interviewed staff, and reviewed records for elopement risk documentation and for care planning appropriate interventions. The audits started 03/10/17, and were completed daily for seven (7) days, then weekly for three (3) weeks, proceeding with a monthly audit for two (2) month and then quarterly for three (3) quarters. 11. The Administrator conducted a clinical Ad Hoc Committee meeting with the entire care team on 03/10/17. The meetings were held on each business day for four (4) weeks to review the audits, findings, and actions taken by the clinical team. The Ad Hoc Committee meetings minutes were submitted to the monthly Safety Committee for review and for further recommendations. The facility held the safety meeting on 03/13/17, and will occur monthly. 12. The facility implemented a notification announcement to alert staff of a potential elopement. Furthermore, the facility began monthly elopement drills starting on 03/13/17. Elopement drill reports were submitted to the monthly Safety Committee meeting for review and recommendation. 13. The facility scheduled a QAPI Committee meeting for 03/31/17, and all audit reports completed during the AOC will be submitted and reviewed for further recommendation. The SSA validated the facility implemented the following actions: 1. Interview with the Medical Director, on 03/16/17 at 9:40 AM via telephone, revealed the facility notified him of the Immediate Jeopardy on 03/10/17. 2. Review of Resident #1's closed record revealed the facility transferred him/her from the Post-Acute unit to the Long Term Care C-unit of the facility on 02/21/17. Resident #1 was fitted with a Wander Guard bracelet. Social Worker #2 documented the notifications in the resident's progress note. On 03/01/17, the facility discharged Resident #1. Interview with the Director Social Services (DSS), on 03/02/17 at 11:05 AM, revealed Resident #1 was transferred to the Long Term Care C-unit due to exit seeking behavior. The facility placed a Wander Guard and called his/her spouse to come and visit. 3. Observations of Resident #2, #3, and #4, on 03/16/17, revealed the residents had Wander Guard bracelets in place. Review of Resident #2, #3, and #4's clinical records revealed the facility reassessed them for elopement risk and reviewed their care plans. The Kardex for direct care staff was updated and stated Personal Alarm: Wander Guard used to alert staff to resident's movement and to assist staff in monitoring movement. The Director of Nursing Services (DNS) had completed the updates on 03/09/17. Interview with the DNS, on 03/16/17 on 3:05 PM, revealed Resident #2, #3, and #4 were reassessed for elopement and their care plans were reviewed to ensure appropriate interventions for elopement were in place. 4. Record review revealed eighty-three (83) residents were screened for elopement and the care plans for ten (10) residents with a Brief Interview for Mental Status (BIMS) score of twelve (12) and below were reviewed and updated by the DNS on 03/10/17. Interview with the DSS, on 03/16/17 at 2:05 PM, and the DNS on 03/16/17 at 3:15 PM, revealed they screened eighty-three (83) residents for elopement risk. They reassessed ten (10) residents with cognitive deficits that ambulated independently for elopement, and reviewed and updated their care plans as needed. 5. Observation of the new Wander Guard sensor on the Post-Acute unit, on 03/17/17 at 3:45 PM, demonstrated by the Maintenance Supervisor (MS), revealed the door alerted when a functioning Wander Guard was nearby. The alarm sounded throughout the Post-Acute unit. Interview with the MS, on 03/17/17 at 2:30 PM, revealed when the Wander Guard alarm on the Post-Acute unit was activated, the alarm sounded at the nurses' station. Staff could not reset the alarm at the nurses' station; staff had to go to the door to reset the alarm. Interview with Register Nurse (RN) #4, on the Post-Acute unit, on 03/16/17 at 8:35 AM, revealed there were no exit-seeking residents on the unit. She stated the facility had not admitted any new residents to the Post-Acute unit. 6. Review of the Ad Hoc Committee Meeting Minutes revealed meetings were held on 03/10/17 through 03/15/17. The Committee reviewed action the facility had taken and audit results. Interview with the DSS, on 3/16/17 at 2:50 PM, the DNS at 3:35 PM, and with the Administrator, on 03/17/17 at 2:50 PM, revealed the nurses screened all new residents on admission for elopement risk and developed a care plan as indicated. Current residents that developed exit-seeking behaviors were assessed and their care plan updated with interventions related to the residents' needs. Interview with the Administrator, on 03/17/17 at 2:52 PM, revealed it was a team approach to come up with appropriate interventions. The Administrator stated the Care Team, which included the DSS, Minimum Data Set (MDS) Coordinator, the Case Manager (CM), the DNS, and herself, were responsible to review new behavior alerts during the daily clinical meetings and update the care plan as indicated. Continued interview at 3:15 PM, revealed the facility held clinical meetings on 03/10/17, and continued on 03/13/17, 03/14/17, 03/15/17, prior to the Ad Hoc meeting. Interview with Licensed Practical Nurse (LPN) #9, on 03/17/17 at 11:07 AM, revealed residents would be assessed for elopement upon admission. Their Care plan would be initiated and behaviors documented in the progress notes. 7. Review of Resident #5, #6, and #7's clinical records revealed staff documented resident behaviors, and elopement and behaviors were care planned. Interview with the DNS, on 03/17/17 at 1:10 PM, revealed the CM and Staff Development Coordinator (SDC) would monitor nursing documentation daily in the morning meetings. They would review Progress Notes, Physician Orders, and Change in Condition to ensure documentation was completed. The DNS stated she made rounds with the Administrator to ensure staff breaks were covered by other staff for adequate supervision of the residents. Interview with the Administrator, on 03/17/17 at 2:52 PM, revealed she expected nurses to document in the progress notes and update mood and behavior changes of residents. She stated the nurses were able to utilize an Alert note to communicate observed behaviors to the CM, the DSS, the DNS, and herself. Interview with LPN #9, on 03/17/17 at 11:07 AM, revealed nurses were responsible for documenting resident behaviors in the progress notes. Interview with the DSS, on 03/16/17 at 2:05 PM, revealed she monitored the clinical records to ensure the nurses were documenting behaviors in the progress notes. 8. Review of the Elopement Lesson Plan and staff sign in sheets revealed the facility educated staff on the Elopement Policy and Procedure. Fifty-seven (57) staff was educated on 03/08/17, twelve (12) staff on 03/11/17, and two (2) staff on 03/12/17. The education also included staff passing a test with an eighty percent (80%) pass rate. Interview with the SDC, on 03/16/17 at 11:45 AM, revealed staff was educated prior to providing direct resident care. The DNS and the CM had educated third (3rd) shift staff prior to beginning their shift. He stated staff that could not be reached by phone was informed via certified mail about the required re-education. Review of the certified mail receipts revealed the facility sent eight (8) staff certified mail regarding required education. Interview with Certified Nursing Assistant (CNA) #4, #9, and #11, LPN #8, and #9, Cook #2, and the Activities Assistant, on 03/16/17 at 10:15 AM, revealed the facility trained them on the Elopement Policy and Procedure. Interview with Administrator, on 03/17/17 at 3:00 PM, revealed the facility trained new staff on elopement and the SDC was primarily responsible for the training. 9. Review of the Wander Guard audits, conducted 03/10/17 through 03/15/17, revealed the DNS and the DSS audited ten (10) identified residents for the function and placement of their Wander Guard devices and for care plans with appropriate interventions. Audits continued at the alleged frequency. Interview with the DSS, on 03/16/17 at 2:05 PM and the DNS, on 03/16/17 at 3:15 PM, revealed they rounded the facility and checked residents' Wander Guards, interviewed staff, and reviewed clinical records for documentation and for appropriate care planned interventions daily. All units and the reception area were checked for the elopement book and confirmation that it was current. 10. Observation of the elopement books on the units and the reception area revealed they were up to date with the residents at risk for elopement. Review of the Wander Guard audits, conducted 03/10/17 through 03/15/17, revealed the DNS and the DSS audited ten (10) identified residents for documentation and appropriate care plan interventions. Interview with the DSS, on 03/16/17 at 2:05 PM and the DNS, on 03/16/17 at 3:15 PM, revealed they rounded the facility and checked residents' Wander Guards, interviewed staff, and reviewed clinical records for documentation and for appropriate care planned interventions. They checked the elopement book and confirmed it was current. Interview with the CM, on 03/16/17, at 12:00 PM, revealed follow-up education was done with the nurses during rounds regarding documentation. 11. Review of the Ad Hoc Committee Meeting Minutes revealed meetings were held on 03/10/17 through 03/15/17. The Committee reviewed action the facility had taken and audit results. Interview with the Administrator, on 03/17/17 at 2:52 PM, revealed the facility held AD Hoc Committee meetings on 03/10/17, 03/13/17, 03/14/17, and 03/15/17. The Administrator stated clinical meetings were held prior to every Ad Hoc meeting and safety issues were discussed. 12. Review of the Elopement Drill Search Report revealed the facility conducted an elopement drill on 03/13/17 at 2:35 PM. There were fifteen (15) employees that participated in the drill as evidence by their signatures on the form. Interview with the SDC, on 03/16/17 at 11:45 AM, revealed the facility conducted an elopement drill on 03/13/17. He stated a resident with a Wander Guard bracelet was taken to an area of the facility to simulate an elopement. Review of the facility's Elopement Plan, not dated, revealed the facility implemented a plan to notify staff of a missing resident by overhead page. Interview with RN #4, on 03/16/17 at 8:35 AM, CNA #9, LPN # 8 and #10 at 10:15 AM, the Activities Assistant, on 03/17/17 at 10:45 AM, CNA #11 at 10:50 AM, and with LPN #9 at 11:07, revealed they were trained and understood the notification announcement. CNA #9 and LPN #10 participated in the drill held on 03/13/17. 13. Review of a copy of the agenda for the QAPI meeting revealed a meeting was scheduled for 03/31/17. The agenda included discussion of elopement scenarios, a recap of the survey, and other quality measure concerns that trended negatively. Interview with the Administrator, on 03/17/17 at 3:20 PM, revealed the QAPI meeting was scheduled for 03/31/17.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective system in place to ensure one (1) of seven (7) sampled residents, Resident #1, received adequate supervision to prevent the resident's elopement from the facility. On 02/21/17, Resident #1 eloped from the facility without staff knowledge. Nursing staff found the resident outside the facility at 4:44 PM, unsupervised, holding on to his/her walker in the parking lot near the facility. Interviews revealed Licensed Practical Nurse (LPN) #5 was working alone on the unit and could not locate Resident #1 after assisting another resident with toileting. LPN #5 initiated a search and through a window, saw the resident in the facility's parking lot. LPN #5 assisted the resident back into the facility with no injury. Staff had observed increased confusion and exit seeking behaviors days prior to the elopement and moved the resident's room closer to the nurse's station; however, no other interventions were developed or implemented to increase supervision. Maintenance staff measured the resident ambulated ninety (90) feet from the Post-Acute unit exit to the parking lot. The facility's failure to have an effective system in place to ensure staff provided adequate supervision of residents has caused, or is likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy was identified on 03/09/17, and determined to exist on 02/21/17. The facility was notified of the Immediate Jeopardy on 03/09/17. The facility provided an acceptable Allegation of Compliance (AOC) on 03/15/17, alleging the removal of Immediate Jeopardy on 03/11/17. The State Survey Agency (SSA) verified Immediate Jeopardy was removed on 03/11/17 as alleged, prior to exit on 03/17/17. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction and monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy, Elopement, revised September 2013, revealed elopement was when a resident who needed supervision left the premises or a safe area without authorization and/or necessary supervision to do so. The facility was to assess and identify residents at risk for elopement and minimize the risk for elopement through individualized interventions. Residents assessed as not a risk for elopement during the pre-admission process, but began to exhibit wandering behaviors or attempt to elope, would be assessed and monitored. The facility was responsible to maintain a system that clearly defined the procedures for monitoring and managing residents at risk for elopement. Identification of environmental hazards, evaluating/analyzing hazards and risks, implementing interventions including adequate supervision, monitoring/modifying interventions as needed, were practices the facility staff was expected to follow. Review of the facility's closed clinical record for Resident #1, revealed the facility admitted the resident on 02/15/17, with [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. Review of the initial nursing assessment for Resident #1 was requested; however, interview with the Administrator on 03/03/17 at 11:00 AM, revealed an initial nursing assessment had not been completed. Review of Resident #1's Daily Skilled Note, dated 02/16/17, revealed the nurse assessed the resident as alert with impaired decision making. Review of Resident #1's Progress Notes, dated 02/16/17, revealed the Director of Social Services (DSS) documented the resident was admitted from the acute hospital and was alert and oriented times three (3) (person, place, and time). Review of Resident #1's Social Services Assessment, dated 02/17/17, revealed Resident #1's mental status was assessed by the DSS as alert and oriented to person only and the resident's short and long term memory was impaired. Documentation revealed no wandering behaviors or elopement attempts. Review of Resident #1's Neurological Check, dated 02/18/17, revealed the nurse assessed the resident was alert and oriented to person only and had periods of confusion. Review of the facility's care plan for Resident #1 revealed a focus area for activities, date initiated 02/20/17. There were no other focus areas care planned to address the resident's short and long term memory impairment and periods of confusion. Observation of the facility's video of Resident #1, on 03/03/17 at 3:55 PM, in presence of the Administrator, revealed the resident exited the Post-Acute unit through the double doors on 02/21/17 at 4:44 PM. The resident used a rolling walker, pushed the door open with his/her left hand, and exited into a small foyer that led to another set of double doors, and then exited the facility. LPN #5 exited the facility at 4:47 PM and walked with the resident back into the facility at 4:48 PM. The resident was dressed in a long sleeve shirt, long pants, and shoes. Review of the facility's investigation for Resident #1's elopement revealed on 02/21/17, Resident #1 was sitting in the rehab dining room and the resident's nurse went to assist another resident. When the nurse looked up, she saw the resident in front of the entrance by the rehab door. The resident did not sustain any injuries and the nurse walked the resident back into the building. The facility moved Resident #1 to the long-term care unit to promote safety and supervision for the remainder of his/her stay. Review of Resident #1's progress note, dated 02/21/17 at 5:04 PM, revealed LPN #5 was in another room with a resident helping them to the restroom. When she came out, she walked into Resident #1's room and he/she was gone. She immediately went outside the front door and Resident #5 was around the corner of the building in the parking lot. When she went out to get the resident, he/she stated he/she was going home. The resident stated he/she was waiting on a ride. LPN #5 walked the resident back into the facility and the resident stated he/she wanted to go home to Florida. Interview with LPN #5, on 03/02/17 at 12:25 PM, revealed she was assigned to care for Resident #1 on 02/21/17, on the Post-acute unit and was by herself part of the shift. She stated Resident #1 had been wandering between his/her room and the dining area. LPN #5 stated that after she assisted another resident with toileting needs, she could not locate Resident #1. She initiated a search and saw through a window, Resident #1 in the parking lot near the facility. She went outside and re-directed the resident back inside the facility. Continued interview with LPN #5 revealed the Post-Acute unit had unsecured exit doors and there was not a receptionist at the desk. After the resident's elopement, LPN #5 stated she asked the Administrator about placing a Wander Guard bracelet on Resident #1; however, the Post-Acute unit was not Wander Guard equipped. LPN #5 stated the facility placed a Wander Guard bracelet on the resident and moved him/her to the C Hall. Interview with LPN #7, on 03/02/17 at 4:10 PM, revealed she received a call from LPN #5 on 02/21/17, who asked to send a Certified Nursing Assistant (CNA) to the Post-Acute unit to help her supervise Resident #1 after he/she had eloped. LPN #7 stated LPN #5 was by herself on the Post-Acute unit and feared the resident might attempt to elope again. Interview with the DSS, on 03/07/17 at 11:10 AM, revealed she knew Resident #1 was confused in the evenings. The DSS stated Registered Nurse (RN) #1 informed her Resident #1 attempted to open an egress door on the unit prior to the 02/21/17 elopement. She stated she thought the incident occurred the second day of the resident's stay. She stated the resident thought he/she was at home and was looking for his/her spouse. The DSS stated she informed the DNS and Administrator and the resident was moved to another room because the resident continued to go to the door looking for his/her spouse. She thought if the resident's room was closer to the nurses' station, the nurses could keep a close eye on him/her. The DSS did not consider the behavior as wandering and deemed it adjusting to the facility. She revealed the room change was the only intervention the facility implemented prior to the resident's elopement. The DSS stated residents on the Post-Acute unit had a lower risk for elopement because they had a higher Brief Interview for Mental Status (BIMS). She stated the unsecured exit/entry doors of the Post-Acute unit had never been a problem prior to Resident #1's elopement. Interview with RN #1, on 03/07/17 at 10:42 AM via telephone, revealed Resident #1 was confused and had attempted to open the door on the West end of the Post-Acute hall prior to the 02/21/17 elopement. The door had an egress and the alarm sounded when the resident attempted to open the door. He was unsure of the date this occurred; however, he recalled having informed the DSS of the incident. RN #1 was unsure alarming an egress door was considered an elopement and asked the DSS to clarify with the Administrator. He stated he kept close supervision of Resident #1 after he/she attempted to leave the unit. RN #1 stated he did not inform the DNS about the incident or request additional help with supervision for the resident. Interview with RN #3, on 03/08/17 at 11:30 AM, revealed she knew Resident #1 had dementia and ambulated frequently with his/her walker on the Post-Acute unit. She stated she worked at night and the resident walked around and had access to exit the facility. RN #3 stated that although the resident did not walk fast, she had to keep an eye on the resident because the Post-Acute unit had no Wander Guard system. Interview with Certified Nursing Assistant (CNA) #7, on 03/08/17 at 3:30 PM, via telephone, revealed she knew Resident #1 had increased confusion in the evenings. Towards the evening, the resident became more active, talked about his/her spouse, and wandered into other resident's rooms. She stated she did not tell the nurses about the resident's behaviors because they were aware of Resident #1's increased confusion and wandering, as it was common knowledge. Interview with CNA #4, on 03/03/17 at 11:50 AM, revealed the Post-Acute unit exit door was not secured and did not have a Wander Guard alert. Interview with the DNS, on 03/03/17 at 10:35 AM, revealed the Post-Acute unit had no alarm on the entry/exit door and a resident that was exit seeking would be able to elope. She stated the facility did not monitor that door. Observation of the facility, on 03/01/17 at 6:20 PM, 03/02/17 at 8:45 AM, 03/03/17 at 8:30 AM and 03/04/17 at 8:06 AM, revealed the Post-Acute unit exit/entry double door was unlocked with no Wander Guard alarm. There was no one at the reception desk that was near the door. Further review of Resident #1's clinical record revealed no documentation of exit seeking behaviors from the time of admission on 02/15/17, to the elopement on 02/21/17. Interview with the DNS, on 03/08/17 at 12:08 PM, revealed the clinical record of Resident #1 contained no documentation indicating the resident had increased confusion and tendencies to wander. She stated she did not know about Resident #1's increased confusion and exit seeking behaviors. The DNS stated no one informed her when the resident's room was moved closer to the nurses' station, she thought the resident had medical issues and needed closer monitoring. She stated had she known about the exit seeking behaviors, she would have put interventions in place. She stated it was alarming that the nurses did not document the observations and assess the resident. Further interview with the DNS, on 03/17/17 at 3:00 PM, revealed a lack of documentation and communication by her staff led to the elopement. She felt she had nothing to go by to evaluate the changes of Resident #1 to assist staff or the resident. She stated she was ultimately responsible to assure residents had adequate supervision. She stated Resident #1's elopement could have had a catastrophic outcome. Interview with the Administrator, on 03/03/17 at 11:12 AM, revealed commuters went in and out of the parking lot and it was not a safe area for residents. Continued interview, on 03/08/17 at 3:42 PM, revealed the Administrator stated she was aware of Resident #1's room change prior to the elopement because the DSS had reported to her about the resident's attempt to exit through the egress door. She did not take any further action and did not discuss the incident with the DNS. Further interview with the Administrator, on 03/17/17 at 3:07 PM, revealed a lack of communication, education, and training led to the elopement. She stated nursing, Social Services, and herself played a key role in the failure to supervise Resident #1. She stated it was a system failure that resulted from a lack of documentation regarding behavior changes of Resident #1, as well as a communication barrier between nursing staff, the DNS, and herself. The facility implemented the following actions to remove the Immediate Jeopardy: 1. The Medical Director was notified of the Immediate Jeopardy on 03/10/17. 2. The facility transferred Resident #1 after the elopement from the Post-Acute unit to the Long Term Care C-unit of the facility and fitted Resident #1 with a Wander Guard bracelet. Notifications were made according to policy. The facility discharged Resident #1 on 03/01/17. 3. The facility reassessed Resident #2, #3, and #4 for their elopement risk and verified that Wander Guard bracelets were in place and functioning. The facility reviewed Resident #2, #3, and 4's care plans, updated the Wander Guard on the Kardex for staff to check and verify function every shift. The Director of Nursing Services (DNS) completed the review and revision of the care plan and Kardex's on 03/09/17. 4. The facility's DNS, Case Manager (CM) and Director of Social Services (DSS), screened eighty-three (83) current residents at the facility for elopement risk. Ten (10) of the eighty-three (83) residents were identified to have a cognitive deficit, as determined by the facility's assessment of a Brief Interview for Mental Status (BIMS) score of twelve (12) or below, and also ambulated independently or by wheel chair. The ten (10) residents were reassessed for elopement risk by the DNS and the care plans for these residents were reviewed and updated by the DNS on 03/10/17. 5. The facility had Wander Guard technicians present installing a new Wander Guard system that was expanded to cover all exit doors when the installation was completed. The installation of the new Wander Guard system began on 02/26/17. The Post-Acute unit was not utilized for any exit seeking residents until the exit door was Wander Guard equipped. The Administrator oversaw the Wander Guard system installation. 6. The facility will screen all new residents by the nurse for elopement risk at the time of admission and care plan interventions as indicated. Any current resident developing exit seeking behaviors was to be assessed immediately. Their care plan was updated with interventions as indicated by Social Services. The care team of the facility includes the Administrator, DSS, the DNS, the Minimum Data Set (MDS) Coordinator, and the CM. The care team reviewed new behavior alerts at the daily clinical meeting and updated resident's care plan as indicated. Clinical meetings were held on 03/10/17 and were continued daily for five (5) business days. 7. Social Services and Licensed Nurses will be responsible to document behaviors. 8. The facility re-educated all facility and agency staff present in the building regarding Elopement Policy and Procedures on 03/08/17. The Staff Development Coordinator (SDC) and the DNS conducted the training. The education included a post-test derived from the Good Samaritan policy and procedures. Fifty-seven (57) staff members were present and educated. Twenty-three (23) of the fifty-seven (57) were agency staff members. The nursing department was to be educated on the completion of the assessment and care plan process by the SDC and the DNS. Twelve (12) staff members that worked as needed schedules remained untrained on 03/08/17. The training took place prior to the start of staff members shift and prior to providing direct resident care. All new facility employees and agency staff received training on Policy and Procedures prior to providing direct care. Completion for the planned training occurred on 03/11/17. 9. The DNS or DSS of the facility audited residents with Wander Guards and verified proper placement and function of the device. Audits were started on 03/10/17 and completed daily for seven (7) days, then weekly for three (3) weeks, proceeding with a monthly audit for two (2) months and then quarterly for three (3) quarters. 10. The DNS or DSS of the facility rounded the facility, interviewed staff, and reviewed records for elopement risk documentation and for care planning appropriate interventions. The audits started 03/10/17, and were completed daily for seven (7) days, then weekly for three (3) weeks, proceeding with a monthly audit for two (2) month and then quarterly for three (3) quarters. 11. The Administrator conducted a clinical Ad Hoc Committee meeting with the entire care team on 03/10/17. The meetings were held on each business day for four (4) weeks to review the audits, findings, and actions taken by the clinical team. The Ad Hoc Committee meetings minutes were submitted to the monthly Safety Committee for review and for further recommendations. The facility held the safety meeting on 03/13/17, and will occur monthly. 12. The facility implemented a notification announcement to alert staff of a potential elopement. Furthermore, the facility began monthly elopement drills starting on 03/13/17. Elopement drill reports were submitted to the monthly Safety Committee meeting for review and recommendation. 13. The facility scheduled a QAPI Committee meeting for 03/31/17, and all audit reports completed during the AOC will be submitted and reviewed for further recommendation. The SSA validated the facility implemented the following actions: 1. Interview with the Medical Director, on 03/16/17 at 9:40 AM via telephone, revealed the facility notified him of the Immediate Jeopardy on 03/10/17. 2. Review of Resident #1's closed record revealed the facility transferred him/her from the Post-Acute unit to the Long Term Care C-unit of the facility on 02/21/17. Resident #1 was fitted with a Wander Guard bracelet. Social Worker #2 documented the notifications in the resident's progress note. On 03/01/17, the facility discharged Resident #1. Interview with the Director Social Services (DSS), on 03/02/17 at 11:05 AM, revealed Resident #1 was transferred to the Long Term Care C-unit due to exit seeking behavior. The facility placed a Wander Guard and called his/her spouse to come and visit. 3. Observations of Resident #2, #3, and #4, on 03/16/17, revealed the residents had Wander Guard bracelets in place. Review of Resident #2, #3, and #4's clinical records revealed the facility reassessed them for elopement risk and reviewed their care plans. The Kardex for direct care staff was updated and stated Personal Alarm: Wander Guard used to alert staff to resident's movement and to assist staff in monitoring movement. The Director of Nursing Services (DNS) had completed the updates on 03/09/17. Interview with the DNS, on 03/16/17 on 3:05 PM, revealed Resident #2, #3, and #4 were reassessed for elopement and their care plans were reviewed to ensure appropriate interventions for elopement were in place. 4. Record review revealed eighty-three (83) residents were screened for elopement and the care plans for ten (10) residents with a Brief Interview for Mental Status (BIMS) score of twelve (12) and below were reviewed and updated by the DNS on 03/10/17. Interview with the DSS, on 03/16/17 at 2:05 PM, and the DNS on 03/16/17 at 3:15 PM, revealed they screened eighty-three (83) residents for elopement risk. They reassessed ten (10) residents with cognitive deficits that ambulated independently for elopement, and reviewed and updated their care plans as needed. 5. Observation of the new Wander Guard sensor on the Post-Acute unit, on 03/17/17 at 3:45 PM, demonstrated by the Maintenance Supervisor (MS), revealed the door alerted when a functioning Wander Guard was nearby. The alarm sounded throughout the Post-Acute unit. Interview with the MS, on 03/17/17 at 2:30 PM, revealed when the Wander Guard alarm on the Post-Acute unit was activated, the alarm sounded at the nurses' station. Staff could not reset the alarm at the nurses' station; staff had to go to the door to reset the alarm. Interview with Register Nurse (RN) #4, on the Post-Acute unit, on 03/16/17 at 8:35 AM, revealed there were no exit-seeking residents on the unit. She stated the facility had not admitted any new residents to the Post-Acute unit. 6. Review of the Ad Hoc Committee Meeting Minutes revealed meetings were held on 03/10/17 through 03/15/17. The Committee reviewed action the facility had taken and audit results. Interview with the DSS, on 3/16/17 at 2:50 PM, the DNS at 3:35 PM, and with the Administrator, on 03/17/17 at 2:50 PM, revealed the nurses screened all new residents on admission for elopement risk and developed a care plan as indicated. Current residents that developed exit-seeking behaviors were assessed and their care plan updated with interventions related to the residents' needs. Interview with the Administrator, on 03/17/17 at 2:52 PM, revealed it was a team approach to come up with appropriate interventions. The Administrator stated the Care Team, which included the DSS, Minimum Data Set (MDS) Coordinator, the Case Manager (CM), the DNS, and herself, were responsible to review new behavior alerts during the daily clinical meetings and update the care plan as indicated. Continued interview at 3:15 PM, revealed the facility held clinical meetings on 03/10/17, and continued on 03/13/17, 03/14/17, 03/15/17, prior to the Ad Hoc meeting. Interview with Licensed Practical Nurse (LPN) #9, on 03/17/17 at 11:07 AM, revealed residents would be assessed for elopement upon admission. Their Care plan would be initiated and behaviors documented in the progress notes. 7. Review of Resident #5, #6, and #7's clinical records revealed staff documented resident behaviors, and elopement and behaviors were care planned. Interview with the DNS, on 03/17/17 at 1:10 PM, revealed the CM and Staff Development Coordinator (SDC) would monitor nursing documentation daily in the morning meetings. They would review Progress Notes, Physician Orders, and Change in Condition to ensure documentation was completed. The DNS stated she made rounds with the Administrator to ensure staff breaks were covered by other staff for adequate supervision of the residents. Interview with the Administrator, on 03/17/17 at 2:52 PM, revealed she expected nurses to document in the progress notes and update mood and behavior changes of residents. She stated the nurses were able to utilize an Alert note to communicate observed behaviors to the CM, the DSS, the DNS, and herself. Interview with LPN #9, on 03/17/17 at 11:07 AM, revealed nurses were responsible for documenting resident behaviors in the progress notes. Interview with the DSS, on 03/16/17 at 2:05 PM, revealed she monitored the clinical records to ensure the nurses were documenting behaviors in the progress notes. 8. Review of the Elopement Lesson Plan and staff sign in sheets revealed the facility educated staff on the Elopement Policy and Procedure. Fifty-seven (57) staff was educated on 03/08/17, twelve (12) staff on 03/11/17, and two (2) staff on 03/12/17. The education also included staff passing a test with an eighty percent (80%) pass rate. Interview with the SDC, on 03/16/17 at 11:45 AM, revealed staff was educated prior to providing direct resident care. The DNS and the CM had educated third (3rd) shift staff prior to beginning their shift. He stated staff that could not be reached by phone was informed via certified mail about the required re-education. Review of the certified mail receipts revealed the facility sent eight (8) staff certified mail regarding required education. Interview with Certified Nursing Assistant (CNA) #4, #9, and #11, LPN #8, and #9, Cook #2, and the Activities Assistant, on 03/16/17 at 10:15 AM, revealed the facility trained them on the Elopement Policy and Procedure. Interview with Administrator, on 03/17/17 at 3:00 PM, revealed the facility trained new staff on elopement and the SDC was primarily responsible for the training. 9. Review of the Wander Guard audits, conducted 03/10/17 through 03/15/17, revealed the DNS and the DSS audited ten (10) identified residents for the function and placement of their Wander Guard devices and for care plans with appropriate interventions. Audits continued at the alleged frequency. Interview with the DSS, on 03/16/17 at 2:05 PM and the DNS, on 03/16/17 at 3:15 PM, revealed they rounded the facility and checked residents' Wander Guards, interviewed staff, and reviewed clinical records for documentation and for appropriate care planned interventions daily. All units and the reception area were checked for the elopement book and confirmation that it was current. 10. Observation of the elopement books on the units and the reception area revealed they were up to date with the residents at risk for elopement. Review of the Wander Guard audits, conducted 03/10/17 through 03/15/17, revealed the DNS and the DSS audited ten (10) identified residents for documentation and appropriate care plan interventions. Interview with the DSS, on 03/16/17 at 2:05 PM and the DNS, on 03/16/17 at 3:15 PM, revealed they rounded the facility and checked residents' Wander Guards, interviewed staff, and reviewed clinical records for documentation and for appropriate care planned interventions. They checked the elopement book and confirmed it was current. Interview with the CM, on 03/16/17, at 12:00 PM, revealed follow-up education was done with the nurses during rounds regarding documentation. 11. Review of the Ad Hoc Committee Meeting Minutes revealed meetings were held on 03/10/17 through 03/15/17. The Committee reviewed action the facility had taken and audit results. Interview with the Administrator, on 03/17/17 at 2:52 PM, revealed the facility held AD Hoc Committee meetings on 03/10/17, 03/13/17, 03/14/17, and 03/15/17. The Administrator stated clinical meetings were held prior to every Ad Hoc meeting and safety issues were discussed. 12. Review of the Elopement Drill Search Report revealed the facility conducted an elopement drill on 03/13/17 at 2:35 PM. There were fifteen (15) employees that participated in the drill as evidence by their signatures on the form. Interview with the SDC, on 03/16/17 at 11:45 AM, revealed the facility conducted an elopement drill on 03/13/17. He stated a resident with a Wander Guard bracelet was taken to an area of the facility to simulate an elopement. Review of the facility's Elopement Plan, not dated, revealed the facility implemented a plan to notify staff of a missing resident by overhead page. Interview with RN #4, on 03/16/17 at 8:35 AM, CNA #9, LPN # 8 and #10 at 10:15 AM, the Activities Assistant, on 03/17/17 at 10:45 AM, CNA #11 at 10:50 AM, and with LPN #9 at 11:07, revealed they were trained and understood the notification announcement. CNA #9 and LPN #10 participated in the drill held on 03/13/17. 13. Review of a copy of the agenda for the QAPI meeting revealed a meeting was scheduled for 03/31/17. The agenda included discussion of elopement scenarios, a recap of the survey, and other quality measure concerns that trended negatively. Interview with the Administrator, on 03/17/17 at 3:20 PM, revealed the QAPI meeting was scheduled for 03/31/17.

Based on interview, record review, and review of the facility's policies, it was determined the facility's Administration failed to have an effective system in place to ensure resources were used effectively and efficiently to ensure adequate supervision for one (1) of seven (7) sampled residents, Resident #1. (Refer to F280 and F323). On 02/21/17, Resident #1 eloped from the facility without staff knowledge. Nursing staff found the resident outside the facility at 4:44 PM, unsupervised, holding on to his/her walker in the parking lot near the facility. Interviews revealed staff could not locate Resident #1 after assisting another resident with toileting. Staff initiated a search and found the resident in the facility's parking lot. Staff assisted the resident back into the facility with no injury. Staff had observed increased confusion and exit seeking behaviors days prior to the elopement and moved the resident's room closer to the nurse's station; however, no other interventions were put in place. The Administration's failure to ensure facility policies/procedures related to elopement were followed and care plan interventions implemented has caused or likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 03/09/17, and determined to exist on 02/21/17. The facility was notified of the Immediate Jeopardy on 03/09/17. The facility provided an acceptable Allegation of Compliance (AOC) on 03/15/17, alleging the removal of Immediate Jeopardy on 03/11/17. The State Survey Agency verified Immediate Jeopardy was removed on 03/11/17 as alleged, prior to exit on 03/17/17. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction and monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy, Safety and Health, revised September 2012, revealed the administrator/executive director/executive manager of the facility was responsible to serve as a role model and assure that all operations were performed with regard for the safety and health of all employees and residents. Further review revealed the center would comply with all applicable safety and health laws, provide ongoing training to all employees in safety and health practices, report and investigate all accidents and incidents, and take prompt action, including education, to prevent recurrence. Review of the facility's policy, Care Plan, revised November 2016, revealed the purpose of the policy was to develop a comprehensive care plan using an interdisciplinary team approach. Residents were to receive and be provided the necessary care and services to attain or maintain the highest practicable well-being in accordance with the comprehensive assessment. Each care plan was to be person centered and directed towards achieving and maintaining the resident's optimal medical, nursing, psychosocial, emotional, spiritual, physical, functional, and educational needs. Through use of departmental assessments, the Resident Assessment Instrument, and review of the physician orders, any problems, needs, and concerns were identified and addressed. Review of the facility's policy, Elopement, revised September 2013, revealed elopement was when a resident who needed supervision left the premises or a safe area without authorization and/or necessary supervision to do so. The facility was to assess and identify residents at risk for elopement and minimize the risk for elopement through individualized interventions. Residents assessed as not a risk for elopement during the pre-admission process, but begin to exhibit wandering behaviors or attempt to elope, would be assessed and monitored by staff. Staff would notify the physician and legal representative and update the resident's care plan. Identification of environmental hazards, evaluating/analyzing hazards and risks, implementing interventions including adequate supervision, monitoring/modifying interventions as needed, were practices the facility staff was expected to follow. Interview and record review revealed the facility assessed Resident #1 on 02/17/17, not at risk for elopement; however, the resident displayed confusion and exit seeking behavior around that time and attempted to exit an egress door. Staff did not document the resident's behavior, and did not revise the care plan with interventions regarding the exit seeking behavior. Resident #1 exited the facility without staff knowledge on 02/21/17. Interview with the Director of Social Services (DSS), on 03/07/17 at 11:10 AM, revealed she knew Resident #1 was confused in the evenings. The DSS stated staff informed her Resident #1 attempted to open an egress door on the unit around the second day of the resident's stay. The DSS stated she informed the Director of Nursing Services (DNS) and the Administrator and moved the resident to another room closer to the nurses' station. Interview with the Administrator, on 03/08/17 at 3:42 PM, revealed the DSS informed her about Resident #1's attempt to exit through the egress door days prior to the 02/21/17 elopement. The Administrator stated she and the DSS decided to move the resident closer to the nurses' station and did not take any further action. Further interview on 03/17/17 at 3:07 PM, revealed the Administrator stated a lack of communication, education, and training led to the elopement. She stated nursing, Social Services, and herself played a key role in the failure to supervise Resident #1. She stated it was a system failure that resulted from a lack of documentation regarding behavior changes of Resident #1, as well as a communication barrier between nursing staff, the DNS, and herself. She stated she was responsible to administer the facility and supervise all departments. The facility implemented the following actions to remove the Immediate Jeopardy: 1. The Medical Director was notified of the Immediate Jeopardy on 03/10/17. 2. The facility transferred Resident #1 after the elopement from the Post-Acute unit to the Long Term Care C-unit of the facility and fitted Resident #1 with a Wander Guard bracelet. Notifications were made according to policy. The facility discharged Resident #1 on 03/01/17. 3. The facility reassessed Resident #2, #3, and #4 for their elopement risk and verified that Wander Guard bracelets were in place and functioning. The facility reviewed Resident #2, #3, and 4's care plans, updated the Wander Guard on the Kardex for staff to check and verify function every shift. The Director of Nursing Services (DNS) completed the review and revision of the care plan and Kardex's on 03/09/17. 4. The facility's DNS, Case Manager (CM) and Director of Social Services (DSS), screened eighty-three (83) current residents at the facility for elopement risk. Ten (10) of the eighty-three (83) residents were identified to have a cognitive deficit, as determined by the facility's assessment of a Brief Interview for Mental Status (BIMS) score of twelve (12) or below, and also ambulated independently or by wheel chair. The ten (10) residents were reassessed for elopement risk by the DNS and the care plans for these residents were reviewed and updated by the DNS on 03/10/17. 5. The facility had Wander Guard technicians present installing a new Wander Guard system that was expanded to cover all exit doors when the installation was completed. The installation of the new Wander Guard system began on 02/26/17. The Post-Acute unit was not utilized for any exit seeking residents until the exit door was Wander Guard equipped. The Administrator oversaw the Wander Guard system installation. 6. The facility will screen all new residents by the nurse for elopement risk at the time of admission and care plan interventions as indicated. Any current resident developing exit seeking behaviors was to be assessed immediately. Their care plan was updated with interventions as indicated by Social Services. The care team of the facility includes the Administrator, DSS, the DNS, the Minimum Data Set (MDS) Coordinator, and the CM. The care team reviewed new behavior alerts at the daily clinical meeting and updated resident's care plan as indicated. Clinical meetings were held on 03/10/17 and were continued daily for five (5) business days. 7. Social Services and Licensed Nurses will be responsible to document behaviors. 8. The facility re-educated all facility and agency staff present in the building regarding Elopement Policy and Procedures on 03/08/17. The Staff Development Coordinator (SDC) and the DNS conducted the training. The education included a post-test derived from the Good Samaritan policy and procedures. Fifty-seven (57) staff members were present and educated. Twenty-three (23) of the fifty-seven (57) were agency staff members. The nursing department was to be educated on the completion of the assessment and care plan process by the SDC and the DNS. Twelve (12) staff members that worked as needed schedules remained untrained on 03/08/17. The training took place prior to the start of staff members shift and prior to providing direct resident care. All new facility employees and agency staff received training on Policy and Procedures prior to providing direct care. Completion for the planned training occurred on 03/11/17. 9. The DNS or DSS of the facility audited residents with Wander Guards and verified proper placement and function of the device. Audits were started on 03/10/17 and completed daily for seven (7) days, then weekly for three (3) weeks, proceeding with a monthly audit for two (2) months and then quarterly for three (3) quarters. 10. The DNS or DSS of the facility rounded the facility, interviewed staff, and reviewed records for elopement risk documentation and for care planning appropriate interventions. The audits started 03/10/17, and were completed daily for seven (7) days, then weekly for three (3) weeks, proceeding with a monthly audit for two (2) month and then quarterly for three (3) quarters. 11. The Administrator conducted a clinical Ad Hoc Committee meeting with the entire care team on 03/10/17. The meetings were held on each business day for four (4) weeks to review the audits, findings, and actions taken by the clinical team. The Ad Hoc Committee meetings minutes were submitted to the monthly Safety Committee for review and for further recommendations. The facility held the safety meeting on 03/13/17, and will occur monthly. 12. The facility implemented a notification announcement to alert staff of a potential elopement. Furthermore, the facility began monthly elopement drills starting on 03/13/17. Elopement drill reports were submitted to the monthly Safety Committee meeting for review and recommendation. 13. The facility scheduled a QAPI Committee meeting for 03/31/17, and all audit reports completed during the AOC will be submitted and reviewed for further recommendation. The SSA validated the facility implemented the following actions: 1. Interview with the Medical Director, on 03/16/17 at 9:40 AM via telephone, revealed the facility notified him of the Immediate Jeopardy on 03/10/17. 2. Review of Resident #1's closed record revealed the facility transferred him/her from the Post-Acute unit to the Long Term Care C-unit of the facility on 02/21/17. Resident #1 was fitted with a Wander Guard bracelet. Social Worker #2 documented the notifications in the resident's progress note. On 03/01/17, the facility discharged Resident #1. Interview with the Director Social Services (DSS), on 03/02/17 at 11:05 AM, revealed Resident #1 was transferred to the Long Term Care C-unit due to exit seeking behavior. The facility placed a Wander Guard and called his/her spouse to come and visit. 3. Observations of Resident #2, #3, and #4, on 03/16/17, revealed the residents had Wander Guard bracelets in place. Review of Resident #2, #3, and #4's clinical records revealed the facility reassessed them for elopement risk and reviewed their care plans. The Kardex for direct care staff was updated and stated Personal Alarm: Wander Guard used to alert staff to resident's movement and to assist staff in monitoring movement. The Director of Nursing Services (DNS) had completed the updates on 03/09/17. Interview with the DNS, on 03/16/17 on 3:05 PM, revealed Resident #2, #3, and #4 were reassessed for elopement and their care plans were reviewed to ensure appropriate interventions for elopement were in place. 4. Record review revealed eighty-three (83) residents were screened for elopement and the care plans for ten (10) residents with a Brief Interview for Mental Status (BIMS) score of twelve (12) and below were reviewed and updated by the DNS on 03/10/17. Interview with the DSS, on 03/16/17 at 2:05 PM, and the DNS on 03/16/17 at 3:15 PM, revealed they screened eighty-three (83) residents for elopement risk. They reassessed ten (10) residents with cognitive deficits that ambulated independently for elopement, and reviewed and updated their care plans as needed. 5. Observation of the new Wander Guard sensor on the Post-Acute unit, on 03/17/17 at 3:45 PM, demonstrated by the Maintenance Supervisor (MS), revealed the door alerted when a functioning Wander Guard was nearby. The alarm sounded throughout the Post-Acute unit. Interview with the MS, on 03/17/17 at 2:30 PM, revealed when the Wander Guard alarm on the Post-Acute unit was activated, the alarm sounded at the nurses' station. Staff could not reset the alarm at the nurses' station; staff had to go to the door to reset the alarm. Interview with Register Nurse (RN) #4, on the Post-Acute unit, on 03/16/17 at 8:35 AM, revealed there were no exit-seeking residents on the unit. She stated the facility had not admitted any new residents to the Post-Acute unit. 6. Review of the Ad Hoc Committee Meeting Minutes revealed meetings were held on 03/10/17 through 03/15/17. The Committee reviewed action the facility had taken and audit results. Interview with the DSS, on 3/16/17 at 2:50 PM, the DNS at 3:35 PM, and with the Administrator, on 03/17/17 at 2:50 PM, revealed the nurses screened all new residents on admission for elopement risk and developed a care plan as indicated. Current residents that developed exit-seeking behaviors were assessed and their care plan updated with interventions related to the residents' needs. Interview with the Administrator, on 03/17/17 at 2:52 PM, revealed it was a team approach to come up with appropriate interventions. The Administrator stated the Care Team, which included the DSS, Minimum Data Set (MDS) Coordinator, the Case Manager (CM), the DNS, and herself, were responsible to review new behavior alerts during the daily clinical meetings and update the care plan as indicated. Continued interview at 3:15 PM, revealed the facility held clinical meetings on 03/10/17, and continued on 03/13/17, 03/14/17, 03/15/17, prior to the Ad Hoc meeting. Interview with Licensed Practical Nurse (LPN) #9, on 03/17/17 at 11:07 AM, revealed residents would be assessed for elopement upon admission. Their Care plan would be initiated and behaviors documented in the progress notes. 7. Review of Resident #5, #6, and #7's clinical records revealed staff documented resident behaviors, and elopement and behaviors were care planned. Interview with the DNS, on 03/17/17 at 1:10 PM, revealed the CM and Staff Development Coordinator (SDC) would monitor nursing documentation daily in the morning meetings. They would review Progress Notes, Physician Orders, and Change in Condition to ensure documentation was completed. The DNS stated she made rounds with the Administrator to ensure staff breaks were covered by other staff for adequate supervision of the residents. Interview with the Administrator, on 03/17/17 at 2:52 PM, revealed she expected nurses to document in the progress notes and update mood and behavior changes of residents. She stated the nurses were able to utilize an Alert note to communicate observed behaviors to the CM, the DSS, the DNS, and herself. Interview with LPN #9, on 03/17/17 at 11:07 AM, revealed nurses were responsible for documenting resident behaviors in the progress notes. Interview with the DSS, on 03/16/17 at 2:05 PM, revealed she monitored the clinical records to ensure the nurses were documenting behaviors in the progress notes. 8. Review of the Elopement Lesson Plan and staff sign in sheets revealed the facility educated staff on the Elopement Policy and Procedure. Fifty-seven (57) staff was educated on 03/08/17, twelve (12) staff on 03/11/17, and two (2) staff on 03/12/17. The education also included staff passing a test with an eighty percent (80%) pass rate. Interview with the SDC, on 03/16/17 at 11:45 AM, revealed staff was educated prior to providing direct resident care. The DNS and the CM had educated third (3rd) shift staff prior to beginning their shift. He stated staff that could not be reached by phone was informed via certified mail about the required re-education. Review of the certified mail receipts revealed the facility sent eight (8) staff certified mail regarding required education. Interview with Certified Nursing Assistant (CNA) #4, #9, and #11, LPN #8, and #9, Cook #2, and the Activities Assistant, on 03/16/17 at 10:15 AM, revealed the facility trained them on the Elopement Policy and Procedure. Interview with Administrator, on 03/17/17 at 3:00 PM, revealed the facility trained new staff on elopement and the SDC was primarily responsible for the training. 9. Review of the Wander Guard audits, conducted 03/10/17 through 03/15/17, revealed the DNS and the DSS audited ten (10) identified residents for the function and placement of their Wander Guard devices and for care plans with appropriate interventions. Audits continued at the alleged frequency. Interview with the DSS, on 03/16/17 at 2:05 PM and the DNS, on 03/16/17 at 3:15 PM, revealed they rounded the facility and checked residents' Wander Guards, interviewed staff, and reviewed clinical records for documentation and for appropriate care planned interventions daily. All units and the reception area were checked for the elopement book and confirmation that it was current. 10. Observation of the elopement books on the units and the reception area revealed they were up to date with the residents at risk for elopement. Review of the Wander Guard audits, conducted 03/10/17 through 03/15/17, revealed the DNS and the DSS audited ten (10) identified residents for documentation and appropriate care plan interventions. Interview with the DSS, on 03/16/17 at 2:05 PM and the DNS, on 03/16/17 at 3:15 PM, revealed they rounded the facility and checked residents' Wander Guards, interviewed staff, and reviewed clinical records for documentation and for appropriate care planned interventions. They checked the elopement book and confirmed it was current. Interview with the CM, on 03/16/17, at 12:00 PM, revealed follow-up education was done with the nurses during rounds regarding documentation. 11. Review of the Ad Hoc Committee Meeting Minutes revealed meetings were held on 03/10/17 through 03/15/17. The Committee reviewed action the facility had taken and audit results. Interview with the Administrator, on 03/17/17 at 2:52 PM, revealed the facility held AD Hoc Committee meetings on 03/10/17, 03/13/17, 03/14/17, and 03/15/17. The Administrator stated clinical meetings were held prior to every Ad Hoc meeting and safety issues were discussed. 12. Review of the Elopement Drill Search Report revealed the facility conducted an elopement drill on 03/13/17 at 2:35 PM. There were fifteen (15) employees that participated in the drill as evidence by their signatures on the form. Interview with the SDC, on 03/16/17 at 11:45 AM, revealed the facility conducted an elopement drill on 03/13/17. He stated a resident with a Wander Guard bracelet was taken to an area of the facility to simulate an elopement. Review of the facility's Elopement Plan, not dated, revealed the facility implemented a plan to notify staff of a missing resident by overhead page. Interview with RN #4, on 03/16/17 at 8:35 AM, CNA #9, LPN # 8 and #10 at 10:15 AM, the Activities Assistant, on 03/17/17 at 10:45 AM, CNA #11 at 10:50 AM, and with LPN #9 at 11:07, revealed they were trained and understood the notification announcement. CNA #9 and LPN #10 participated in the drill held on 03/13/17. 13. Review of a copy of the agenda for the QAPI meeting revealed a meeting was scheduled for 03/31/17. The agenda included discussion of elopement scenarios, a recap of the survey, and other quality measure concerns that trended negatively. Interview with the Administrator, on 03/17/17 at 3:20 PM, revealed the QAPI meeting was scheduled for 03/31/17.

Based on interview, closed record review and review of the facility's policy and procedures, it was determined the facility failed to have an effective system in place to ensure a resident's physician was notified immediately of any resident who sustained an injury and potentially required physician intervention for one (1) of sixteen (16) sampled residents (Resident #14). The facility also failed to notify the family of the resident's injury timely. (Refer to F309) On 09/16/14 at 11:30 AM, Resident #14 sustained an open wound to the face above the right eye with profuse bleeding when State Registered Nursing Assistant (SRNA) #3 attempted a transfer using a lift without staff assistance. However, there was no documented evidence the resident's physician was notified of the injury. Interviews revealed between 3:30 PM and 4:00 PM, Registered Nurse (RN) #1 and Minimum Date Set (MDS) Nurse #1 found Resident #14 with bruising around the right eye with significant swelling and increased bleeding that had soaked through the initial dressing. At 4:00 PM the Director of Nursing (DON) gave direction to RN #1 to prepare the resident for transfer to the hospital for evaluation. However, interviews revealed neither the physician nor the ambulance service was notified as instructed. At 5:00 PM, the resident was found unresponsive and in respiratory distress. The facility made an urgent call to the ambulance company at 5:08 PM with arrival at 5:18 PM. The resident was found with no pulse or spontaneous respirations and was pronounced dead at 5:20 PM. The facility's failure to have an effective system in place to ensure the resident's physician was notified immediately in case of an injury that required a physician's intervention, placed Resident #14 and other at risk residents in a situation that could cause or was likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 09/24/14 and determined to exist 09/16/14. The facility was notified of the Immediate Jeopardy on 09/25/14. The facility provided an acceptable Allegation of Compliance on 10/01/14 that alleged removal of Immediate Jeopardy on 09/30/14, the State Survey Agency verified Immediate Jeopardy was removed on 09/30/14 as alleged at 42 CFR 483.10 Resident Rights (F157) with the scope and severity lowered to a "D" while the facility monitors the effectiveness of the implemented plan of correction. The findings include: Review of the facility's policy and procedure regarding A Fallen or Injured Resident, revised June 2014, revealed the purpose was to give prompt treatment and prevent further injury. The policy directed staff, in case of complications; notify the physician and follow orders; for residents with suspected head injury notify the physician by phone, not fax. Review of facility's incident report for Resident #14's injury, dated 09/16/14, revealed the wound nurse (Minimum Data Set Nurse #1) measured the wound at 0.1 centimeter (cm) x 1.5 cm. The area was cleaned and pressure applied to the wound with some decrease in bleeding. The report indicated the injury type as a laceration located on the face. The Injury report noted the family and resident's physician were notified at 1:00 PM on 09/16/14. However, interview with staff and the resident's physician and family revealed this notification was not conducted. Interview with Licensed Practical Nurse (LPN) #1, on 09/23/14 at 3:21 PM, revealed she did not notify the resident's family or tell the resident's physician of her concerns at the time of the incident because she was busy with other tasks. LPN #1 stated she did not actually notify the family or the physician until the next shift. Interview with Minimum Data Set (MDS) Nurse #1, on 09/23/14 at 5:07 PM, revealed she told Registered Nurse (RN) #1 around 3:20 PM to go ahead and prepare the paperwork for the resident to be transferred, notify the resident's physician, and call the ambulance service. Review of the Facsimile (fax) Transmission Verification Report, not signed, dated or timed revealed there was no confirmation of the physician notification ever being sent. Further review of the fax revealed the resident obtained a split/gash measuring 0.1 x 1.5 cm above the right eye during a transfer and had a moderate amount of bleeding and steri-strips were applied. Interview with the DON, on 09/25/14 at 11:50 AM, revealed she went back to the room around 4:00 PM to assess the resident and told RN #1 the resident needed to go immediately for sutures and evaluation at the hospital. Review of the second Facsimile (fax) Transmission Verification Report, dated 09/16/14, revealed a confirmation time of 4:34 PM. The fax specified the resident sustained [REDACTED]. The gash continued to moderately bleed and was it okay to send the resident out to be sutured. Further interview with LPN #1, on 09/24/14 at 12:01 PM, revealed on 09/16/14 at 4:00 PM, she sent a fax to the resident's physician requesting an order to send the resident to the emergency room and called the family for the first time to let them know the resident was injured and required stitches. The LPN further stated the resident's physician preferred notifications through fax; however, if something was emergent it was the policy to page the physician. LPN #1 stated she did not know why she did not page the doctor per the facility's policy and procedure. Interview with RN #1, on 09/23/14 at 2:45 PM, revealed he answered a call from the resident's physician who was upset and said if there was an emergency the facility should call and not send a fax. The RN #1 further stated he received an order to transfer the resident to the hospital; however, failed to write the order. RN #1 stated he did not call the ambulance service as was instructed because he thought someone else was taking care of it. Interview with the resident's family member, on 09/24/14 at 11:47 AM, revealed he was not told until late afternoon of the injury and was told at that time the resident required stitches. The family member then stated that a short while later the facility called to say the resident had passed away. Further interview with LPN #1, on 09/25/14 at 11:29 AM, revealed if there was any type of accident they were supposed to notify the family and the physician. Continued review of the closed record did not reveal any evidence the physician or family were notified as documented in the incident report dated 09/16/14. Interview with Resident #14's physician, on 09/24/14 at 4:42 PM, revealed she was not notified until late afternoon that the resident had been hit in the head. The physician stated she was told the resident needed to go out for stitches but was not aware of when the incident actually occurred. The physician stated she was called later by the facility and told she needed to sign the death certificate. The physician stated she was very confused by this because she had given an order for [REDACTED]. The facility provided an Allegation of Compliance (AOC) on 09/29/14 alleging the Immediate Jeopardy was removed on 09/30/14; the facility took the following steps to remove the Immediate Jeopardy. 1. The SRNA (SRNA #3) involved in the incident was suspended after the incident on 09/16/14 pending investigation of the incident. 2. A meeting was held to discuss the investigation, root cause of the Immediate Jeopardy, Good Samaritan Society policies and procedures (review included safe resident handling, incident reporting and notification of change of condition and action plan), on 09/25/14 at 2:00 PM. Attendees of the meeting on 09/25/14 were the Administrator, Director of Nursing, Staff Development/Quality Assurance Coordinator, Human Resources Director, Good Samaritan Society (GASS) Rehabilitation/Skilled Consultants, Good Samaritan Society Quality Improvement Consultant and a Good Samaritan Society Workforce Consultant. 3. All policies and procedures reviewed at the 2:00 PM meeting on 09/25/14 were found to be appropriate with no revisions required. A lesson plan was developed by the attendees for re-education. 4. A meeting was held, on 09/25/14 at 4:00 PM, to communicate the Immediate Jeopardy situation, assign tasks and communicate mandatory adjusted schedules. Attendees included the Director of Nursing, Staff Development/Quality Assurance Coordinator and Nurse Case Managers. 5. On 09/26/14 at 5:00 AM, a meeting was held to provide re-education in response to the Immediate Jeopardy and to discuss re-education to follow for the entire active nursing staff. Attendees included the Administrator, Director of Nursing, Staff Development/Quality Assurance Coordinator, and Nurse Case Managers with re-education provided by a Good Samaritan Society Rehabilitation/Skilled Consultant. 6. On 09/26/14 an inventory of mechanical lift slings was reviewed by the Administrator and the Environmental Services Director and it was identified that a sufficient number of slings were present. There were eighty-eight (88) available slings for a total of nineteen (19) residents requiring the use of a mechanical lift. Soiled slings were placed in the soiled utility rooms by nursing staff to be laundered. Laundry staff cleaned and inspected slings and returned them to the floor the very next day. 7. A one-hundred (100)% review was initiated on 09/25/14 and concluded on 09/28/14 to ensure accuracy (determination of type of assistance required for bed mobility and transfers) of seventy-nine (79) current residents' Mobilization User Defined Assessments (UDA) by the Director of Nursing. Ten (10) of the seventy-nine (79) residents were re-assessed by completing the Mobilization UDA for three (3) consecutive shifts on 09/27/14 and 09/28/14 by Nurse Case Managers and floor nurses. 8. One-hundred (100)% review of seventy-nine (79) current residents' care plans was initiated on 09/25/14 and completed on 09/28/14 by the Director of Nursing to ensure care plans and Kardexs included the level of assist for bed mobility and transfer, included the number of staff members required for use of the lift, the type of lift to be used, and the sling size, if indicated. 9. Re-education was provided to SRNA staff and licensed nursing staff beginning at 5:00 AM on 09/26/14 on all shifts and continued through 09/27/14 for compliance by Good Samaritan Society Rehabilitation/Skilled Consultant, Nurse Case Manager/Safe Resident Handling Coordinator and Staff Development/Quality Assurance Coordinator. Beginning on first (1st) shift of 09/26/14 no nursing staff member was permitted to provide resident care until re-education was completed. As of 09/29/14 seventy (70) employees (all current full and part-time nursing staff) had received the re-education which included passing a post-test and return demonstration for use of the mechanical lift. Two (2) prn/on-call nursing employees who were not scheduled to work will receive the re-education prior to working. The re-education included 1) care delivered per care plan, 2) quality of care, 3) accidents and 4) clinical records. 10. Audits will be completed daily times seven (7) days by licensed nurses for completion of mobilization (UDA) on each shift in the first twenty-four (24) hours of admission/readmission and with change of condition for accurate care planning/Kardexs for level of assistance for bed mobility and transfer including number of staff, type of lift, and sling size if indicated. 11. Audits will be completed daily times seven (7) days by licensed nurses observing one (1) SRNA on each unit on each shift in assisting residents with bed mobility and transfer to ensure safe care per the resident's care plan. 12. Medical record audits will be completed daily times seven (7) days by licensed nurses to ensure an incident report has been completed with each incident, Good Samaritan Society facility investigation policy was initiated, physician and resident's responsible party were notified with appropriate documentation, resident monitoring and assessment was completed and documented in appropriate UDA's and progress notes. 13. The facility developed a compliance Ad-Hoc Committee chaired by the facility Administrator to manage the development of the Plan of Correction for ongoing compliance and to oversee the implementation of the Plan of Correction with Good Samaritan Society Consultant support and assistance. Committee members include the Director of Nursing, the Staff Development/Quality Assurance Coordinator, Nurse Case Managers, Human Resource Director, Health Information Manager, and the Medical Director. All audit results will be submitted to the Ad-Hoc Committee for review and follow-up action as indicated. The Ad-Hoc Committee minutes will be reported to the Continuing Quality Improvement Committee Monthly. Through observation, interview and record review the State Survey Agency validated the Allegation of Compliance with removal of Immediate Jeopardy on 09/30/14 as alleged prior to exit on 10/02/14 as follows: 1. Review of the personnel file for SRNA #3 revealed she was suspended from work after the incident on 09/16/14 pending the facility investigation and remained suspended throughout the survey including date of exit of 10/02/14. 2. A group interview including the Administrator, the Director of Nursing, the Staff Development Coordinator, the Human Resource Director, two (2) Good Samaritan Society Rehabilitation/Skilled Consultants (per telephone conference call), a Good Samaritan Society Quality Improvement (QI) Coordinator (per telephone conference call), and the Good Samaritan Society Workforce Consultant (per telephone conference call), on 10/02/14 at 2:00 PM, revealed the Administrator, the Director of Nursing, the Staff Development Coordinator and the Human Resource Director were present in person at the meeting held, on 09/25/14 at 2:00 PM, and the two (2) GSS Consultants, the GSS QI Coordinator and the GSS Workforce Consultant were at the meeting via telephone conference call to discuss the investigation regarding Resident #14, the root cause of the Immediate Jeopardy, GSS policies and procedures to include safe resident handling, incident reporting and notification of change of condition and to develop an action plan (lesson plan). Review of the lesson plan agenda (not dated) provided as proof for the AOC which included training on safe assistance with bed mobility, transfers and use of mechanical lifts and slings, and also included training on the writing of the individualized nursing care plan based on individualized needs and on following the residents' plans of care. Review of the sign-in sheets for the meeting held on 09/25/14 at 2:00 PM, confirmed the signatures of the attendees. 3. Review of the lesson plan developed in the meeting, on 09/25/14 at 2:00 PM, revealed an agenda, content, and SRNA and licensed nurse post-tests to address the Immediate Jeopardy compliance. Review of the lesson plan developed "Providing Resident Care - Individualized, Safe, Documented" revealed an agenda, content, and SRNA and licensed nurse post-tests to address the Immediate Jeopardy compliance. The length of the training session outlined on the agenda was thirty (30) minutes for SRNAs and one (1) hour for licensed nurses with the purpose of the training to be correction activity for Immediate Jeopardy F-tags to include policies regarding safe handling of residents, incident reporting, notification of resident change of condition, data collection and UDA assessment instructions and use of mechanical lifts and slings. 4. Interview with Nurse Case Managers #1 and #2, the DON, and the Staff Development Coordinator, on 10/02/14 at 3:06 PM, 3:15 PM, and 3:20 PM, respectively revealed they had attended the meeting held, on 09/25/14 at 4:00 PM, to discuss the Immediate Jeopardy situation, to assign tasks and to communicate mandatory adjusted schedules for the nursing staff. Review of the sign-in sheet for the meeting held on 09/25/14 at 4:00 PM confirmed the signatures of the attendees. 5. A group interview including the Administrator, the Director of Nursing, the Staff Development Coordinator, GSS Rehabilitation/Skilled Consultant #2 (per telephone conference call) and Nurse Case Managers #1, #2 and #3, on 10/02/14 at 2:00 PM, revealed they were all present in person at the meeting held, on 09/26/14 at 5:00 AM, and GSS Rehabilitation/Skilled Consultant #2 provided the re-education to that staff in the meeting with discussion of re-education for the entire active nursing staff. Review of the sign-in sheet for the meeting held on 09/26/14 confirmed the signatures of the attendees. 6. Observation of the mechanical lift slings located in the laundry and on each nursing unit, on 10/02/14 at 9:00 AM, revealed there were eighty-eight (88) slings available for use. Twelve (12) of the slings observed were soiled and awaiting washing and inspection. Interview with the Administrator and the Environmental Services Director, on 10/02/14 at 12:16 PM, revealed they both participated in an inventory of the facility mechanical lift slings on 09/26/14. The Administrator and the Environmental Services Director indicated the soiled slings were to be placed in the soiled utility rooms by nursing staff to be laundered and the laundry staff was to launder, dry and inspect the slings before stocking them on each nursing unit the next day. Interview with SRNA #7, on 10/02/14 at 3:50 PM, revealed she would place a soiled sling in a bag in the soiled utility room on the nursing unit to be laundered and it was her understanding the laundry staff would inspect the slings for any defects before returning them to the nursing units. Interview with the Housekeeping/Laundry Supervisor, on 10/02/14 at 4:00 PM, revealed the laundry staff cleaned the mechanical lift slings seven (7) days a week and inspected them before returning them to the nursing units for use. She stated if a sling was defective it would be given to Case Manager #3 for replacement. Interview with Case Manager #3, on 10/02/14 at 4:10 PM, revealed he received the defective slings identified by the laundry staff or any nursing personnel and would order a replacement right away and the replacement would usually be provided within a week. Interview with the DON, on 10/02/14 at 4:10 PM, revealed mechanical lift slings were stored in the clean utility rooms on each nursing unit and were laundered and inspected by the laundry staff. 7. Further interview with the DON, on 10/02/14 at 4:10 PM, revealed she initiated a one-hundred 100% audit of the seventy-nine (79) residents' Mobilization UDA's in the facility on 09/25/14 and completed the audit on 09/28/14. Review of the UDA's for Resident #17, Resident #18, Resident #19 and Resident #20 revealed they were accurate assessments of the residents' needs. Re-assessment documents were reviewed for ten (10) of the seventy-nine (79) residents reviewed which were completed for three (3) consecutive shifts on 09/27/14 and 09/28/14. Interview with Case Manager #1, and RN #1, on 10/02/14 at 4:15 PM, and 4:20 PM, respectively revealed they assisted with the re-assessments for ten (10) of the seventy-nine (79) residents reviewed which were completed for three (3) consecutive shifts on 09/27/14 and 09/28/14. Review of the audit initiated on 09/27/14 and concluded on 09/28/14 confirmed ten (10) residents were reviewed for reassessment by the DON. 8. Observation of Resident #17, on 09/30/14 at 3:25 PM, on 10/01/14 at 8:35 AM, and 10:30 AM, revealed the resident's plan of care was being followed by the nursing staff. Observation of Resident #17, on 10/01/14 at 11:00 AM, revealed two (2) SRNAs performing a mechanical lift transfer of the resident from the bed to a wheelchair using the appropriate sling identified on the plan of care and using appropriate procedure for the transfer. Observation of Resident #18, on 09/30/14 at 3:45 PM, 10/01/14 at 8:45 AM and 10:45 AM, revealed the resident was being cared for per the assessed nursing/SRNA plan of care. Observation of Resident #19, on 09/30/14 at 3:11 PM and 10/01/14 at 1:30 PM, revealed the resident's plan of care was being followed by the nursing staff. Review of the clinical records for Resident #17, Resident #18 and Resident #19's revealed Minimum Data Set (MDS) comprehensive reviews completed in the past thirty (30) days and compared to the residents' records revealed accurate assessments had been completed. Review of the nursing and SRNA care plans for Resident #17, Resident #18 and Resident #19 revealed they had been created from the comprehensive MDSs, completed in the past thirty (30) days and had been updated/revised as indicated. Review of the Mobilization UDA dated 08/28/14 for Resident #17 revealed the resident was to be transferred using the appropriate sling size with a mechanical lift as assessed. Interview with the DON, on 10/02/14 at 4:10 PM, revealed she initiated a one-hundred 100% audit of the seventy-nine (79) residents' (in the facility at the time) care plans on 09/25/14 and completed that audit on 09/28/14 to ensure care plans and Kardexs included the level of assist for bed mobility and transfer, the number of staff required for use of the lift and the type of lift and sling to be used, if indicated. Review of the audits completed by the DON confirmed they were completed between 09/25/14 and 09/28/14. 9. Review of the SRNA and licensed nurse sign-in sheets for the re-education trainings revealed all but two (2) on-call nursing employees had completed the training between 09/26/14 at 5:00 AM and 09/27/14. A telephone interview with the GSS Rehabilitation/Skilled Consultant #2, on 10/02/14 at 2:00 PM, revealed she had conducted the lesson plan training on 09/26/14 through 09/29/14 with the assistance of Nurse Case Managers #1 and #2. Interview with Nurse Case Managers #1 and #2, on 10/02/14 at 2:20 PM, revealed they had participated in the lesson plan training done on 09/26/14 through 09/27/14. Interview with the Staff Development Coordinator on 10/02/14 at 2:30 PM revealed she had participated in the lesson plan training on use of the slings and mechanical lifts and had observed staff with return demonstrations of use of the slings and lifts on 09/26/14 through 09/29/14. Interview with LPN #2, on 10/02/14 at 3:40 PM, revealed she had attended an in-service training last week about lift use, charting, incident reporting, and calling the doctor. She stated she demonstrated the use of the mechanical lifts and had a written post-test on the training content. Interview with LPN #3, on 10/02/14 at 3:43 PM, revealed she had attended an in-service training on 09/27/14 about mechanical lift use, charting, incident reporting, and calling the doctor. She stated she also demonstrated the use of the mechanical lifts and had a written post-test on the training content. Interview with SRNA #7, on 10/02/14 at 3:48 PM, revealed she attended an in-service training on 09/26/14 about the use of the resident care plans and lift/sling use and she did a return demonstration and had a post-test. Interview with SRNA #8, on 10/02/14 at 3:52 PM, revealed she attended an in-service training on 09/26/14 about the use of the resident care plans and lift/sling use and she did a return demonstration and had a post-test. 10. Review of the seven (7) daily audits, initiated 09/29/14, confirmed a daily audit by licensed nurses for completion of the Mobilization UDA on each shift in the first twenty-four (24) hrs of admission/readmission and with change of condition, for accurate care planning/Kardexs for level of assist for bed mobility and transfer including number of staff required, type of lift and sling size, if indicated. Interview with LPN #3, on 10/02/14 at 4:20 PM, revealed she had completed three (3) of the required seven (7) daily audits to be done by licensed nurses. Interview with RN #2, on 10/02/14 at 4:25 PM, revealed he had completed two (2) of the required seven (7) daily audits to be done by licensed nurses. 11. Review of the audits, initiated 09/27/14, confirmed the audits for proper use of the lift were completed with observations. Interview with LPN #3, on 10/02/14 at 4:20 PM, revealed she had observed SRNA #2, on day shift on 09/29/14, assisting Resident #17 with bed mobility and lift/sling transfer to ensure the safe care per the resident's care plan. LPN #3 stated she had completed three (3) of the required seven (7) daily audits to include the observation of a SRNA giving care per the resident's plan of care. Interview with RN #2, on 10/02/14 at 4:25 PM, revealed he had completed two (2) of the required seven (7) daily audits to be done by licensed nurses, with observations of SRNAs providing care. 12. Further interview with LPN #3, on 10/02/14 at 4:20 PM, indicated she also participated in a medical record audit initiated 09/29/14 to ensure an incident report had been completed for an incident occurring on 10/01/14 (not reportable) and the appropriate documentation and resident assessment and monitoring occurred timely. Interview with RN #1, on 10/02/14 at 4:25 PM, revealed she also had completed a medical record audit on 09/29/14 on second (2nd) shift regarding a change in resident condition to ensure the resident's responsible party was notified, the physician was notified, appropriate assessment and monitoring of the resident was completed and timely documentation in the progress notes. Review of that audit sheet indicated RN #1 had completed that audit on 2nd shift on 09/29/14. 13. Interview with the Administrator, the DON, the Staff Development Coordinator, the Human Resource Director and the Medical Director, on 10/02/14 at 4:35 PM, revealed they were all to be participants in a newly developed Compliance Ad-Hoc Committee to manage the development of the Plan of Correction (POC) for ongoing compliance. They indicated they are to oversee the implementation of the POC with GSS Consultant support and assistance, ensure all audit results are submitted to the Committee for review and follow-up action, as indicated. The Administrator stated the Ad-Hoc Committee minutes would be reported to the Continuing Quality Improvement Committee monthly. Review of the sign-in sheet for the Ad-Hoc meeting revealed it took place on 09/29/14 with the Administrator, the DON, the Staff Development/Quality Coordinator, the Human Resource Director, the Medical Records Director, both MDS Coordinators, and the Medical Director. The next Quality Assurance meeting is scheduled to be held on 10/28/14.

Based on observation, interview, closed record review, and review of the facility's policies and procedures, it was determined the facility failed to have an effective system to ensure the comprehensive care plan was implemented to provide the appropriate size sling and the appropriate number of staff present for the positioning of one (1) of sixteen (16) sampled residents, (Resident #14) which resulted in an injury to the resident. (Refer to F323) On 09/16/14 at 11:30 AM, State Registered Nursing Assistant (SRNA) #3, failed to follow Resident #14's care plan for transfers and utilization of a lift. Record review revealed Resident #14's care plan directed staff to use two assist with transfers, and noted the size and type of sling to be used for the resident. However, SRNA #3, without assistance, attempted to reposition Resident #14 for transfer, onto a mechanical lift sling that was smaller than the resident's facility assessed size. While SRNA #3 was positioning the resident onto the lift sling, Resident 14's head hit the lift arm hooks, resulting in a 1.5 centimeter laceration above the right eye, with profuse bleeding. Interviews revealed between 3:30 PM and 4:00 PM, Registered Nurse (RN) #1 and Minimum Date Set (MDS) Nurse #1 found Resident #14 with bruising around the right eye with significant swelling and increased bleeding that had soaked through the initial dressing. At 4:00 PM the Director of Nursing (DON) gave direction to RN #1 to prepare the resident for transfer to the hospital for evaluation. However, interviews revealed neither the physician nor the ambulance service was notified as instructed. At 5:00 PM, the resident was found unresponsive and in respiratory distress. The facility made an urgent call to the ambulance company at 5:08 PM with arrival at 5:18 PM. The resident was found with no pulse or spontaneous respirations and was pronounced dead at 5:20 PM. The facility's failure to have an effective system in place to ensure care plans were implemented placed Resident #14 and other residents at risk in a situation that could cause or was likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 09/24/14 and determined to exist 09/16/14. The facility was notified of the Immediate Jeopardy on 09/25/14. The facility provided an acceptable Allegation of Compliance on 10/01/14 that alleged removal of Immediate Jeopardy on 09/30/14. The State Survey Agency verified Immediate Jeopardy was removed on 09/30/14 as alleged, at 42 CFR 483.20 Resident Assessment (F282) with the scope and severity lowered to a "D" while the facility monitors the effectiveness of the implemented plan of correction. The findings include: Review of the facility's policy and procedure titled, Care Plans, revised December 2005, revealed the purpose was to establish a means of recording identified client problems and planned interventions. The care plan provided a means of evaluating the effectiveness of interventions and determining what modifications were necessary. Review of the closed clinical record for Resident #14 revealed the facility admitted the resident on 09/17/08 with [DIAGNOSES REDACTED]. Review of the residents comprehensive care plan revealed the resident had an Activities of Daily Living (ADL) deficit related to immobility and dementia, initiated on 06/04/13, and required total assistance using two (2) persons for transfers with the total lift using a large high back sling and two (2) people for turning and repositioning. Review of the Mobilization Support data Collection Tool, dated 01/17/14, revealed the resident required a total lift for transfer between surfaces using a large high back sling. The facility further assessed the resident using the Minimum Data Set (MDS), dated [DATE], as requiring extensive assistance with bed mobility and transfers. Interview with SRNA #3, on 09/24/14 at 10:45 AM and 09/25/14 at 9:08 AM, revealed she was going to get the resident out of bed and place him/her in a wheelchair to transport him/her to the dining room for lunch. SRNA #3 stated they were already late and she was rushed to get the resident out of bed. The SRNA said she did not review the resident's care plan in the Kiosk prior to the incident because she had taken care of the resident before and knew he/she used a high back sling; however, the SRNA thought the resident was to use a medium sized sling. The SRNA indicated the lift sling already under the resident was wet and she was unable to locate a clean sling to use. The SRNA checked the C/D Hall linen closet and the A/D Hall linen closet, but was unable to find a clean lift sling and did not know of another place to look. She decided to use the roommate's sling which was already in the room. The SRNA stated the roommate's sling was a full body, long seat sling in a size small. Continued interview with SRNA #3, on 09/24/14 at 10:45 AM, revealed she knew the sling was different and smaller; however, she was trying to hurry and just needed to make sure the resident was perfectly centered in order for the straps to attach to the mechanical lift. The SRNA stated during the process of trying to attach the straps she realized the resident was going to need to be readjusted again and with the lift still positioned over the resident, she turned the resident to his/her left side. The lift arm hooks where the sling attached to the mechanical lift hit the right side of the resident's head. SRNA #3 explained the resident sustained [REDACTED]. SRNA #3 further detailed she knew she was supposed to use the right type and size sling and had been trained on ensuring the right sling, but she was in a hurry and did not review the care plan or ask for help. The SRNA further stated she was trained to always have two (2) people to assist with turning and repositioning as well as transferring, but she did not ask anyone for help. SRNA #3 said SRNA #5 came into the room once the resident was attached to the lift and helped move the resident safely to the chair, but the injury had already occurred at that point. The SRNA stated the purpose of having someone else there to assist was to help spot potential hazards and prevent injury to the resident. Interview with SRNA #4, on 09/24/14 at 12:26 PM, and SRNA #2, on 09/25/14 at 9:54 AM, revealed they used two (2) people for the actual transfer with the lift; however, they did not get assistance to put the resident in the sling or to hook the sling to the lift. Interview with SRNA #1, on 09/25/14 at 9:55 AM, revealed she knew transfer information on residents was in the Kiosk on the Kardex. The SRNA stated she was aware two (2) people were required for transfers; however, she did get assistance to place the resident in the sling. Interview with Licensed Practical Nurse (LPN) #1, on 09/25/14 at 11:29 AM, revealed the purpose of the care plan was to ensure the residents were getting the right care for their personal needs. The LPN stated not following the care plan placed the residents at risk for injury. LPN #1 further stated she did not monitor the SRNAs to ensure the care plan was being followed and assumed they knew what to do since they had worked at the facility for so long. Interview with the DON, on 09/24/14 at 12:30 PM, revealed the SRNAs accessed information from the care plan on the Kardex which was in the computer Kiosk. The DON stated SRNA #3 did not review the Kardex to ensure the appropriate type and size sling needed for Resident #14 was being used. In addition, Resident #14 was care planned to have two (2) people to assist with mobility and that was not done either. The DON said the SRNA had cared for the resident before and should have known what equipment was needed. The DON stated the mechanical lift slings were kept in the C/D Hall linen closet, the therapy room, and in room B12 on the other unit. The location of the sling was information included in the mechanical lift training. Continued interview with the DON, on 09/25/14 at 11:50 AM, revealed she monitored the care plans in the care plan meetings and made rounds that included going into resident rooms to ensure the care plans were being followed. However, the DON could not confirm actually watching the SRNAs using the mechanical lift to ensure the appropriate type and size slings were being used. The facility provided an Allegation of Compliance (AOC) on 09/29/14 alleging the Immediate Jeopardy was removed on 09/30/14; the facility took the following steps to remove the Immediate Jeopardy. 1. The SRNA (SRNA #3) involved in the incident was suspended after the incident on 09/16/14 pending investigation of the incident. 2. A meeting was held to discuss the investigation, root cause of the Immediate Jeopardy, Good Samaritan Society policies and procedures (review included safe resident handling, incident reporting and notification of change of condition and action plan), on 09/25/14 at 2:00 PM. Attendees of the meeting on 09/25/14 were the Administrator, Director of Nursing, Staff Development/Quality Assurance Coordinator, Human Resources Director, Good Samaritan Society (GASS) Rehabilitation/Skilled Consultants, Good Samaritan Society Quality Improvement Consultant and a Good Samaritan Society Workforce Consultant. 3. All policies and procedures reviewed at the 2:00 PM meeting on 09/25/14 were found to be appropriate with no revisions required. A lesson plan was developed by the attendees for re-education. 4. A meeting was held, on 09/25/14 at 4:00 PM, to communicate the Immediate Jeopardy situation, assign tasks and communicate mandatory adjusted schedules. Attendees included the Director of Nursing, Staff Development/Quality Assurance Coordinator and Nurse Case Managers. 5. On 09/26/14 at 5:00 AM, a meeting was held to provide re-education in response to the Immediate Jeopardy and to discuss re-education to follow for the entire active nursing staff. Attendees included the Administrator, Director of Nursing, Staff Development/Quality Assurance Coordinator, and Nurse Case Managers with re-education provided by a Good Samaritan Society Rehabilitation/Skilled Consultant. 6. On 09/26/14 an inventory of mechanical lift slings was reviewed by the Administrator and the Environmental Services Director and it was identified that a sufficient number of slings were present. There were eighty-eight (88) available slings for a total of nineteen (19) residents requiring the use of a mechanical lift. Soiled slings were placed in the soiled utility rooms by nursing staff to be laundered. Laundry staff cleaned and inspected slings and returned them to the floor the very next day. 7. A one-hundred (100)% review was initiated on 09/25/14 and concluded on 09/28/14 to ensure accuracy (determination of type of assistance required for bed mobility and transfers) of seventy-nine (79) current residents' Mobilization User Defined Assessments (UDA) by the Director of Nursing. Ten (10) of the seventy-nine (79) residents were re-assessed by completing the Mobilization UDA for three (3) consecutive shifts on 09/27/14 and 09/28/14 by Nurse Case Managers and floor nurses. 8. One-hundred (100)% review of seventy-nine (79) current residents' care plans was initiated on 09/25/14 and completed on 09/28/14 by the Director of Nursing to ensure care plans and Kardexs included the level of assist for bed mobility and transfer, included the number of staff members required for use of the lift, the type of lift to be used, and the sling size, if indicated. 9. Re-education was provided to SRNA staff and licensed nursing staff beginning at 5:00 AM on 09/26/14 on all shifts and continued through 09/27/14 for compliance by Good Samaritan Society Rehabilitation/Skilled Consultant, Nurse Case Manager/Safe Resident Handling Coordinator and Staff Development/Quality Assurance Coordinator. Beginning on first (1st) shift of 09/26/14 no nursing staff member was permitted to provide resident care until re-education was completed. As of 09/29/14 seventy (70) employees (all current full and part-time nursing staff) had received the re-education which included passing a post-test and return demonstration for use of the mechanical lift. Two (2) prn/on-call nursing employees who were not scheduled to work will receive the re-education prior to working. The re-education included 1) care delivered per care plan, 2) quality of care, 3) accidents and 4) clinical records. 10. Audits will be completed daily times seven (7) days by licensed nurses for completion of mobilization (UDA) on each shift in the first twenty-four (24) hours of admission/readmission and with change of condition for accurate care planning/Kardex for level of assistance for bed mobility and transfer including number of staff, type of lift, and sling size if indicated. 11. Audits will be completed daily times seven (7) days by licensed nurses observing one (1) SRNA on each unit on each shift in assisting residents with bed mobility and transfer to ensure safe care per the resident's care plan. 12. Medical record audits will be completed daily times seven (7) days by licensed nurses to ensure an incident report has been completed with each incident, Good Samaritan Society facility investigation policy was initiated, physician and resident's responsible party were notified with appropriate documentation, resident monitoring and assessment was completed and documented in appropriate UDA's and progress notes. 13. The facility developed a compliance Ad-Hoc Committee chaired by the facility Administrator to manage the development of the Plan of Correction for ongoing compliance and to oversee the implementation of the Plan of Correction with Good Samaritan Society Consultant support and assistance. Committee members include the Director of Nursing, the Staff Development/Quality Assurance Coordinator, Nurse Case Managers, Human Resource Director, Health Information Manager, and the Medical Director. All audit results will be submitted to the Ad-Hoc Committee for review and follow-up action as indicated. The Ad-Hoc Committee minutes will be reported to the Continuing Quality Improvement Committee Monthly. Through observation, interview and record review the State Survey Agency validated the Allegation of Compliance with removal of Immediate Jeopardy on 09/30/14 as alleged prior to exit on 10/02/14 as follows: 1. Review of the personnel file for SRNA #3 revealed she was suspended from work after the incident on 09/16/14 pending the facility investigation and remained suspended throughout the survey including date of exit of 10/02/14. 2. A group interview including the Administrator, the Director of Nursing, the Staff Development Coordinator, the Human Resource Director, two (2) Good Samaritan Society Rehabilitation/Skilled Consultants (per telephone conference call), a Good Samaritan Society Quality Improvement (QI) Coordinator (per telephone conference call), and the Good Samaritan Society Workforce Consultant (per telephone conference call), on 10/02/14 at 2:00 PM, revealed the Administrator, the Director of Nursing, the Staff Development Coordinator and the Human Resource Director were present in person at the meeting held, on 09/25/14 at 2:00 PM, and the two (2) GSS Consultants, the GSS QI Coordinator and the GSS Workforce Consultant were at the meeting via telephone conference call to discuss the investigation regarding Resident #14, the root cause of the Immediate Jeopardy, GSS policies and procedures to include safe resident handling, incident reporting and notification of change of condition and to develop an action plan (lesson plan). Review of the lesson plan agenda (not dated) provided as proof for the AOC which included training on safe assistance with bed mobility, transfers and use of mechanical lifts and slings, and also included training on the writing of the individualized nursing care plan based on individualized needs and on following the residents' plans of care. Review of the sign-in sheets for the meeting held on 09/25/14 at 2:00 PM, confirmed the signatures of the attendees. 3. Review of the lesson plan developed in the meeting, on 09/25/14 at 2:00 PM, revealed an agenda, content, and SRNA and licensed nurse post-tests to address the Immediate Jeopardy compliance. Review of the lesson plan developed "Providing Resident Care - Individualized, Safe, Documented" revealed an agenda, content, and SRNA and licensed nurse post-tests to address the Immediate Jeopardy compliance. The length of the training session outlined on the agenda was thirty (30) minutes for SRNAs and one (1) hour for licensed nurses with the purpose of the training to be correction activity for Immediate Jeopardy F-tags to include policies regarding safe handling of residents, incident reporting, notification of resident change of condition, data collection and UDA assessment instructions and use of mechanical lifts and slings. 4. Interview with Nurse Case Managers #1 and #2, the DON, and the Staff Development Coordinator, on 10/02/14 at 3:06 PM, 3:15 PM, and 3:20 PM, respectively revealed they had attended the meeting held, on 09/25/14 at 4:00 PM, to discuss the Immediate Jeopardy situation, to assign tasks and to communicate mandatory adjusted schedules for the nursing staff. Review of the sign-in sheet for the meeting held on 09/25/14 at 4:00 PM confirmed the signatures of the attendees. 5. A group interview including the Administrator, the Director of Nursing, the Staff Development Coordinator, GSS Rehabilitation/Skilled Consultant #2 (per telephone conference call) and Nurse Case Managers #1, #2 and #3, on 10/02/14 at 2:00 PM, revealed they were all present in person at the meeting held, on 09/26/14 at 5:00 AM, and GSS Rehabilitation/Skilled Consultant #2 provided the re-education to that staff in the meeting with discussion of re-education for the entire active nursing staff. Review of the sign-in sheet for the meeting held on 09/26/14 confirmed the signatures of the attendees. 6. Observation of the mechanical lift slings located in the laundry and on each nursing unit, on 10/02/14 at 9:00 AM, revealed there were eighty-eight (88) slings available for use. Twelve (12) of the slings observed were soiled and awaiting washing and inspection. Interview with the Administrator and the Environmental Services Director, on 10/02/14 at 12:16 PM, revealed they both participated in an inventory of the facility mechanical lift slings on 09/26/14. The Administrator and the Environmental Services Director indicated the soiled slings were to be placed in the soiled utility rooms by nursing staff to be laundered and the laundry staff was to launder, dry and inspect the slings before stocking them on each nursing unit the next day. Interview with SRNA #7, on 10/02/14 at 3:50 PM, revealed she would place a soiled sling in a bag in the soiled utility room on the nursing unit to be laundered and it was her understanding the laundry staff would inspect the slings for any defects before returning them to the nursing units. Interview with the Housekeeping/Laundry Supervisor, on 10/02/14 at 4:00 PM, revealed the laundry staff cleaned the mechanical lift slings seven (7) days a week and inspected them before returning them to the nursing units for use. She stated if a sling was defective it would be given to Case Manager #3 for replacement. Interview with Case Manager #3, on 10/02/14 at 4:10 PM, revealed he received the defective slings identified by the laundry staff or any nursing personnel and would order a replacement right away and the replacement would usually be provided within a week. Interview with the DON, on 10/02/14 at 4:10 PM, revealed mechanical lift slings were stored in the clean utility rooms on each nursing unit and were laundered and inspected by the laundry staff. 7. Further interview with the DON, on 10/02/14 at 4:10 PM, revealed she initiated a one-hundred 100% audit of the seventy-nine (79) residents' Mobilization UDA's in the facility on 09/25/14 and completed the audit on 09/28/14. Review of the UDA's for Resident #17, Resident #18, Resident #19 and Resident #20 revealed they were accurate assessments of the residents' needs. Re-assessment documents were reviewed for ten (10) of the seventy-nine (79) residents reviewed which were completed for three (3) consecutive shifts on 09/27/14 and 09/28/14. Interview with Case Manager #1, and RN #1, on 10/02/14 at 4:15 PM, and 4:20 PM, respectively revealed they assisted with the re-assessments for ten (10) of the seventy-nine (79) residents reviewed which were completed for three (3) consecutive shifts on 09/27/14 and 09/28/14. Review of the audit initiated on 09/27/14 and concluded on 09/28/14 confirmed ten (10) residents were reviewed for reassessment by the DON. 8. Observation of Resident #17, on 09/30/14 at 3:25 PM, on 10/01/14 at 8:35 AM, and 10:30 AM, revealed the resident's plan of care was being followed by the nursing staff. Observation of Resident #17, on 10/01/14 at 11:00 AM, revealed two (2) SRNA's performing a mechanical lift transfer of the resident from the bed to a wheelchair using the appropriate sling identified on the plan of care and using appropriate procedure for the transfer. Observation of Resident #18, on 09/30/14 at 3:45 PM, 10/01/14 at 8:45 AM and 10:45 AM, revealed the resident was being cared for per the assessed nursing/SRNA plan of care. Observation of Resident #19, on 09/30/14 at 3:11 PM and 10/01/14 at 1:30 PM, revealed the resident's plan of care was being followed by the nursing staff. Review of the clinical records for Resident #17, Resident #18 and Resident #19's revealed Minimum Data Set (MDS) comprehensive reviews completed in the past thirty (30) days and compared to the residents' records revealed accurate assessments had been completed. Review of the nursing and SRNA care plans for Resident #17, Resident #18 and Resident #19 revealed they had been created from the comprehensive MDSs, completed in the past thirty (30) days and had been updated/revised as indicated. Review of the Mobilization UDA dated 08/28/14 for Resident #17 revealed the resident was to be transferred using the appropriate sling size with a mechanical lift as assessed. Interview with the DON, on 10/02/14 at 4:10 PM, revealed she initiated a one-hundred 100% audit of the seventy-nine (79) residents' (in the facility at the time) care plans on 09/25/14 and completed that audit on 09/28/14 to ensure care plans and Kardexs included the level of assist for bed mobility and transfer, the number of staff required for use of the lift and the type of lift and sling to be used, if indicated. Review of the audits completed by the DON confirmed they were completed between 09/25/14 and 09/28/14. 9. Review of the SRNA and licensed nurse sign-in sheets for the re-education trainings revealed all but two (2) on-call nursing employees had completed the training between 09/26/14 at 5:00 AM and 09/27/14. A telephone interview with the GSS Rehabilitation/Skilled Consultant #2, on 10/02/14 at 2:00 PM, revealed she had conducted the lesson plan training on 09/26/14 through 09/29/14 with the assistance of Nurse Case Managers #1 and #2. Interview with Nurse Case Managers #1 and #2, on 10/02/14 at 2:20 PM, revealed they had participated in the lesson plan training done on 09/26/14 through 09/27/14. Interview with the Staff Development Coordinator on 10/02/14 at 2:30 PM revealed she had participated in the lesson plan training on use of the slings and mechanical lifts and had observed staff with return demonstrations of use of the slings and lifts on 09/26/14 through 09/29/14. Interview with LPN #2, on 10/02/14 at 3:40 PM, revealed she had attended an in-service training last week about lift use, charting, incident reporting, and calling the doctor. She stated she demonstrated the use of the mechanical lifts and had a written post-test on the training content. Interview with LPN #3, on 10/02/14 at 3:43 PM, revealed she had attended an in-service training on 09/27/14 about mechanical lift use, charting, incident reporting, and calling the doctor. She stated she also demonstrated the use of the mechanical lifts and had a written post-test on the training content. Interview with SRNA #7, on 10/02/14 at 3:48 PM, revealed she attended an in-service training on 09/26/14 about the use of the resident care plans and lift/sling use and she did a return demonstration and had a post-test. Interview with SRNA #8, on 10/02/14 at 3:52 PM, revealed she attended an in-service training on 09/26/14 about the use of the resident care plans and lift/sling use and she did a return demonstration and had a post-test. 10. Review of the seven (7) daily audits, initiated 09/29/14, confirmed a daily audit by licensed nurses for completion of the Mobilization UDA on each shift in the first twenty-four (24) hrs of admission/readmission and with change of condition, for accurate care planning/Kardex for level of assist for bed mobility and transfer including number of staff required, type of lift and sling size, if indicated. Interview with LPN #3, on 10/02/14 at 4:20 PM, revealed she had completed three (3) of the required seven (7) daily audits to be done by licensed nurses. Interview with RN #2, on 10/02/14 at 4:25 PM, revealed he had completed two (2) of the required seven (7) daily audits to be done by licensed nurses. 11. Review of the audits, initiated 09/27/14, confirmed the audits for proper use of the lift were completed with observations. Interview with LPN #3, on 10/02/14 at 4:20 PM, revealed she had observed SRNA #2, on day shift on 09/29/14, assisting Resident #17 with bed mobility and lift/sling transfer to ensure the safe care per the resident's care plan. LPN #3 stated she had completed three (3) of the required seven (7) daily audits to include the observation of a SRNA giving care per the resident's plan of care. Interview with RN #2, on 10/02/14 at 4:25 PM, revealed he had completed two (2) of the required seven (7) daily audits to be done by licensed nurses, with observations of SRNAs providing care. 12. Further interview with LPN #3, on 10/02/14 at 4:20 PM, indicated she also participated in a medical record audit initiated 09/29/14 to ensure an incident report had been completed for an incident occurring on 10/01/14 (not reportable) and the appropriate documentation and resident assessment and monitoring occurred timely. Interview with RN #1, on 10/02/14 at 4:25 PM, revealed she also had completed a medical record audit on 09/29/14 on second (2nd) shift regarding a change in resident condition to ensure the resident's responsible party was notified, the physician was notified, appropriate assessment and monitoring of the resident was completed and timely documentation in the progress notes. Review of that audit sheet indicated RN #1 had completed that audit on 2nd shift on 09/29/14. 13. Interview with the Administrator, the DON, the Staff Development Coordinator, the Human Resource Director and the Medical Director, on 10/02/14 at 4:35 PM, revealed they were all to be participants in a newly developed Compliance Ad-Hoc Committee to manage the development of the Plan of Correction (POC) for ongoing compliance. They indicated they are to oversee the implementation of the POC with GSS Consultant support and assistance, ensure all audit results are submitted to the Committee for review and follow-up action, as indicated. The Administrator stated the Ad-Hoc Committee minutes would be reported to the Continuing Quality Improvement Committee monthly. Review of the sign-in sheet for the Ad-Hoc meeting revealed it took place on 09/29/14 with the Administrator, the DON, the Staff Development/Quality Coordinator, the Human Resource Director, the Medical Records Director, both MDS Coordinators, and the Medical Director. The next Quality Assurance meeting is scheduled to be held on 10/28/14.

Based on interview, closed record review, review of the facility's policies and procedures and incident report, it was determined the facility failed to ensure one (1) of the sixteen (16) sampled residents, Resident #14, received the necessary care and services for a head injury obtained from the mechanical lift during the facility's attempt to transfer the resident. (Refer to F157, F282, F323) On [DATE], the nursing staff failed to obtain initial vital signs and complete a neurological assessment when Resident #14 sustained a 1.5 centimeter laceration above the right eye with profuse bleeding during a transfer with a mechanical lift. The Director of Nursing (DON) was not notified of the injury until approximately 2:00 PM and she instructed the staff to apply a dressing to the wound. Interviews revealed between 3:30 PM and 4:00 PM, Registered Nurse (RN) #1 and Minimum Data Set (MDS) Nurse #1 found Resident #14 with bruising around the right eye with significant swelling and increased bleeding that had soaked through the initial dressing. However, interviews and record review revealed no documented evidence of assessment and/or monitoring of Resident #14. At 4:00 PM the DON was again notified of the change of condition and gave direction to RN #1 to prepare the resident for transfer to the hospital for evaluation. However, interviews revealed neither the physician nor the ambulance service was notified as instructed. At 5:00 PM, the resident was found unresponsive and in respiratory distress. The facility made an urgent call to the ambulance company at 5:08 PM with arrival at 5:18 PM. The resident was found with no pulse or spontaneous respirations and was pronounced dead at 5:20 PM. The facility's failure to ensure residents received appropriate care and services and monitoring after an injury placed Resident #14 and other residents at risk in a situation that was likely to cause serious injury, harm, impairment or death to a resident. The Immediate Jeopardy was identified on [DATE] and determined to exist [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. The facility provided an acceptable Allegation of Compliance on [DATE] that alleged removal of Immediate Jeopardy on [DATE]. The State Survey Agency verified Immediate Jeopardy was removed on [DATE] as alleged, at 42 CFR 483.25 Quality of Care (F309) with the scope and severity lowered to a "D" while the facility monitored the effectiveness of the implemented plan of correction. The findings include: Review of the facility's policy and procedures titled Fallen or Injured Resident, revised [DATE], revealed the purpose was to give prompt treatment and prevent further injury. The policy specified the following steps should be completed in the event of an injury: if bleeding apply continuous firm pressure; do not remove soaked dressing instead add more layers to absorb the blood; take the resident's blood pressure, pulse and respirations to help assess the resident's condition; perform a full body exam, check pulse oximetry, and review the resident's medications for potential complications; notify the physician and follow orders; for residents with suspected head injury notify the physician by phone, not fax; notify the family or responsible party, continue to monitor the resident's condition, and complete the incident report. Review of the facility's policy and procedures titled Completing Incident/Injury Report Forms, revised [DATE], revealed the purpose was to document a resident's incident/accident, possible causative factors, corrective action, and assure reporting and follow-up of all incidents/accidents involving a resident. The facility's procedure in the event of an incident included; completing a body review for injuries and bleeding, taking vital signs and noting times, dial 911 if the injury may be serious or if in doubt as to the seriousness of the resident's condition, and use of first aid measures. Review of the closed clinical record for Resident #14 revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of the resident's comprehensive care plan, initiated on [DATE], revealed the resident had a deficit in Activities of Daily Living (ADL) and required total assist of staff for a total lift using a large high back sling and with two (2) people assist to turn and reposition. Review of the Mobilization Support Data Collection Tool, dated [DATE], revealed the facility determined the resident required a total lift for transfer between surfaces using a large high back sling. The facility further assessed the resident using the Minimum Data Set (MDS), dated [DATE], as requiring extensive assistance with bed mobility and transfers, and determined the Brief Interview for Mental Status (BIMS) score was a two (2) out of a possible fifteen (15). Review of facility's incident report for Resident #14's injury, dated [DATE], revealed the wound nurse measured the wound at 0.1 centimeter (cm) x 1.5 cm. The area was cleaned and pressure applied to the wound with some decrease in bleeding. The report indicated the injury type as a laceration located on the face. The resident's pain level was marked as "hurts even more". The form was marked the resident was alert and oriented to person. The Injury report noted the family and resident's physician were notified at 1:00 PM on [DATE]. Interview with SRNA #3, on [DATE] at 10:45 AM, revealed sometime around 11:30 AM she was getting Resident #14 ready to transfer using a mechanical lift without assistance. She turned Resident #14 to the right side to adjust the sling for the mechanical lift while the mechanical lift was already in position over the resident. SRNA #3 stated the lift arm hooks hit the resident's head as he/she was turned to the side. The SRNA stated when she turned the resident back over she noted a cut above the resident's right eye, which profusely bled. SRNA #3 stated SRNA #5 came into the resident's room to offer assistance and was sent to get the nurse and some washcloths. The SRNA revealed the laceration was already swelling when Licensed Practical Nurse (LPN) #1 entered the room around 11:50 AM. SRNA #3 stated the LPN tried to place steri-strips on the area, but they would not stick due to the bleeding, and an hour after the incident, the area was still bleeding and dripping down the resident's cheek. Interview with SRNA #5, on [DATE] at 3:09 PM, revealed the resident hit his/her head on a bolt that held the handle onto the arm of the lift. Per interview, there was a protective cover, but from underneath the bolt was still sharp. SRNA #5 stated she went to get LPN #1, they washed the resident's face, and put a cloth on his/her face. LPN #1 put strips on the wound then added a thick pad and wrapped the resident's head; however, there was a little continuous stream of blood. Interview with LPN #1, on [DATE] at 3:21 PM, revealed she was notified approximately 11:50 AM when the resident's head was hit by the mechanical lift hooks while staff attempted to attach the sling. The LPN stated Resident #14 had swelling and a gash above the right eye with a small stream of blood flowing down the resident's face. Continued interview with LPN #1, on [DATE] at 12:01 PM, revealed she cleaned the wound and applied steri-strips, but they would not stick due to the bleeding so she asked for MDS Nurse #2 to come and see the resident as she was the wound nurse for the facility. LPN #1 stated MDS #2 cleaned the area again and applied a second set of steri-strips and LPN #1 was told to monitor the wound. Interview with MDS Nurse #2, on [DATE] at 12:31 PM, revealed she was notified by LPN #1 that Resident #14 was injured and went to see the resident between 12:45 PM and 1:00 PM on [DATE]. MDS Nurse #2 stated she tried to get the bleeding to stop for fifteen (15) to twenty (20) minutes then applied another set of steri-strips. The MDS Nurse further stated the bleeding was initially a constant stream down the resident's face, then slowed; however, never stopped completely. MDS Nurse #2 indicated she did not think the injury was emergent; however, she did not inquire of the resident's vital signs and did not complete them herself. The MDS Nurse stated she did look at the resident's pupils but did not document this was ever done. MDS Nurse #2 stated the resident should not have been bleeding an hour after the incident; however, per interview, she never asked when the injury actually occurred to make that determination. Review of MDS #2's nursing notes, dated [DATE] at 12:50 PM, revealed the resident had a "split" to skin that was bleeding. The notes specified no deep trauma was noted and did not describe how that was determined. The notes did identify some swelling and bruising, but did not reflect the measures taken to stop the bleeding or that the bleeding never actually stopped. Continued interview with LPN #1, on [DATE] at 12:01 PM, revealed an hour later the wound was a little more swollen and still bleeding with fresh blood streaked down the resident's cheek and on the resident's clothes. The LPN stated she was concerned about the bleeding and notified the DON around 2:00 PM on [DATE] of the incident. Interview with the DON, on [DATE] at 12:30 PM, revealed she was told around 2:00 PM on [DATE] that the resident received a skin tear from hitting his/her head on the mechanical lift. The DON stated she went to look at the resident and did not notice bruising, swelling, or any evidence there had been much bleeding. The DON denied seeing the blood on the resident's face or clothes and said she only noticed a little oozing around the steri-strips. However, the DON did report she told LPN #1 to apply a dressing to see if the bleeding would slow down, and never asked what time the injury actually occurred to determine the length of time the resident had been bleeding. The DON further stated the resident appeared fine; however, she did not complete a neurological assessment or complete a set of vital signs. In addition, the DON stated she was told by LPN #1 that vital signs had been obtained, but she never checked to ensure they were actually done. Continued interview with LPN #1, on [DATE] at 12:01 PM, revealed she was told by the DON the resident would be fine once the bleeding stopped and to apply a dressing. The LPN stated she applied a thick dressing on the wound and wrapped the resident's head with gauze to keep it in place. Interview with SRNA #4, on [DATE] at 12:26 PM, revealed she went to see the resident around 2:00 PM and the resident was still bleeding from the [MEDICAL CONDITION]. The SRNA stated LPN #1 applied a dressing and she asked the LPN if they were going to send the resident out to the emergency room . SRNA #4 stated she was told the family would not want the resident to be sent out for treatment. Continued interview with LPN #1, on [DATE] at 12:01 PM, revealed she did not notify the resident's family or physician of the injury until the next shift because she was busy with other tasks. She further stated she did not complete the incident report until around 3:00 PM or so. She never obtained the resident's blood pressure, pulse, respirations, or used the pulse oximeter. LPN #1 stated the resident was awake, and did not seem different neurologically, but she never performed a neurological assessment to monitor the resident's condition. However, per the facility's policy and procedures titled Fallen or Injured Resident staff should take the resident's blood pressure, pulse and respirations to help assess the resident's condition; perform a full body exam, check pulse oximetry; review the resident's medications for potential complications; and, notify the physician and follow orders. Further review of Resident #14's record revealed LPN #1's nursing notes for [DATE], which indicated the resident was last observed at 1:30 PM by the LPN. There were no other entries made until the next shift at 3:00 PM. Interview with MDS Nurse #1, on [DATE] at 5:07 PM, revealed she was told in report around 3:20 PM that Resident #14 was injured with the lift and had a skin tear. The MDS Nurse stated she went to see the resident after report and found the resident sitting up in a chair with a dressing and gauze wrapped around the resident's head. MDS Nurse #1 stated the resident had bled through the dressing and a large area of blood was on the dressing. She lifted up the bandage and saw the resident's eye had swollen shut and had a dark purple bruise around the eye. The MDS Nurse stated she had been told the DON wanted to just monitor the resident's condition and that the resident only had a skin tear. MDS Nurse #1 said she told RN #1 to go ahead and prepare the paperwork for the resident to be transferred, notify the resident's physician, and call the ambulance service, then left to talk with the DON about the resident's injury. Interview with RN #1, on [DATE] at 2:45 PM, revealed he was told of the resident's injury during shift change report around 3:00 PM on [DATE]. The RN said when he went to assess the resident he noticed approximately a quarter sized area of fresh blood on the resident bandage with minor bruising above and around the resident's right eye and did not notice the swelling. RN #1 stated he was not overly concerned as the resident seemed to be breathing fine. The RN further mentioned MDS Nurse #1 came into the room and said the resident would need stitches and then left to go talk with the DON. The RN stated he directed the SRNAs to return the resident to bed and then left Resident #14 to complete blood sugars and pass medications to the other residents. RN #1 indicated he did not actually assess the resident, never took vital signs, and did not complete the transfer forms because he thought the DON and LPN #1 would take care of everything. Interview with SRNA #5, on [DATE] at 3:09 PM, revealed she went back to check on Resident #14 when the other SRNAs were told to put the resident back in bed between 3:30 PM and 4:00 PM. SRNA #5 said the resident was breathing, but the resident's eyes were no longer open and it was like he/she had gone to sleep. The SRNA further stated it was a good while before a nurse came back in to check on the resident; however, could not specify a length of time. Interview with the DON, on [DATE] at 11:50 AM, revealed she went back to the room around 4:00 PM to assess the resident and told RN #1 the resident needed to go immediately for sutures and evaluation at the hospital. The DON said she did not do any type of neurological assessment or complete a set of vital signs because the resident's color looked fine everywhere else, and nothing alarmed her as to the resident's stability. Review of the nursing notes written by the DON, dated [DATE] at 4:00 PM, revealed she was notified by RN #1 the resident had increased bleeding. The nursing notes specified the area had become swollen and significantly bruised. The nurse was to notify the physician and the family of the need to go to the hospital for evaluation and was told transportation was arranged. Interview with LPN #1, on [DATE] at 12:01 PM, revealed on [DATE] at 4:00 PM, she sent a fax to the resident's physician requesting an order to send the resident to the emergency room and called the family for the first time to let them know the resident was injured and required stitches. LPN #1 stated she did not know why she did not page the doctor per the facility's policy and procedure, which stated for residents with suspected head injury notify the physician by phone, not fax. Record review revealed two (2) Facsimile (fax) Transmission Verification Report regarding Resident #14. Review of one Facsimile (fax) Transmission Verification Report, not signed, dated or timed, revealed there was no confirmation of the physician notification ever being sent. Review of the fax revealed the resident obtained a split/gash measuring 0.1 x 1.5 cm above the right eye during a transfer and had a moderate amount of bleeding and steri-strips were applied. Review of the second Facsimile (fax) Transmission Verification Report, dated [DATE], revealed a confirmation time of 4:34 PM. The fax specified the resident sustained [REDACTED]. The gash continued to moderately bleed and was it okay to send the resident out to be sutured. Interview with the Staff Development Nurse, on [DATE] at 12:44 PM, revealed she went to see the resident around 5:00 PM and SRNA #5 was in the room. The Staff Development Nurse indicated the resident was having difficulty breathing and his/her skin color appeared yellow. The Staff Development Nurse stated she was not able to obtain a pulse oximeter reading and turned up the resident's oxygen to three (3) liters per minute. The Staff Development Nurse stated she sent SRNA #5 to get the DON immediately. Interview with DON, on [DATE] at 12:30 PM, revealed around 5:00 PM SRNA #5 came to her and said she needed to come to Resident #14's room immediately. The DON stated the resident was having difficulty breathing and was already on oxygen at three (3) liters per minute via nasal cannula and the Staff Development Nurse was trying to get a pulse oximeter reading. The DON said the resident's eyes were open, but the resident was not responsive. The DON indicated she was trying to get the patient to respond and turned the oxygen up to seven (7) liters. She left the room and came out to the desk and told RN #1 the situation was now urgent and they needed Emergency Medical Services (EMS). The DON stated she had been told someone had already called the ambulance services for EMS to transfer the resident to the hospital and that it would be an hour wait, so she told RN #1 to call again. Further interview with RN #1, on [DATE] at 2:45 PM, revealed he answered a call from the resident's physician who was upset and said if there was an emergency the facility should call and not send a fax. The RN further stated he received an order to transfer the resident to the hospital but did not write the order. RN #1 stated he did not call the ambulance service as was instructed because he thought someone else was taking care of it. However, he heard the ambulance had been called and that it would be an hour to an hour and a half wait. He stated he did not know who had actually called. However, an additional interview with LPN #1, on [DATE] at 3:21 PM, revealed RN #1 called the ambulance service at approximately 5:00 PM, but did not know if anyone ever completed the resident's transfer forms. Interview with MDS Nurse #1, on [DATE] at 5:07 PM, revealed RN #1 had told her the next day there was only one (1) call made to EMS and he did not realize it was an emergent situation when he had originally been told to call for the ambulance. Interview with Emergency Medical System (EMS) Dispatch Manager, on [DATE] at 2:58 PM, revealed all calls were recorded. The Dispatch Manager identified all recordings for [DATE] was reviewed and only one call came from the facility on [DATE] and that was at 5:08 PM. Review of the Ambulance Run Forms, dated [DATE], revealed the initial call was received at 5:09 PM and they were at the resident's side by 5:20 PM. The Ambulance Run Forms specified the resident was found unresponsive, cyanotic, pupils were constricted, and non-reactive. There was no pulse or respirations and was deceased at 5:20 PM on [DATE]. Interview with Resident #14's physician, on [DATE] at 4:42 PM, revealed she was not notified until late afternoon that the resident had been hit in the head. The physician stated she was told the resident needed to go out for stitches and was not aware of when the incident actually occurred. The Physician indicated the head was very vascular and would bleed a lot, but after an hour or hour and a half of bleeding, the resident should have been sent out for stitches. The physician stated she was called later by the facility and told she needed to sign the death certificate. The physician stated she was very confused by this because she had given an order for [REDACTED]. Interview with the resident's family member, on [DATE] at 11:47 AM, revealed he was not told until late afternoon of the injury and a short while later he received a call that the resident had passed away. Further interview with SRNA #3, on [DATE] at 10:45 AM, revealed she was not asked to complete an incident report or write a statement when the injury was reported per the facility's policy. The SRNA stated the procedure had always been that if there was an accident the resident was assessed, vital signs obtained, an incident report completed, and written statements obtained. However, that was not done this time. SRNA #3 stated she was not called until later that evening after the resident had passed away and told she would have to come in and write a statement for the facility. Interview with LPN #1, on [DATE] at 11:29 AM, revealed if there was an injury involved with an accident she really was not sure what should be done, and stated as a nurse she should assess the situation and vital signs were a part of that assessment. LPN #1 revealed this was not done with Resident #14 and it should have been. The LPN indicated vital signs and an initial assessment would have provided a baseline to compare to if there were changes in the resident's condition. LPN #1 said she just did not have a reason as to why it was not done. Interview with the DON, on [DATE] at 11:50 AM, revealed she did not feel she got a clear picture from the nursing staff as to what happened and what was going on. The DON stated she was initially told it was just a skin tear and that they did get vital signs. However, the DON stated she did not ensure the vital signs had been done, did not obtain them herself during assessment, or ensure the ambulance was en route after giving direction to the nursing staff. The facility provided an Allegation of Compliance (AOC) on [DATE] alleging the Immediate Jeopardy was removed on [DATE]; the facility took the following steps to remove the Immediate Jeopardy. 1. The SRNA (SRNA #3) involved in the incident was suspended after the incident on [DATE] pending investigation of the incident. 2. A meeting was held to discuss the investigation, root cause of the Immediate Jeopardy, Good Samaritan Society policies and procedures (review included safe resident handling, incident reporting and notification of change of condition and action plan), on [DATE] at 2:00 PM. Attendees of the meeting on [DATE] were the Administrator, Director of Nursing, Staff Development/Quality Assurance Coordinator, Human Resources Director, Good Samaritan Society (GASS) Rehabilitation/Skilled Consultants, Good Samaritan Society Quality Improvement Consultant and a Good Samaritan Society Workforce Consultant. 3. All policies and procedures reviewed at the 2:00 PM meeting on [DATE] were found to be appropriate with no revisions required. A lesson plan was developed by the attendees for re-education. 4. A meeting was held, on [DATE] at 4:00 PM, to communicate the Immediate Jeopardy situation, assign tasks and communicate mandatory adjusted schedules. Attendees included the Director of Nursing, Staff Development/Quality Assurance Coordinator and Nurse Case Managers. 5. On [DATE] at 5:00 AM, a meeting was held to provide re-education in response to the Immediate Jeopardy and to discuss re-education to follow for the entire active nursing staff. Attendees included the Administrator, Director of Nursing, Staff Development/Quality Assurance Coordinator, and Nurse Case Managers with re-education provided by a Good Samaritan Society Rehabilitation/Skilled Consultant. 6. On [DATE] an inventory of mechanical lift slings was reviewed by the Administrator and the Environmental Services Director and it was identified that a sufficient number of slings were present. There were eighty-eight (88) available slings for a total of nineteen (19) residents requiring the use of a mechanical lift. Soiled slings were placed in the soiled utility rooms by nursing staff to be laundered. Laundry staff cleaned and inspected slings and returned them to the floor the very next day. 7. A one-hundred (100)% review was initiated on [DATE] and concluded on [DATE] to ensure accuracy (determination of type of assistance required for bed mobility and transfers) of seventy-nine (79) current residents' Mobilization User Defined Assessments (UDA) by the Director of Nursing. Ten (10) of the seventy-nine (79) residents were re-assessed by completing the Mobilization UDA for three (3) consecutive shifts on [DATE] and [DATE] by Nurse Case Managers and floor nurses. 8. One-hundred (100)% review of seventy-nine (79) current residents' care plans was initiated on [DATE] and completed on [DATE] by the Director of Nursing to ensure care plans and Kardexs included the level of assist for bed mobility and transfer, included the number of staff members required for use of the lift, the type of lift to be used, and the sling size, if indicated. 9. Re-education was provided to SRNA staff and licensed nursing staff beginning at 5:00 AM on [DATE] on all shifts and continued through [DATE] for compliance by Good Samaritan Society Rehabilitation/Skilled Consultant, Nurse Case Manager/Safe Resident Handling Coordinator and Staff Development/Quality Assurance Coordinator. Beginning on first (1st) shift of [DATE] no nursing staff member was permitted to provide resident care until re-education was completed. As of [DATE] seventy (70) employees (all current full and part-time nursing staff) had received the re-education which included passing a post-test and return demonstration for use of the mechanical lift. Two (2) prn/on-call nursing employees who were not scheduled to work will receive the re-education prior to working. The re-education included 1) care delivered per care plan, 2) quality of care, 3) accidents and 4) clinical records. 10. Audits will be completed daily times seven (7) days by licensed nurses for completion of mobilization (UDA) on each shift in the first twenty-four (24) hours of admission/readmission and with change of condition for accurate care planning/Kardex for level of assistance for bed mobility and transfer including number of staff, type of lift, and sling size if indicated. 11. Audits will be completed daily times seven (7) days by licensed nurses observing one (1) SRNA on each unit on each shift in assisting residents with bed mobility and transfer to ensure safe care per the resident's care plan. 12. Medical record audits will be completed daily times seven (7) days by licensed nurses to ensure an incident report has been completed with each incident, Good Samaritan Society facility investigation policy was initiated, physician and resident's responsible party were notified with appropriate documentation, resident monitoring and assessment was completed and documented in appropriate UDA's and progress notes. 13. The facility developed a compliance Ad-Hoc Committee chaired by the facility Administrator to manage the development of the Plan of Correction for ongoing compliance and to oversee the implementation of the Plan of Correction with Good Samaritan Society Consultant support and assistance. Committee members include the Director of Nursing, the Staff Development/Quality Assurance Coordinator, Nurse Case Managers, Human Resource Director, Health Information Manager, and the Medical Director. All audit results will be submitted to the Ad-Hoc Committee for review and follow-up action as indicated. The Ad-Hoc Committee minutes will be reported to the Continuing Quality Improvement Committee Monthly. Through observation, interview and record review the State Survey Agency validated the Allegation of Compliance with removal of Immediate Jeopardy on [DATE] as alleged prior to exit on [DATE] as follows: 1. Review of the personnel file for SRNA #3 revealed she was suspended from work after the incident on [DATE] pending the facility investigation and remained suspended throughout the survey including date of exit of [DATE]. 2. A group interview including the Administrator, the Director of Nursing, the Staff Development Coordinator, the Human Resource Director, two (2) Good Samaritan Society Rehabilitation/Skilled Consultants (per telephone conference call), a Good Samaritan Society Quality Improvement (QI) Coordinator (per telephone conference call), and the Good Samaritan Society Workforce Consultant (per telephone conference call), on [DATE] at 2:00 PM, revealed the Administrator, the Director of Nursing, the Staff Development Coordinator and the Human Resource Director were present in person at the meeting held, on [DATE] at 2:00 PM, and the two (2) GSS Consultants, the GSS QI Coordinator and the GSS Workforce Consultant were at the meeting via telephone conference call to discuss the investigation regarding Resident #14, the root cause of the Immediate Jeopardy, GSS policies and procedures to include safe resident handling, incident reporting and notification of change of condition and to develop an action plan (lesson plan). Review of the lesson plan agenda (not dated) provided as proof for the AOC which included training on safe assistance with bed mobility, transfers and use of mechanical lifts and slings, and also included training on the writing of the individualized nursing care plan based on individualized needs and on following the residents' plans of care. Review of the sign-in sheets for the meeting held on [DATE] at 2:00 PM, confirmed the signatures of the attendees. 3. Review of the lesson plan developed in the meeting, on [DATE] at 2:00 PM, revealed an agenda, content, and SRNA and licensed nurse post-tests to address the Immediate Jeopardy compliance. Review of the lesson plan developed "Providing Resident Care - Individualized, Safe, Documented" revealed an agenda, content, and SRNA and licensed nurse post-tests to address the Immediate Jeopardy compliance. The length of the training session outlined on the agenda was thirty (30) minutes for SRNAs and one (1) hour for licensed nurses with the purpose of the training to be correction activity for Immediate Jeopardy F-tags to include policies regarding safe handling of residents, incident reporting, notification of resident change of condition, data collection and UDA assessment instructions and use of mechanical lifts and slings. 4. Interview with Nurse Case Managers #1 and #2, the DON, and the Staff Development Coordinator, on [DATE] at 3:06 PM, 3:15 PM, and 3:20 PM, respectively revealed they had attended the meeting held, on [DATE] at 4:00 PM, to discuss the Immediate Jeopardy situation, to assign tasks and to communicate mandatory adjusted schedules for the nursing staff. Review of the sign-in sheet for the meeting held on [DATE] at 4:00 PM confirmed the signatures of the attendees. 5. A group interview including the Administrator, the Director of Nursing, the Staff Development Coordinator, GSS Rehabilitation/Skilled Consultant #2 (per telephone conference call) and Nurse Case Managers #1, #2 and #3, on [DATE] at 2:00 PM, revealed they were all present in person at the meeting held, on [DATE] at 5:00 AM, and GSS Rehabilitation/Skilled Consultant #2 provided the re-education to that staff in the meeting with discussion of re-education for the entire active nursing staff. Review of the sign-in sheet for the meeting held on [DATE] confirmed the signatures of the attendees. 6. Observation of the mechanical lift slings located in the laundry and on each nursing unit, on [DATE] at 9:00 AM, revealed there were eighty-eight (88) slings available for use. Twelve (12) of the slings observed were soiled and awaiting washing and inspection. Interview with the Administrator and the Environmental Services Director, on [DATE] at 12:16 PM, revealed they both participated in an inventory of the facility mechanical lift slings on [DATE]. The Administrator and the Environmental Services Director indicated the soiled slings we

Based on interview, closed record review, review of the facility's policies and procedures, the manufacturer's operating Instructions for the Ultralift, and the facility's mechanical lift training, it was determined the facility failed to have an effective system to ensure staff received training on the use of assistive devices and failed to ensure assistive devices were used properly to prevent accidents for one (1) of sixteen (16) sampled residents, (Resident #14). The facility staff attempted to transfer Resident #14 without assistance, with the mechanical lift using the wrong size and type of sling that resulted in a head laceration. (Refer to F282). On 09/16/14 at approximately 11:30 AM, State Registered Nursing Assistant (SRNA) #3 attempted to reposition Resident #14, without the assistance of staff to guide the lift arm and protect the resident from injury as directed by the manufacturer's instructions and the resident's care plan. The SRNA further attempted to utilize a mechanical lift sling that was smaller than the resident's assessed size for transfer into a chair. With the mechanical lift positioned over the resident, it placed the lift arm hooks above the resident's head. The SRNA turned the resident to ensure he/she was centered on the sling and the lift arm hooks hit the resident's head and resulted in a 1.5 centimeter laceration above the right eye with profuse bleeding. Interviews revealed between 3:30 PM and 4:00 PM, Registered Nurse (RN) #1 and Minimum Date Set (MDS) Nurse #1 found Resident #14 with bruising around the right eye with significant swelling and increased bleeding that had soaked through the initial dressing. At 4:00 PM the Director of Nursing (DON) gave direction to RN #1 to prepare the resident for transfer to the hospital for evaluation. However, interviews revealed neither the physician nor the ambulance service was notified as instructed. At 5:00 PM, the resident was found unresponsive and in respiratory distress. The facility made an urgent call to the ambulance company at 5:08 PM with arrival at 5:18 PM. The resident was found with no pulse or spontaneous respirations and was pronounced dead at 5:20 PM. The facility's failure to have an effective system in place to ensure assistive devices were used properly to prevent accidents placed Resident #14 and other residents at risk in a situation that was likely to cause serious injury, harm, impairment or death to a resident. The Immediate Jeopardy was identified on 09/24/14 and determined to exist 09/16/14. The facility was notified of the Immediate Jeopardy on 09/25/14. The facility provided an acceptable Allegation of Compliance on 10/01/14 that alleged removal of Immediate Jeopardy on 09/30/14, the State Survey Agency verified Immediate Jeopardy was removed on 09/30/14 as alleged at 42 CFR 483.25 Quality of Care (F323) with the scope and severity lowered to a "D" while the facility monitors the effectiveness of the implemented plan of correction. The findings include: Review of the facility's policy and procedures titled Mobility Support and Positioning: Mobility, revised November 2013, revealed safety precautions included inspection of the lift and sling; following specific transfer instructions for the resident; use of the appropriate number of staff required; and proper operation of the lift. Two or more staff should use the total lift to transfer a resident from surface to surface. The procedure for surface to surface transfer with the total lift: check Kiosk for correct lift and sling size; position sling under the resident; position lift in front of or over the resident; position sling bar close enough to attach sling being careful to control the hanger bar to avoid hitting the resident; and, attach the straps. Review of the manufacturer's Operating Instructions for the Ultralift, copyright 11/23/11, revealed a sequential procedure for staff to follow: identify the correct lift and type of sling; position the sling under the resident; position the lift in front of or over the resident; position the sling bar close enough to attach the sling, taking control over the hanger bar at all times to avoid hitting the resident. Review of the closed clinical record for Resident #14 revealed the facility admitted the resident on 09/17/08 with [DIAGNOSES REDACTED]. Review of the resident's comprehensive care plan, initiated 06/04/13, revealed the resident had an Activities of Daily Living (ADL) deficit and required total assist for a total lift using a large high back sling and to have two (2) people assist to turn and reposition. Review of the Mobilization Support Data Collection Tool, dated 01/17/14, revealed the resident required a total lift for transfer between surfaces using a large high back sling. The facility assessed the resident using the Minimum Data Set (MDS), dated [DATE], and determined the resident required extensive assistance with bed mobility and transfers. Interview with SRNA #3, on 09/24/14 at 10:45 AM, revealed she was going to get the resident up for lunch, on 09/16/14 around 11:30 AM. The SRNA stated she had looked in the C/D Hall linen room, but there were no more slings in the room. Continued interview with SRNA #3, on 09/25/14 at 9:08 AM, revealed she was not positive, but thought the resident normally used a medium high back sling. SRNA#3 stated she knew the information was available in the Kiosk on the Kardex; however, she stated she decided to use the roommate's sling even though it was a different type and a size small. SRNA #3 stated because the pad was so much smaller, positioning of the resident was very important to keep the resident centered. The SRNA further stated the type and size sling the resident normally used wrapped around the resident more as if to cuddle in the sling and there was more material with which to maneuver. Additional interview with SRNA #3, on 09/24/14 at 10:45 AM, revealed while trying to attach the sling straps to the mechanical lift, she realized the resident was not centered enough to be able to attach all the straps. While the mechanical lift was still in place over the resident and approximately five (5) inches from his/her chest, the SRNA turned the resident to his/her left side to reposition the sling and the lift arm hook hit the right side of the resident's face. SRNA #3 stated she remembered hearing a noise, but the resident never yelled out so she continued to position the resident. She turned the resident back over to attach the sling and noticed a cut above the resident's right eye with profuse bleeding. The SRNA stated SRNA #5 entered the room to see why they had not made it the dining room, and assisted with the transfer to the chair. Interview with SRNA #5, on 09/23/14 at 3:09 PM, revealed the sling was too small and the side of the resident's body was right at the edge. The sling was not long enough either and fell mid-thigh and not right above the knee. SRNA #5 stated the sling was not only to small, but the wrong type. The resident was supposed to use a high back sling for transfers and said the shape of the two (2) slings were completely different. SRNA #5 further stated the resident was observed with a cut above the eye with a little continuous stream of blood. Interview with the DON, on 09/24/14 at 12:30 PM, revealed she was told Resident #14 was hit in the head with the mechanical lift while rushing to get the resident up for lunch. The DON stated the resident was to have two (2) people assist with mobility and SRNA #3 had cared for the resident before and knew what size and type of sling to use for a safe transfer. The DON indicated the sling used was too small for the straps to be safely attached to the mechanical lift. Interview with SRNA #4, on 09/24/14 at 12:26 PM, revealed she used two (2) people for the actual transfer with the lift; however, she usually had the resident already on the sling and hooked up to the lift before getting assistance. Interview with SRNA #2, on 09/25/14 at 9:54 AM, revealed she always used two (2) people to transfer and knew not to turn or reposition someone while the lift was positioned over them; however, she always placed the resident on the sling before asking for assist with the actual transfer. Interview with SRNA #1, on 09/25/14 at 9:55 AM, revealed she was aware two (2) people were required for transfers; however, she always attached the lift sling prior to getting help. Interview with Licensed Practical Nurse (LPN) #1, on 09/25/14 at 11:29 AM, revealed most of the SRNAs had the same group of residents and knew what devices needed to be used. The LPN stated she never went around and monitored them to ensure they were using the mechanical lifts correctly. LPN #1 stated SRNA #3 had worked at the facility for years and took it for granted she would use the correct lift sling and safely position the resident. Interview with the Staff Development Nurse, on 09/24/14 at 2:24 PM, revealed she last trained all the staff in 06/26/14 (this was not provided to the state agency for review) on the use of the mechanical lift which included a check off for the proper use procedure. However, the Staff Development Nurse revealed it did not include information about not positioning residents while the lift was in position over the resident. Review of SRNA #3's personnel file revealed she had completed training on the use of the lift on 02/03/14 and in 06/04/14. Further interview with SRNA #3, on 09/25/14 at 9:08 AM, revealed she had not been told the lift should not be positioned over the resident during positioning, but she knew she was not supposed to do it because of the potential for injury to the residents. However, per interview, she was rushing to get the resident to the dining room. Interview with the DON, on 09/24/14 at 12:30 PM, revealed she was not aware the training did not include positioning of residents with the mechanical lift in place over the resident. However, review of the facility's policy and procedures and the lift manufacturer's instructions revealed staff should position the sling bar close enough to attach the sling, and to control the hanger bar to avoid hitting the resident. Further interview with the DON, on 09/25/14 at 11:50 AM, revealed she monitored safe handling of residents and use of the mechanical lift by monitoring the incident reports daily and ensured any concerns or blank areas were immediately addressed. The DON did not provide any other evidence of monitoring. The facility provided an Allegation of Compliance (AOC) on 09/29/14 alleging the Immediate Jeopardy was removed on 09/30/14; the facility took the following steps to remove the Immediate Jeopardy. 1. The SRNA (SRNA #3) involved in the incident was suspended after the incident on 09/16/14 pending investigation of the incident. 2. A meeting was held to discuss the investigation, root cause of the Immediate Jeopardy, Good Samaritan Society policies and procedures (review included safe resident handling, incident reporting and notification of change of condition and action plan), on 09/25/14 at 2:00 PM. Attendees of the meeting on 09/25/14 were the Administrator, Director of Nursing, Staff Development/Quality Assurance Coordinator, Human Resources Director, Good Samaritan Society (GASS) Rehabilitation/Skilled Consultants, Good Samaritan Society Quality Improvement Consultant and a Good Samaritan Society Workforce Consultant. 3. All policies and procedures reviewed at the 2:00 PM meeting on 09/25/14 were found to be appropriate with no revisions required. A lesson plan was developed by the attendees for re-education. 4. A meeting was held, on 09/25/14 at 4:00 PM, to communicate the Immediate Jeopardy situation, assign tasks and communicate mandatory adjusted schedules. Attendees included the Director of Nursing, Staff Development/Quality Assurance Coordinator and Nurse Case Managers. 5. On 09/26/14 at 5:00 AM, a meeting was held to provide re-education in response to the Immediate Jeopardy and to discuss re-education to follow for the entire active nursing staff. Attendees included the Administrator, Director of Nursing, Staff Development/Quality Assurance Coordinator, and Nurse Case Managers with re-education provided by a Good Samaritan Society Rehabilitation/Skilled Consultant. 6. On 09/26/14 an inventory of mechanical lift slings was reviewed by the Administrator and the Environmental Services Director and it was identified that a sufficient number of slings were present. There were eighty-eight (88) available slings for a total of nineteen (19) residents requiring the use of a mechanical lift. Soiled slings were placed in the soiled utility rooms by nursing staff to be laundered. Laundry staff cleaned and inspected slings and returned them to the floor the very next day. 7. A one-hundred (100)% review was initiated on 09/25/14 and concluded on 09/28/14 to ensure accuracy (determination of type of assistance required for bed mobility and transfers) of seventy-nine (79) current residents' Mobilization User Defined Assessments (UDA) by the Director of Nursing. Ten (10) of the seventy-nine (79) residents were re-assessed by completing the Mobilization UDA for three (3) consecutive shifts on 09/27/14 and 09/28/14 by Nurse Case Managers and floor nurses. 8. One-hundred (100)% review of seventy-nine (79) current residents' care plans was initiated on 09/25/14 and completed on 09/28/14 by the Director of Nursing to ensure care plans and Kardexs included the level of assist for bed mobility and transfer, included the number of staff members required for use of the lift, the type of lift to be used, and the sling size, if indicated. 9. Re-education was provided to SRNA staff and licensed nursing staff beginning at 5:00 AM on 09/26/14 on all shifts and continued through 09/27/14 for compliance by Good Samaritan Society Rehabilitation/Skilled Consultant, Nurse Case Manager/Safe Resident Handling Coordinator and Staff Development/Quality Assurance Coordinator. Beginning on first (1st) shift of 09/26/14 no nursing staff member was permitted to provide resident care until re-education was completed. As of 09/29/14 seventy (70) employees (all current full and part-time nursing staff) had received the re-education which included passing a post-test and return demonstration for use of the mechanical lift. Two (2) prn/on-call nursing employees who were not scheduled to work will receive the re-education prior to working. The re-education included 1) care delivered per care plan, 2) quality of care, 3) accidents and 4) clinical records. 10. Audits will be completed daily times seven (7) days by licensed nurses for completion of mobilization (UDA) on each shift in the first twenty-four (24) hours of admission/readmission and with change of condition for accurate care planning/Kardex for level of assistance for bed mobility and transfer including number of staff, type of lift, and sling size if indicated. 11. Audits will be completed daily times seven (7) days by licensed nurses observing one (1) SRNA on each unit on each shift in assisting residents with bed mobility and transfer to ensure safe care per the resident's care plan. 12. Medical record audits will be completed daily times seven (7) days by licensed nurses to ensure an incident report has been completed with each incident, Good Samaritan Society facility investigation policy was initiated, physician and resident's responsible party were notified with appropriate documentation, resident monitoring and assessment was completed and documented in appropriate UDA's and progress notes. 13. The facility developed a compliance Ad-Hoc Committee chaired by the facility Administrator to manage the development of the Plan of Correction for ongoing compliance and to oversee the implementation of the Plan of Correction with Good Samaritan Society Consultant support and assistance. Committee members include the Director of Nursing, the Staff Development/Quality Assurance Coordinator, Nurse Case Managers, Human Resource Director, Health Information Manager, and the Medical Director. All audit results will be submitted to the Ad-Hoc Committee for review and follow-up action as indicated. The Ad-Hoc Committee minutes will be reported to the Continuing Quality Improvement Committee Monthly. Through observation, interview and record review the State Survey Agency validated the Allegation of Compliance with removal of Immediate Jeopardy on 09/30/14 as alleged prior to exit on 10/02/14 as follows: 1. Review of the personnel file for SRNA #3 revealed she was suspended from work after the incident on 09/16/14 pending the facility investigation and remained suspended throughout the survey including date of exit of 10/02/14. 2. A group interview including the Administrator, the Director of Nursing, the Staff Development Coordinator, the Human Resource Director, two (2) Good Samaritan Society Rehabilitation/Skilled Consultants (per telephone conference call), a Good Samaritan Society Quality Improvement (QI) Coordinator (per telephone conference call), and the Good Samaritan Society Workforce Consultant (per telephone conference call), on 10/02/14 at 2:00 PM, revealed the Administrator, the Director of Nursing, the Staff Development Coordinator and the Human Resource Director were present in person at the meeting held, on 09/25/14 at 2:00 PM, and the two (2) GSS Consultants, the GSS QI Coordinator and the GSS Workforce Consultant were at the meeting via telephone conference call to discuss the investigation regarding Resident #14, the root cause of the Immediate Jeopardy, GSS policies and procedures to include safe resident handling, incident reporting and notification of change of condition and to develop an action plan (lesson plan). Review of the lesson plan agenda (not dated) provided as proof for the AOC which included training on safe assistance with bed mobility, transfers and use of mechanical lifts and slings, and also included training on the writing of the individualized nursing care plan based on individualized needs and on following the residents' plans of care. Review of the sign-in sheets for the meeting held on 09/25/14 at 2:00 PM, confirmed the signatures of the attendees. 3. Review of the lesson plan developed in the meeting, on 09/25/14 at 2:00 PM, revealed an agenda, content, and SRNA and licensed nurse post-tests to address the Immediate Jeopardy compliance. Review of the lesson plan developed "Providing Resident Care - Individualized, Safe, Documented" revealed an agenda, content, and SRNA and licensed nurse post-tests to address the Immediate Jeopardy compliance. The length of the training session outlined on the agenda was thirty (30) minutes for SRNAs and one (1) hour for licensed nurses with the purpose of the training to be correction activity for Immediate Jeopardy F-tags to include policies regarding safe handling of residents, incident reporting, notification of resident change of condition, data collection and UDA assessment instructions and use of mechanical lifts and slings. 4. Interview with Nurse Case Managers #1 and #2, the DON, and the Staff Development Coordinator, on 10/02/14 at 3:06 PM, 3:15 PM, and 3:20 PM, respectively revealed they had attended the meeting held, on 09/25/14 at 4:00 PM, to discuss the Immediate Jeopardy situation, to assign tasks and to communicate mandatory adjusted schedules for the nursing staff. Review of the sign-in sheet for the meeting held on 09/25/14 at 4:00 PM confirmed the signatures of the attendees. 5. A group interview including the Administrator, the Director of Nursing, the Staff Development Coordinator, GSS Rehabilitation/Skilled Consultant #2 (per telephone conference call) and Nurse Case Managers #1, #2 and #3, on 10/02/14 at 2:00 PM, revealed they were all present in person at the meeting held, on 09/26/14 at 5:00 AM, and GSS Rehabilitation/Skilled Consultant #2 provided the re-education to that staff in the meeting with discussion of re-education for the entire active nursing staff. Review of the sign-in sheet for the meeting held on 09/26/14 confirmed the signatures of the attendees. 6. Observation of the mechanical lift slings located in the laundry and on each nursing unit, on 10/02/14 at 9:00 AM, revealed there were eighty-eight (88) slings available for use. Twelve (12) of the slings observed were soiled and awaiting washing and inspection. Interview with the Administrator and the Environmental Services Director, on 10/02/14 at 12:16 PM, revealed they both participated in an inventory of the facility mechanical lift slings on 09/26/14. The Administrator and the Environmental Services Director indicated the soiled slings were to be placed in the soiled utility rooms by nursing staff to be laundered and the laundry staff was to launder, dry and inspect the slings before stocking them on each nursing unit the next day. Interview with SRNA #7, on 10/02/14 at 3:50 PM, revealed she would place a soiled sling in a bag in the soiled utility room on the nursing unit to be laundered and it was her understanding the laundry staff would inspect the slings for any defects before returning them to the nursing units. Interview with the Housekeeping/Laundry Supervisor, on 10/02/14 at 4:00 PM, revealed the laundry staff cleaned the mechanical lift slings seven (7) days a week and inspected them before returning them to the nursing units for use. She stated if a sling was defective it would be given to Case Manager #3 for replacement. Interview with Case Manager #3, on 10/02/14 at 4:10 PM, revealed he received the defective slings identified by the laundry staff or any nursing personnel and would order a replacement right away and the replacement would usually be provided within a week. Interview with the DON, on 10/02/14 at 4:10 PM, revealed mechanical lift slings were stored in the clean utility rooms on each nursing unit and were laundered and inspected by the laundry staff. 7. Further interview with the DON, on 10/02/14 at 4:10 PM, revealed she initiated a one-hundred 100% audit of the seventy-nine (79) residents' Mobilization UDA's in the facility on 09/25/14 and completed the audit on 09/28/14. Review of the UDA's for Resident #17, Resident #18, Resident #19 and Resident #20 revealed they were accurate assessments of the residents' needs. Re-assessment documents were reviewed for ten (10) of the seventy-nine (79) residents reviewed which were completed for three (3) consecutive shifts on 09/27/14 and 09/28/14. Interview with Case Manager #1, and RN #1, on 10/02/14 at 4:15 PM, and 4:20 PM, respectively revealed they assisted with the re-assessments for ten (10) of the seventy-nine (79) residents reviewed which were completed for three (3) consecutive shifts on 09/27/14 and 09/28/14. Review of the audit initiated on 09/27/14 and concluded on 09/28/14 confirmed ten (10) residents were reviewed for reassessment by the DON. 8. Observation of Resident #17, on 09/30/14 at 3:25 PM, on 10/01/14 at 8:35 AM, and 10:30 AM, revealed the resident's plan of care was being followed by the nursing staff. Observation of Resident #17, on 10/01/14 at 11:00 AM, revealed two (2) SRNAs performing a mechanical lift transfer of the resident from the bed to a wheelchair using the appropriate sling identified on the plan of care and using appropriate procedure for the transfer. Observation of Resident #18, on 09/30/14 at 3:45 PM, 10/01/14 at 8:45 AM and 10:45 AM, revealed the resident was being cared for per the assessed nursing/SRNA plan of care. Observation of Resident #19, on 09/30/14 at 3:11 PM and 10/01/14 at 1:30 PM, revealed the resident's plan of care was being followed by the nursing staff. Review of the clinical records for Resident #17, Resident #18 and Resident #19's revealed Minimum Data Set (MDS) comprehensive reviews completed in the past thirty (30) days and compared to the residents' records revealed accurate assessments had been completed. Review of the nursing and SRNA care plans for Resident #17, Resident #18 and Resident #19 revealed they had been created from the comprehensive MDSs, completed in the past thirty (30) days and had been updated/revised as indicated. Review of the Mobilization UDA dated 08/28/14 for Resident #17 revealed the resident was to be transferred using the appropriate sling size with a mechanical lift as assessed. Interview with the DON, on 10/02/14 at 4:10 PM, revealed she initiated a one-hundred 100% audit of the seventy-nine (79) residents' (in the facility at the time) care plans on 09/25/14 and completed that audit on 09/28/14 to ensure care plans and Kardexs included the level of assist for bed mobility and transfer, the number of staff required for use of the lift and the type of lift and sling to be used, if indicated. Review of the audits completed by the DON confirmed they were completed between 09/25/14 and 09/28/14. 9. Review of the SRNA and licensed nurse sign-in sheets for the re-education trainings revealed all but two (2) on-call nursing employees had completed the training between 09/26/14 at 5:00 AM and 09/27/14. A telephone interview with the GSS Rehabilitation/Skilled Consultant #2, on 10/02/14 at 2:00 PM, revealed she had conducted the lesson plan training on 09/26/14 through 09/29/14 with the assistance of Nurse Case Managers #1 and #2. Interview with Nurse Case Managers #1 and #2, on 10/02/14 at 2:20 PM, revealed they had participated in the lesson plan training done on 09/26/14 through 09/27/14. Interview with the Staff Development Coordinator on 10/02/14 at 2:30 PM revealed she had participated in the lesson plan training on use of the slings and mechanical lifts and had observed staff with return demonstrations of use of the slings and lifts on 09/26/14 through 09/29/14. Interview with LPN #2, on 10/02/14 at 3:40 PM, revealed she had attended an in-service training last week about lift use, charting, incident reporting, and calling the doctor. She stated she demonstrated the use of the mechanical lifts and had a written post-test on the training content. Interview with LPN #3, on 10/02/14 at 3:43 PM, revealed she had attended an in-service training on 09/27/14 about mechanical lift use, charting, incident reporting, and calling the doctor. She stated she also demonstrated the use of the mechanical lifts and had a written post-test on the training content. Interview with SRNA #7, on 10/02/14 at 3:48 PM, revealed she attended an in-service training on 09/26/14 about the use of the resident care plans and lift/sling use and she did a return demonstration and had a post-test. Interview with SRNA #8, on 10/02/14 at 3:52 PM, revealed she attended an in-service training on 09/26/14 about the use of the resident care plans and lift/sling use and she did a return demonstration and had a post-test. 10. Review of the seven (7) daily audits, initiated 09/29/14, confirmed a daily audit by licensed nurses for completion of the Mobilization UDA on each shift in the first twenty-four (24) hrs of admission/readmission and with change of condition, for accurate care planning/Kardex for level of assist for bed mobility and transfer including number of staff required, type of lift and sling size, if indicated. Interview with LPN #3, on 10/02/14 at 4:20 PM, revealed she had completed three (3) of the required seven (7) daily audits to be done by licensed nurses. Interview with RN #2, on 10/02/14 at 4:25 PM, revealed he had completed two (2) of the required seven (7) daily audits to be done by licensed nurses. 11. Review of the audits, initiated 09/27/14, confirmed the audits for proper use of the lift were completed with observations. Interview with LPN #3, on 10/02/14 at 4:20 PM, revealed she had observed SRNA #2, on day shift on 09/29/14, assisting Resident #17 with bed mobility and lift/sling transfer to ensure the safe care per the resident's care plan. LPN #3 stated she had completed three (3) of the required seven (7) daily audits to include the observation of a SRNA giving care per the resident's plan of care. Interview with RN #2, on 10/02/14 at 4:25 PM, revealed he had completed two (2) of the required seven (7) daily audits to be done by licensed nurses, with observations of SRNAs providing care. 12. Further interview with LPN #3, on 10/02/14 at 4:20 PM, indicated she also participated in a medical record audit initiated 09/29/14 to ensure an incident report had been completed for an incident occurring on 10/01/14 (not reportable) and the appropriate documentation and resident assessment and monitoring occurred timely. Interview with RN #1, on 10/02/14 at 4:25 PM, revealed she also had completed a medical record audit on 09/29/14 on second (2nd) shift regarding a change in resident condition to ensure the resident's responsible party was notified, the physician was notified, appropriate assessment and monitoring of the resident was completed and timely documentation in the progress notes. Review of that audit sheet indicated RN #1 had completed that audit on 2nd shift on 09/29/14. 13. Interview with the Administrator, the DON, the Staff Development Coordinator, the Human Resource Director and the Medical Director, on 10/02/14 at 4:35 PM, revealed they were all to be participants in a newly developed Compliance Ad-Hoc Committee to manage the development of the Plan of Correction (POC) for ongoing compliance. They indicated they are to oversee the implementation of the POC with GSS Consultant support and assistance, ensure all audit results are submitted to the Committee for review and follow-up action, as indicated. The Administrator stated the Ad-Hoc Committee minutes would be reported to the Continuing Quality Improvement Committee monthly. Review of the sign-in sheet for the Ad-Hoc meeting revealed it took place on 09/29/14 with the Administrator, the DON, the Staff Development/Quality Coordinator, the Human Resource Director, the Medical Records Director, both MDS Coordinators, and the Medical Director. The next Quality Assurance meeting is scheduled to be held on 10/28/14.

Based on interview, closed record review, review of the facility's policy Completing Incident/Injury Report Forms, it was determined the facility failed to have an effective system in place to ensure the clinical record completely and accurately reflected the resident's base line status, injury and change of condition for one (1) of the sixteen (16) sampled residents, (Resident #14). (Refer to F157 and F309). The facility staff failed to document in the clinical record specific information regarding the details of how an injury occurred to Resident #14, a baseline status and assessment of the resident, notification of the family and resident's physician, care and services the resident received, decline in the resident's condition, and emergent care provided to the resident by facility staff. On 09/16/14, Resident #14 sustained a 1.5 centimeter laceration above the right eye, with profuse bleeding, during a transfer with a mechanical lift. Interviews and record review revealed no documented evidence of assessment and/or monitoring of Resident #14. At 4:00 PM the Director of Nursing (DON) gave direction to RN #1 to prepare the resident for transfer to the hospital for evaluation. However, interview and record review revealed neither the physician nor the ambulance service was notified as instructed. At 5:00 PM, the resident was found unresponsive and in respiratory distress. The facility made an urgent call to the ambulance company at 5:08 PM with arrival at 5:18 PM. The resident was found with no pulse or spontaneous respirations and was pronounced dead at 5:20 PM. The facility's failure to ensure the clinical record completely and accurately reflected the resident's base line status, injury, and change of condition placed Resident #14 and other residents at risk in a situation that was likely to cause serious injury, harm, impairment or death to a resident. The Immediate Jeopardy was identified on 09/24/14 and determined to exist 09/16/14. The facility was notified of the Immediate Jeopardy on 09/25/14. The facility provided an acceptable Allegation of Compliance on 10/01/14 that alleged removal of Immediate Jeopardy on 09/30/14. The State Survey Agency verified Immediate Jeopardy was removed on 09/30/14 as alleged, at 42 CFR 483.75 Administration (F514) with the scope and severity lowered to a "D" while the facility monitored the effectiveness of the implemented plan of correction. The findings include: The facility did not provide a policy for Charting and Documentation. Review of the facility's policy and procedure Completing Incident/Injury Report Forms, revised December 2010, revealed the purpose was to document a resident's incident/accident, possible causative factors, corrective action, and assure reporting and follow-up of all incidents/accidents involving a resident. The facility's procedure in the event of an incident included: completing a body review for injuries and bleeding; obtaining vital signs and noting times; calling 911 if the injury might be serious or if in doubt as to the seriousness of the resident's condition; and, use of first aid measures. Review of the closed clinical record for Resident #14 revealed the facility admitted the resident on 09/17/08 with the [DIAGNOSES REDACTED]. The facility assessed the resident using the Minimum Data Set (MDS), dated [DATE], as requiring extensive assistance with bed mobility and transfers. Review of facility's incident report for Resident #14's injury, dated 09/16/14, revealed the wound nurse measured the wound at 0.1 centimeter (cm) x 1.5 cm. The area was cleaned and pressure applied to the wound with some decrease in bleeding. The report indicated the injury type as a laceration located on the face. The resident's pain level was marked as "hurts even more". The form was marked the resident was alert and oriented to person. The Injury report noted the family and resident's physician were notified at 1:00 PM on 09/16/14. However, there was no documented evidence in the resident's clinical record this notification was conducted. Interview with SRNA #3, on 09/24/14 at 10:45 AM, revealed while getting Resident #14 up for lunch with the mechanical lift on 09/16/14 between 12:00 PM and 12:30 PM, the SRNA turned the resident to the right side to adjust the sling for the mechanical lift while the lift was already in position over the resident. The SRNA stated the sling was the wrong type and size for the resident and the lift arm hooks hit the resident's head and inflicted a cut above the eye that was profusely bleeding. Review of LPN #1's nursing notes, dated 09/16/14 at 12:00 PM, revealed the LPN described the wound as a gash with no mention of the swelling around the injury or that the blood was streaming down the resident's face to the point steri-strips would not stick. There was no documentation that vital signs or a neurological assessment were completed following the head injury. Review of LPN #1's nurse note entry, dated 09/16/14 at 1:30 PM, revealed the right eye gash continued to have a small amount of bleeding and the wound was cleaned and a dressing was applied. The note indicated the DON was notified who stated to continue to monitor and reapply steri-strips when the bleeding stops. There was no other documentation entered in the record or evidence the resident was seen again until the next shift. Interview with Licensed Practical Nurse (LPN) #1, on 09/23/14 at 3:21 PM, revealed the injury above the eye had some swelling and was bleeding down the resident's face. Further interview, on 09/24/14 at 12:01 PM, revealed the LPN applied steri-strips, but they would not stick due to the amount of bleeding and she notified the wound nurse to come and assess the resident. Further interview, on 09/25/14 at 11:29 AM, revealed documentation in the record was to show what was going on with the resident and what the resident's condition was at a given time. LPN #1 stated if you do not document no one would know what care was provided, and it would be like nothing happened. Interview with MDS Nurse #2, on 09/24/14 at 12:31 PM, revealed she was the facility's wound nurse and was notified around 12:45 PM that Resident #14 had sustained a head injury and was bleeding. The MDS Nurse initially stated the resident had a skin tear, then, said it did not fit the definition for a skin tear and that the injury was a gash. She further stated the injury was a clean cut, then, decided the wound was actually a laceration. The MDS nurse revealed the bleeding was a constant stream down the resident's face and every time she cleaned it, it would start bleeding again. MDS Nurse #2 stated she continued to try and control the bleeding for fifteen (15) to twenty (20) minutes, but it never completely stopped. The MDS nurse revealed she did carry a pen light and checked the resident's pupils; however, could not report the size or response with the light as none of the information above was documented. Review of Minimum Data Set (MDS) Nurse #2's nursing notes, dated 09/16/14 at 12:50 PM, revealed the resident's wound was a split to the skin that was bleeding. The notes revealed no deep trauma was noted, but did not describe how that was determined. The notes did identify some swelling and bruising, but did not reflect the measures taken to stop the bleeding or that the bleeding never stopped during that shift. Continued interview with MDS Nurse #2, on 09/16/14 at 12:31 PM, revealed she did not completely and accurately chart what she observed while in the resident's room and knew she was supposed to document everything. The MDS nurse stated she thought someone else would document what happened. Interview with MDS Nurse #1, on 09/23/14 at 5:07 PM, revealed she was told the resident sustained [REDACTED]. The MDS nurse stated the resident's eye was swollen shut, had dark purple bruising above and around the eye and the wound was still bleeding. The MDS nurse further stated she told RN #1 the resident needed stitches, and he needed to call the physician, call the ambulance, and get the paperwork ready. However, review of the late entry nurses notes, dated 09/16/14, revealed no evidence MDS Nurse #1 documented any activity in the record. There was no evidence of documentation as to when the resident's condition changed, that vital signs or a neurological assessment was completed, or who and when the ambulance service was notified. Further review of the late entry nurses note by RN #1, dated 09/16/14 at 3:00 PM, revealed the resident had normal coloring and no signs or symptoms of distress. The notes did not mention the swelling or bruising on the resident's face, and did not mention the directives given by MDS Nurse #1. Interview with Registered Nurse (RN) #1, on 09/23/14 at 2:45 PM, revealed the physician called back and gave an order to transfer the resident to the hospital. However, RN #1 stated he never wrote the order to transfer to the hospital because he thought someone else had already done that. The RN further stated he never looked in the computer to ensure it was actually done. Interview with the DON, on 09/24/14 at 12:30 PM, revealed Resident #14's documentation did not contain a lot of information, and she did not realize there had been so very little documented until reviewing the information after the resident passed away. The DON stated the facility was told by their corporate office to not make any more late entries into Resident #14's clinical record because it was not good practice. The DON further stated during her chart audits she reviewed the entire chart for any incidents that occurred. She had noticed incorrect coding and charting before and talked with that person individually as problems arose. The DON further indicated there had been training before on documentation. Interview with Staff Development, on 09/25/14 at 12:44 PM, revealed there had never been any training on ensuring documentation during incident/accidents or what to include. Staff Development stated the training completed involved using User Defined Assessments (USD) which would prompt the nurse what to chart for certain medical problems; however, not emergent concerns. The facility provided an Allegation of Compliance (AOC) on 09/29/14 alleging the Immediate Jeopardy was removed on 09/30/14; the facility took the following steps to remove the Immediate Jeopardy. 1. The SRNA (SRNA #3) involved in the incident was suspended after the incident on 09/16/14 pending investigation of the incident. 2. A meeting was held to discuss the investigation, root cause of the Immediate Jeopardy, Good Samaritan Society policies and procedures (review included safe resident handling, incident reporting and notification of change of condition and action plan), on 09/25/14 at 2:00 PM. Attendees of the meeting on 09/25/14 were the Administrator, Director of Nursing, Staff Development/Quality Assurance Coordinator, Human Resources Director, Good Samaritan Society (GASS) Rehabilitation/Skilled Consultants, Good Samaritan Society Quality Improvement Consultant and a Good Samaritan Society Workforce Consultant. 3. All policies and procedures reviewed at the 2:00 PM meeting on 09/25/14 were found to be appropriate with no revisions required. A lesson plan was developed by the attendees for re-education. 4. A meeting was held, on 09/25/14 at 4:00 PM, to communicate the Immediate Jeopardy situation, assign tasks and communicate mandatory adjusted schedules. Attendees included the Director of Nursing, Staff Development/Quality Assurance Coordinator and Nurse Case Managers. 5. On 09/26/14 at 5:00 AM, a meeting was held to provide re-education in response to the Immediate Jeopardy and to discuss re-education to follow for the entire active nursing staff. Attendees included the Administrator, Director of Nursing, Staff Development/Quality Assurance Coordinator, and Nurse Case Managers with re-education provided by a Good Samaritan Society Rehabilitation/Skilled Consultant. 6. On 09/26/14 an inventory of mechanical lift slings was reviewed by the Administrator and the Environmental Services Director and it was identified that a sufficient number of slings were present. There were eighty-eight (88) available slings for a total of nineteen (19) residents requiring the use of a mechanical lift. Soiled slings were placed in the soiled utility rooms by nursing staff to be laundered. Laundry staff cleaned and inspected slings and returned them to the floor the very next day. 7. A one-hundred (100)% review was initiated on 09/25/14 and concluded on 09/28/14 to ensure accuracy (determination of type of assistance required for bed mobility and transfers) of seventy-nine (79) current residents' Mobilization User Defined Assessments (UDA) by the Director of Nursing. Ten (10) of the seventy-nine (79) residents were re-assessed by completing the Mobilization UDA for three (3) consecutive shifts on 09/27/14 and 09/28/14 by Nurse Case Managers and floor nurses. 8. One-hundred (100)% review of seventy-nine (79) current residents' care plans was initiated on 09/25/14 and completed on 09/28/14 by the Director of Nursing to ensure care plans and Kardexs included the level of assist for bed mobility and transfer, included the number of staff members required for use of the lift, the type of lift to be used, and the sling size, if indicated. 9. Re-education was provided to SRNA staff and licensed nursing staff beginning at 5:00 AM on 09/26/14 on all shifts and continued through 09/27/14 for compliance by Good Samaritan Society Rehabilitation/Skilled Consultant, Nurse Case Manager/Safe Resident Handling Coordinator and Staff Development/Quality Assurance Coordinator. Beginning on first (1st) shift of 09/26/14 no nursing staff member was permitted to provide resident care until re-education was completed. As of 09/29/14 seventy (70) employees (all current full and part-time nursing staff) had received the re-education which included passing a post-test and return demonstration for use of the mechanical lift. Two (2) prn/on-call nursing employees who were not scheduled to work will receive the re-education prior to working. The re-education included 1) care delivered per care plan, 2) quality of care, 3) accidents and 4) clinical records. 10. Audits will be completed daily times seven (7) days by licensed nurses for completion of mobilization (UDA) on each shift in the first twenty-four (24) hours of admission/readmission and with change of condition for accurate care planning/Kardex for level of assistance for bed mobility and transfer including number of staff, type of lift, and sling size if indicated. 11. Audits will be completed daily times seven (7) days by licensed nurses observing one (1) SRNA on each unit on each shift in assisting residents with bed mobility and transfer to ensure safe care per the resident's care plan. 12. Medical record audits will be completed daily times seven (7) days by licensed nurses to ensure an incident report has been completed with each incident, Good Samaritan Society facility investigation policy was initiated, physician and resident's responsible party were notified with appropriate documentation, resident monitoring and assessment was completed and documented in appropriate UDA's and progress notes. 13. The facility developed a compliance Ad-Hoc Committee chaired by the facility Administrator to manage the development of the Plan of Correction for ongoing compliance and to oversee the implementation of the Plan of Correction with Good Samaritan Society Consultant support and assistance. Committee members include the Director of Nursing, the Staff Development/Quality Assurance Coordinator, Nurse Case Managers, Human Resource Director, Health Information Manager, and the Medical Director. All audit results will be submitted to the Ad-Hoc Committee for review and follow-up action as indicated. The Ad-Hoc Committee minutes will be reported to the Continuing Quality Improvement Committee Monthly. Through observation, interview and record review the State Survey Agency validated the Allegation of Compliance with removal of Immediate Jeopardy on 09/30/14 as alleged prior to exit on 10/02/14 as follows: 1. Review of the personnel file for SRNA #3 revealed she was suspended from work after the incident on 09/16/14 pending the facility investigation and remained suspended throughout the survey including date of exit of 10/02/14. 2. A group interview including the Administrator, the Director of Nursing, the Staff Development Coordinator, the Human Resource Director, two (2) Good Samaritan Society Rehabilitation/Skilled Consultants (per telephone conference call), a Good Samaritan Society Quality Improvement (QI) Coordinator (per telephone conference call), and the Good Samaritan Society Workforce Consultant (per telephone conference call), on 10/02/14 at 2:00 PM, revealed the Administrator, the Director of Nursing, the Staff Development Coordinator and the Human Resource Director were present in person at the meeting held, on 09/25/14 at 2:00 PM, and the two (2) GSS Consultants, the GSS QI Coordinator and the GSS Workforce Consultant were at the meeting via telephone conference call to discuss the investigation regarding Resident #14, the root cause of the Immediate Jeopardy, GSS policies and procedures to include safe resident handling, incident reporting and notification of change of condition and to develop an action plan (lesson plan). Review of the lesson plan agenda (not dated) provided as proof for the AOC which included training on safe assistance with bed mobility, transfers and use of mechanical lifts and slings, and also included training on the writing of the individualized nursing care plan based on individualized needs and on following the residents' plans of care. Review of the sign-in sheets for the meeting held on 09/25/14 at 2:00 PM, confirmed the signatures of the attendees. 3. Review of the lesson plan developed in the meeting, on 09/25/14 at 2:00 PM, revealed an agenda, content, and SRNA and licensed nurse post-tests to address the Immediate Jeopardy compliance. Review of the lesson plan developed "Providing Resident Care - Individualized, Safe, Documented" revealed an agenda, content, and SRNA and licensed nurse post-tests to address the Immediate Jeopardy compliance. The length of the training session outlined on the agenda was thirty (30) minutes for SRNAs and one (1) hour for licensed nurses with the purpose of the training to be correction activity for Immediate Jeopardy F-tags to include policies regarding safe handling of residents, incident reporting, notification of resident change of condition, data collection and UDA assessment instructions and use of mechanical lifts and slings. 4. Interview with Nurse Case Managers #1 and #2, the DON, and the Staff Development Coordinator, on 10/02/14 at 3:06 PM, 3:15 PM, and 3:20 PM, respectively revealed they had attended the meeting held, on 09/25/14 at 4:00 PM, to discuss the Immediate Jeopardy situation, to assign tasks and to communicate mandatory adjusted schedules for the nursing staff. Review of the sign-in sheet for the meeting held on 09/25/14 at 4:00 PM confirmed the signatures of the attendees. 5. A group interview including the Administrator, the Director of Nursing, the Staff Development Coordinator, GSS Rehabilitation/Skilled Consultant #2 (per telephone conference call) and Nurse Case Managers #1, #2 and #3, on 10/02/14 at 2:00 PM, revealed they were all present in person at the meeting held, on 09/26/14 at 5:00 AM, and GSS Rehabilitation/Skilled Consultant #2 provided the re-education to that staff in the meeting with discussion of re-education for the entire active nursing staff. Review of the sign-in sheet for the meeting held on 09/26/14 confirmed the signatures of the attendees. 6. Observation of the mechanical lift slings located in the laundry and on each nursing unit, on 10/02/14 at 9:00 AM, revealed there were eighty-eight (88) slings available for use. Twelve (12) of the slings observed were soiled and awaiting washing and inspection. Interview with the Administrator and the Environmental Services Director, on 10/02/14 at 12:16 PM, revealed they both participated in an inventory of the facility mechanical lift slings on 09/26/14. The Administrator and the Environmental Services Director indicated the soiled slings were to be placed in the soiled utility rooms by nursing staff to be laundered and the laundry staff was to launder, dry and inspect the slings before stocking them on each nursing unit the next day. Interview with SRNA #7, on 10/02/14 at 3:50 PM, revealed she would place a soiled sling in a bag in the soiled utility room on the nursing unit to be laundered and it was her understanding the laundry staff would inspect the slings for any defects before returning them to the nursing units. Interview with the Housekeeping/Laundry Supervisor, on 10/02/14 at 4:00 PM, revealed the laundry staff cleaned the mechanical lift slings seven (7) days a week and inspected them before returning them to the nursing units for use. She stated if a sling was defective it would be given to Case Manager #3 for replacement. Interview with Case Manager #3, on 10/02/14 at 4:10 PM, revealed he received the defective slings identified by the laundry staff or any nursing personnel and would order a replacement right away and the replacement would usually be provided within a week. Interview with the DON, on 10/02/14 at 4:10 PM, revealed mechanical lift slings were stored in the clean utility rooms on each nursing unit and were laundered and inspected by the laundry staff. 7. Further interview with the DON, on 10/02/14 at 4:10 PM, revealed she initiated a one-hundred 100% audit of the seventy-nine (79) residents' Mobilization UDA's in the facility on 09/25/14 and completed the audit on 09/28/14. Review of the UDA's for Resident #17, Resident #18, Resident #19 and Resident #20 revealed they were accurate assessments of the residents' needs. Re-assessment documents were reviewed for ten (10) of the seventy-nine (79) residents reviewed which were completed for three (3) consecutive shifts on 09/27/14 and 09/28/14. Interview with Case Manager #1, and RN #1, on 10/02/14 at 4:15 PM, and 4:20 PM, respectively revealed they assisted with the re-assessments for ten (10) of the seventy-nine (79) residents reviewed which were completed for three (3) consecutive shifts on 09/27/14 and 09/28/14. Review of the audit initiated on 09/27/14 and concluded on 09/28/14 confirmed ten (10) residents were reviewed for reassessment by the DON. 8. Observation of Resident #17, on 09/30/14 at 3:25 PM, on 10/01/14 at 8:35 AM, and 10:30 AM, revealed the resident's plan of care was being followed by the nursing staff. Observation of Resident #17, on 10/01/14 at 11:00 AM, revealed two (2) SRNAs performing a mechanical lift transfer of the resident from the bed to a wheelchair using the appropriate sling identified on the plan of care and using appropriate procedure for the transfer. Observation of Resident #18, on 09/30/14 at 3:45 PM, 10/01/14 at 8:45 AM and 10:45 AM, revealed the resident was being cared for per the assessed nursing/SRNA plan of care. Observation of Resident #19, on 09/30/14 at 3:11 PM and 10/01/14 at 1:30 PM, revealed the resident's plan of care was being followed by the nursing staff. Review of the clinical records for Resident #17, Resident #18 and Resident #19's revealed Minimum Data Set (MDS) comprehensive reviews completed in the past thirty (30) days and compared to the residents' records revealed accurate assessments had been completed. Review of the nursing and SRNA care plans for Resident #17, Resident #18 and Resident #19 revealed they had been created from the comprehensive MDSs, completed in the past thirty (30) days and had been updated/revised as indicated. Review of the Mobilization UDA dated 08/28/14 for Resident #17 revealed the resident was to be transferred using the appropriate sling size with a mechanical lift as assessed. Interview with the DON, on 10/02/14 at 4:10 PM, revealed she initiated a one-hundred 100% audit of the seventy-nine (79) residents' (in the facility at the time) care plans on 09/25/14 and completed that audit on 09/28/14 to ensure care plans and Kardexs included the level of assist for bed mobility and transfer, the number of staff required for use of the lift and the type of lift and sling to be used, if indicated. Review of the audits completed by the DON confirmed they were completed between 09/25/14 and 09/28/14. 9. Review of the SRNA and licensed nurse sign-in sheets for the re-education trainings revealed all but two (2) on-call nursing employees had completed the training between 09/26/14 at 5:00 AM and 09/27/14. A telephone interview with the GSS Rehabilitation/Skilled Consultant #2, on 10/02/14 at 2:00 PM, revealed she had conducted the lesson plan training on 09/26/14 through 09/29/14 with the assistance of Nurse Case Managers #1 and #2. Interview with Nurse Case Managers #1 and #2, on 10/02/14 at 2:20 PM, revealed they had participated in the lesson plan training done on 09/26/14 through 09/27/14. Interview with the Staff Development Coordinator on 10/02/14 at 2:30 PM revealed she had participated in the lesson plan training on use of the slings and mechanical lifts and had observed staff with return demonstrations of use of the slings and lifts on 09/26/14 through 09/29/14. Interview with LPN #2, on 10/02/14 at 3:40 PM, revealed she had attended an in-service training last week about lift use, charting, incident reporting, and calling the doctor. She stated she demonstrated the use of the mechanical lifts and had a written post-test on the training content. Interview with LPN #3, on 10/02/14 at 3:43 PM, revealed she had attended an in-service training on 09/27/14 about mechanical lift use, charting, incident reporting, and calling the doctor. She stated she also demonstrated the use of the mechanical lifts and had a written post-test on the training content. Interview with SRNA #7, on 10/02/14 at 3:48 PM, revealed she attended an in-service training on 09/26/14 about the use of the resident care plans and lift/sling use and she did a return demonstration and had a post-test. Interview with SRNA #8, on 10/02/14 at 3:52 PM, revealed she attended an in-service training on 09/26/14 about the use of the resident care plans and lift/sling use and she did a return demonstration and had a post-test. 10. Review of the seven (7) daily audits, initiated 09/29/14, confirmed a daily audit by licensed nurses for completion of the Mobilization UDA on each shift in the first twenty-four (24) hrs of admission/readmission and with change of condition, for accurate care planning/Kardex for level of assist for bed mobility and transfer including number of staff required, type of lift and sling size, if indicated. Interview with LPN #3, on 10/02/14 at 4:20 PM, revealed she had completed three (3) of the required seven (7) daily audits to be done by licensed nurses. Interview with RN #2, on 10/02/14 at 4:25 PM, revealed he had completed two (2) of the required seven (7) daily audits to be done by licensed nurses. 11. Review of the audits, initiated 09/27/14, confirmed the audits for proper use of the lift were completed with observations. Interview with LPN #3, on 10/02/14 at 4:20 PM, revealed she had observed SRNA #2, on day shift on 09/29/14, assisting Resident #17 with bed mobility and lift/sling transfer to ensure the safe care per the resident's care plan. LPN #3 stated she had completed three (3) of the required seven (7) daily audits to include the observation of a SRNA giving care per the resident's plan of care. Interview with RN #2, on 10/02/14 at 4:25 PM, revealed he had completed two (2) of the required seven (7) daily audits to be done by licensed nurses, with observations of SRNAs providing care. 12. Further interview with LPN #3, on 10/02/14 at 4:20 PM, indicated she also participated in a medical record audit initiated 09/29/14 to ensure an incident report had been completed for an incident occurring on 10/01/14 (not reportable) and the appropriate documentation and resident assessment and monitoring occurred timely. Interview with RN #1, on 10/02/14 at 4:25 PM, revealed she also had completed a medical record audit on 09/29/14 on second (2nd) shift regarding a change in resident condition to ensure the resident's responsible party was notified, the physician was notified, appropriate assessment and monitoring of the resident was completed and timely documentation in the progress notes. Review of that audit sheet indicated RN #1 had completed that audit on 2nd shift on 09/29/14. 13. Interview with the Administrator, the DON, the Staff Development Coordinator, the Human Resource Director and the Medical Director, on 10/02/14 at 4:35 PM, revealed they were all to be participants in a newly developed Compliance Ad-Hoc Committee to manage the development of the Plan of Correction (POC) for ongoing compliance. They indicated they are to oversee the implementation of the POC with GSS Consultant support and assistance, ensure all audit results are submitted to the Committee for review and follow-up action, as indicated. The Administrator stated the Ad-Hoc Committee minutes would be reported to the Continuing Quality Improvement Committee monthly. Review of the sign-in sheet for the Ad-Hoc meeting revealed it took place on 09/29/14 with the Administrator, the DON, the Staff Development/Quality Coordinator, the Human Resource Director, the Medical Records Director, both MDS Coordinators, and the Medical Director. The next Quality Assurance meeting is scheduled to be held on 10/28/14.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective system to ensure care plan interventions were implemented for one (1) of nine (9) sampled residents (Resident #1) regarding elopement risk. The Comprehensive Care Plan detailed interventions to address the resident's alteration in mood status/behavior related to [DIAGNOSES REDACTED]. Interventions included to observe the resident for changes in mood and behaviors and report these changes to the charge nurse or social services; and, to encourage the resident to remain in the common area due to exit seeking behaviors. However, the facility failed to follow the care plan intervention to report any changes in cognition to the charge nurse or social service when the resident exhibited exit seeking behaviors. Resident #1 was admitted , on 04/02/10, and had a past history of risk for elopement; however, his/her wander guard bracelet had been discontinued by the physician on 11/07/11, due to no further exit seeking behaviors. On 04/06/12, the resident began to have exit seeking behaviors again, with multiple attempts of elopement, and redirection of the resident was not effective. From 04/06/12 through 06/06/12, Resident #1 attempted to leave the facility six (6) times. On 06/06/12, Resident #1 exited the building in a wheelchair and was out of the facility for approximately 20 minutes when a Hospice aide found the resident in the parking lot, adjacent to the building, and brought the resident back into the building with no injury assessed by staff. (Refer to F323). The facility failed to follow the resident's care plan intervention to report changes and reassess for risk for elopement. The facility's failure to follow the plan of care placed residents at risk for elopement in a situation that is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified, on 06/15/12, and was determined to exist, on 06/06/12. The facility provided a credible Allegation of Compliance (AOC) on 06/19/12, alleging Immediate Jeopardy was removed on 06/19/12. The State Agency verified Immediate Jeopardy was removed, on 06/19/12, prior to exit, on 06/20/12, which lowered the scope and severity to a "D" while the facility's Quality Assurance Committee monitors the effectiveness of implemented action plans to achieve and maintain compliance. The findings include: The facility did not have a specific policy on following the Comprehensive Care Plan; however, interventions were addressed in the facility's Elopement Policy, revised July 2008, regarding sample care plan interventions to develop and follow for residents who attempted elopement after admission and when needed. Those interventions included: 1) account for residents at risk for elopement every 15-30 minutes; 2) provide the resident with a wrist or ankle identification bracelet; 3) mark the resident's clothing with his/her name; 4) photograph the resident on admission and PRN and keep in designated place; 5) require sign-out sheets at nurses' station; 6) use door alarms; 7) use of video cameras; 8) use of resident safety alarms; and, 9) provide appropriate activities. Review of the clinical record revealed Resident #1 had an admission date of [DATE], with [DIAGNOSES REDACTED]. The facility initially assessed Resident #1, on 04/02/10, for high risk for elopement based on the resident's impaired cognition and exit seeking behaviors, and placed a wander guard bracelet on the resident at that time. However, on 11/07/11, the physician ordered the wander guard to be discontinued due to no further exit seeking behaviors. Review of the nurse's notes revealed on 04/06/12, the resident began to have exit seeking behaviors again, with multiple attempts at elopement, and redirection was not effective. From 04/06/12 until the time of the elopement on 06/06/12, Resident #1 attempted to leave the facility six (6) times on 04/06/12, 04/24/12, 04/28/12, 05/19/12, 05/21/12, and 05/25/12. Review of Resident #1's last quarterly assessment, dated 04/30/12, revealed the resident had evidence of wandering coded as occurring 1-3 days; however, the facility failed to reassess the resident for the risk of elopement or apply the wander guard device. There was no evidence the resident had been assessed for risk for elopement although multiple nurse's notes indicated exit seeking behavior exhibited by Resident # 1. Review of the Care Plan, dated 05/09/12, for Resident #1, revealed facility interventions to address the resident's alteration in mood status/ behavior related to [DIAGNOSES REDACTED]. However, the resident continued exit seeking behavior on three occasions: 05/19/12; 05/21/12; and 05/25/12. Interventions included to observe for changes in mood and behaviors and report these changes to charge nurse or social services, and to encourage resident to remain in common area due to exit seeking behaviors. In addition, interventions included providing cues and supervision as needed. Interview with the MDS Assessment Nurse, on 06/19/12 at 2:45 PM, revealed the Social Services Director was responsible for completion of the Cognition Section of the Comprehensive Assessment; however, stated she did not always attend the care plan meetings. The MDS Assessment Nurse stated the issue with elopement could have been prevented if the resident had been reassessed, and followed through the care plan process with application of a wander guard. Interview with the Social Services Director, on 06/19/12 at 2:30 PM, revealed she was responsible for completion of the Cognition Section of the Comprehensive Assessment and reviewed residents who were exit seeking or have exhibited behaviors; however, stated she did not consider pacing to be an exit seeking behavior. In addition, the Social Services Director stated there was knowledge that Resident #1 was noted to be wandering in April 2012, prior to the elopement; however, she did not consider this at the time. Interview revealed the care plan intervention of observing and reassessing the resident's behavior had not been followed. Interview with the Unit Manager on the A/B Hall, on 06/14/12 at 5:15 PM, revealed the floor nurses were responsible to ensure that care plans were followed, and were responsible for identifying the need for reassessment and updating the plan of care. Interview with Licensed Practical Nurse (LPN) #4, on 06/15/12 at 1:30 PM, revealed any residents exhibiting behaviors should be re-assessed, and the care plan and CNA care plan should be updated. Per interview, nurses were responsible to ensure care plans were being followed. Interview with Certified Nurse Aide (CNA) #4, on 06/15/12 at 11:00 PM, revealed Resident #1 had been wandering and combative with redirection most of the night on 06/06/12 (11-7 shift). The CNA stated she was responsible for Resident #1 and stated the resident had rolled him/herself around the facility. CNA #4 also stated when she started her rounds that evening, she had to make sure the resident was still on the unit each time she came out of a resident's room. CNA #4 revealed Resident #1 tried to get out of the facility all the time, and this had been reported to the floor nurse. The CNA stated the resident needed a wander guard, but did not know why he/she did not have one. CNA #4 revealed the resident had behaviors listed on the CNA care plan and to report to the nurse any behaviors. Interview with the Director of Nursing (DON), on 06/14/12 at 12:30 PM, revealed Resident #1's care plan interventions for cognitive deficit should have been followed by reporting the wandering behaviors, and the resident should have been reassessed for elopement risk after exhibiting exit seeking behaviors beginning on 04/06/12. Interview further revealed if the resident had been reassessed and received a wander guard device, prior to 06/06/12, the elopement could have been prevented, because there would have been a different sounding alarm from the door alarm. Review of the Allegation of Compliance (AOC) revealed the facility took the following actions: 1. Upon return to the facility on [DATE], Resident #1 was assessed and found to have no injuries. A wander guard bracelet was applied. Resident #1 was reassessed for wandering/elopement behavior. Fifteen minute checks were initiated on 06/06/12, and monitored. The facility initiated an investigation on 06/06/12. 2. All elopement risk assessments which included the resident census of eighty-five (85) were completed on 06/06/12 with care plans and Certified Nurse Aide plans of care updated. All residents were re-assessed for wandering behaviors and wander guards applied for resident safety, by 6/16/12, by Unit Managers, Weekend Supervisor, or Staff development nurse. The facility determined nine (9) residents to be at risk for elopement. 3. The Staff Development Nurse re-trained all nursing staff on 06/06/12, to include Policies on "How to properly assess and supervise the resident at risk for elopement" , " Elopement Policy and Procedure", " Care Plan Policy and procedure", "Wander Guard Policy and Procedure." The Wander Guard Policy was revised on 06/06/12 by the Director of Nursing. 4. A new Quick Reference Binder was developed, on 06/06/12, to identify all residents assessed at risk for elopement. The binder will identify each resident assessed for elopement with a digital photo of the resident and will also contain policies for Elopement, Wander Guard, and the Door Alarm Systems. 5 . A revision was completed for the Resident at Risk for Elopement Policy on 06/15/12 by the Director Nursing Services, with the new Pre-Assessment Form initiated. All (PRN) 'as needed' staff have been called and notified that they will not be able to work until they receive the in-services. 6. All resident care plans were revised and all care plans updated and ensured that all residents at risk were identified. Through this process the Unit Managers and floor nurses will ensure implementation of the care plan interventions. All resident care plans will be audited for proficiency and effectiveness by 6/18/12 by Medical record Staff. 7. The Rehabilitation/Skilled Care Consultant re-educated the MDS Assessment Nurse, on 06/15/12 via conference call, regarding reassessment with change of condition, care planning and behavior interventions. The MDS Assessment Nurse will also complete the Good Samaritan Society's Learning Center courses titled: 1) Dementia: Wandering and Elopement; and 2) Elopement: Do you Know Where Your Resident Is? This was completed on 6/15/12. The Alternate MDS Assessment Nurse was educated on 06/18/12 utilizing the above course titles. 8. The Social Worker Consultant, via telephone conference on 06/15/12, re-educated the Social Services Director regarding need for on-going assessment of resident changes in condition, updating changes in condition on the resident's care plan, and assessment and care planning if the comprehensive assessments are coded for wandering. The Social Services Director will complete the Learning Center courses for: 1) Dementia: Wandering and Elopement; and 2) Elopement: Do you Know Where Your Resident Is? (completed on 06/15/12). The part time Social Services worker was educated on 06/18/12. 9. QA measures were put into place, on 06/06/12 by the Administrator, DON, Social Services Director, Environmental Services Director, along with consultation of the Medical Director, and the Rehabilitation/Skilled Care Consultant. These QA measures included all residents to be reassessed for elopement after the incident, all care plans to be updated, all staff to be trained on the elopement policy, door alarm system, and updating and following care plans. The informal Continuous Quality Improvement (CQI) meeting discussed and devised a plan to ensure the safety of each resident in the facility. This had been discussed on a daily basis since the elopement occurred on 06/06/12. The Director of Nursing, Unit Managers, Weekend Supervisor, or Staff Development nurse will complete chart audits for all residents exhibiting wandering behavior weekly x4, then monthly x 2 to ensure assessments are completed, safety devices are in place. and care plans are updated. An audit tool (unnamed) was developed and will be submitted to Continuous Quality Improvement (CQI)committee for further recommendations. The State Agency validated the AOC as follows: 1. The State Agency validated, through record review, the assessment of Resident #1, dated 06/06/12, was documented in the nurses notes. The State Agency validated through record review, evidence of 15 minute checks completed for Resident #1, on 06/06/12. Observations of Resident #1, on 06/13/12 at 10:25 AM, and 10:40 AM, and on 06/14/12 at 11:30 AM, revealed the resident sitting in the common area fully dressed sitting in a wheelchair at the table. The resident had his/her head on the table and appeared to be sleeping. A wander guard, and tab alarm was being utilized by the resident. 2. The State Agency validated through record review, and observation that the nine (9) residents (#1, 2, 3, 7, 8, 9, 10, 11, 12) found to be at risk for elopement on 06/06/12, were reassessed, and care plans developed. This included the complete resident census of eighty-five (85) residents. This was verified on 06/19/12, with updated care plans for all nine resident determined by the facility to be at risk for elopement. 3. The State Agency validated through record review evidence of education provided to staff which included policies for: Elopement Policy, Assessment and Intervention for residents at risk for elopement, Care Plan Updating, and Supervision of care. Training was completed on 06/06/12, 06/15/12, 06/16/12, and 06/18/12. The facility staff roster indicted one-hundred and thirty-two (132) of the one-hundred and sixty one (161) total staff had been educated by 06/18/12 on the policies and procedures. The facility provided documentation of a detailed plan to train the remaining thirty-two (32) prior to the date of their return to work. In addition, the State Agency verified through record review and interview, the revision of the Wander Guard Policy revised on 06/06/12 by the DON. This was verified on 06/19/12 during interviews with LPN #1 and LPN #10 at 2:00 PM, LPN #6 at 2:45 PM, LPN #8 at 3:20 PM, LPN #9 at 3:40 PM and LPN #7 at 4:35. The State Agency validated through interview with the staff and record review that the revision of the Elopement Policies and Wander Guard Policies were completed and provided to the staff by 06/18/12. This was verified on 06/19/12 by CNA #2 at 10:35 PM, CNA # 3 at 11:05 PM, CNA #4 at 11:00 PM, and CNA # 5 at 10:30 PM. 4. The State Agency validated through record review and interviews with the Receptionist on 06/19/12 at 2:30 PM, and interviews with LPN #1 at 2:00 PM, LPN #6 at 2:45 PM, LPN #7 at 4:35, LPN #8 at 3:20 PM, LPN #9 at 3:40 PM, and LPN #10 at 2:00 PM, that a Dark [MEDICATION NAME] Quick Reference Binder was located at the front entrance and at both nurse's station. All binders contained photos of all nine residents identified at risk for elopement with policies and procedures regarding elopement procedures, and wander guard policy. 5. The State Agency validated through record review, and interview, on 06/19/12 at 11:45 AM, with the Staff Development Nurse, the revised policy for residents at risk for elopement, revised on 06/15/12 by the DON, with the new Pre-Assessment Form initiated. Review of the 9 residents assessed at risk for elopement verified the new Pre-Assessment Form had been completed for each resident. Documentation reviewed and interview with the Staff Development Coordinator, on 06/19/12 at 11:45 AM, regarding notification of all 'as needed staff' revealed that they would not be able to work until they received the in-services. 6. The State Agency validated through record review that all resident care plans were audited for proficiency and effectiveness by 6/18/12 by Medical Records staff. This was verified on 06/19/12. 7. The State Agency validated through record review and interview with the MDS Assessment Nurse, on 06/19/12 at 2:30 PM, the education was received, on 06/15/12, via conference call with the Rehabilitation/Skilled Care Consultant and the Education Courses, were completed on 6/15/12. Review of training shows the Alternate MDS Assessment Nurse received education on 06/18/12. 8. The State Agency validated re-education of the Social Services Director by the Social Worker Consultant via telephone conference, on 06/15/12, regarding need for on-going assessment of resident changes in condition, updating changes in condition on the resident's care plan, and assessment and care planning if Comprehensive Assessments are coded for wandering. Training Courses were verified, on 06/19/12, and was completed by Social Services Director, on 06/15/12, and the part time Social Services worker was educated on 06/18/12. 9. The State Agency validated through interview with the Administrator, on 06/19/12 at 2:30 PM, and interview with the Director of Nursing, on 06/19/12 at 12:30 PM, and record review revealed the QA measures were put into place, on 06/06/12, by the Administrator, DON, Social Services Director, Environmental Services Director, and Rehabilitation/Skilled Care Consultant. The State Agency verified through interview, on 06/19/12 at 1:00 PM, and record review that the Medical Director was consulted on 06/06/12 via telephone conference. The informal Continuous Quality Improvement (CQI) meeting was verified on 06/19/12, to have occurred on 06/06/12. QA measures included Interventions to reassess all residents, identify residents at risk, train all staff on following and updating care plans, were put into place on 06/06/12. The State Agency validated through record review the facility completed an investigation on 06/11/12. The Director of Nursing, Unit Managers, Weekend Supervisor, or Staff Development nurse will complete chart audits for all residents exhibiting wandering behavior weekly x4, then monthly x 2 to ensure assessments are completed and safety devices are in place. The audit tool to be used (unnamed) was reviewed and will be submitted to Continuous Quality Improvement (CQI) committee for further recommendations.

Based on observation, interview, record review, and review of the facility's policy and investigative report, it was determined the facility failed to have an effective system to provide adequate assessment, supervision, and monitoring for one (1) of nine (9) sampled residents. (Resident #1) The facility's policy regarding Elopement, was to maintain a system which clearly defined the mechanisms and procedures for monitoring and managing residents at risk for elopement by identifying hazards and resident risks; evaluating/analyzing hazards and risks; implementing interventions; and monitoring/modifying interventions as needed. This included assessment of all residents to be assessed for risk of elopement through the pre-admission and/or admission process and as needed. On 06/06/12, Resident #1 eloped from the facility without staff knowledge, and was found in the parking lot at 6:15 AM, adjacent to the facility by a Hospice aide, who was coming to the facility. The facility previously assessed Resident #1, on 04/02/10, at high risk for elopement; however, the physician had ordered the wander guard be discontinued on 11/07/11, after the resident had no further exit seeking behaviors at that time. On 04/06/12, the resident began exhibiting exit seeking behaviors, with multiple attempts at elopement, and redirection was not effective. From 04/06/12 through 06/06/12, Resident #1 attempted to leave the facility six (6) times on 04/06/12, 04/24/12, 04/28/12, 05/19/12, 05/21/12, and 05/25/12. The facility failed to reassess the resident for elopement risk and the wander guard device, which would sound an audible alert to staff when the resident attempted to exit the facility. In addition, the facility had a locking door alarm system in operation at the time of Resident #1's elopement. On 06/06/12, around 1:00 AM, a pharmacy technician exited the building, and nursing staff on the AB Hall reset the front door lock, but failed to reset the alarming sound, located at the AB nurse's station, and the alarm continued to sound. With the alarming sound continuing at the AB nurse's station, Resident #1 was able to push on the front door for 15 seconds, causing the emergency exit system to open the doors. The resident was able to exit the front door without staff knowledge on 06/06/12. The facility's failure to provide adequate supervision/monitoring placed residents at risk in a situation that was likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy was identified on 06/15/12 and was determined to exist on 06/06/12. The facility provided a credible Allegation of Compliance (AOC) on 06/19/12 alleging Immediate Jeopardy was removed on 06/19/12. The State Agency verified Immediate Jeopardy was removed on 06/19/12 prior to exit on 06/20/12, which lowered the scope and severity to a "D", while the facility develops and implements the Plan of Correction to establish and maintain an effective system to ensure residents receive adequate supervision/monitoring to prevent accidents. The findings include: Review of the facility's policy regarding Elopement, revised July 2008, revealed all residents would be assessed for risk of elopement through the pre-admission and/or admission process and as needed....8. a resident who was assessed to not be at risk for elopement during the pre-admission process, but begins to exhibit wandering behaviors or attempts to elope would be assessed and monitored in the following way: 1) Any significant changes in the resident's status will be documented in the IDT notes. Review of the facility's investigation dated 06/06/12, revealed Resident #1 exited the facility without staff knowledge. Review of the facility's investigation, dated 06/06/12, revealed Resident #1 exited the building in a wheelchair and was out of the facility for approximately 20 minutes when a Hospice aide found him/her in the parking lot, adjacent to the building, and brought the resident back into the building. The resident was assessed by nursing staff and no injuries were found. No medical interventions were required. Nursing staff initiated 15 minute checks on Resident #1 at that time. The investigation also revealed the resident had episodes of confusion and had short term and long term memory loss, with psychiatric services was following on an as needed basis. The resident could not remember the incident. Record review revealed Resident #1 was admitted , on 04/02/10, with multiple [DIAGNOSES REDACTED]. The facility initially assessed Resident #1, on 04/02/10, as high risk for elopement based on the resident's impaired cognition and exit seeking behaviors, and placed a wander guard bracelet on the resident at that time. However, on 11/07/11, the physician ordered the wander guard to be discontinued due to no further exit seeking behaviors. On 04/06/12, the resident began to have exit seeking behaviors again, with multiple attempts at elopement, and redirection was not effective. Review of the Nurses notes from 04/06/12 until the time of the elopement, on 06/06/12, revealed Resident #1 attempted to leave the facility six (6) times on 04/06/12, 04/24/12, 04/28/12, 05/19/12, 05/21/12, and 05/25/12. Continued record review revealed a Nurse's note, dated 04/06/12, that stated multiple attempts of elopement with redirection were not effective. Nurse's note, dated 04/24/12, revealed at 3:00 AM, the resident was fretful and exit seeking; stated "I'm going home", and unable to redirect. Nurse's note, dated 04/28/12, revealed a statement from the resident, "Get me out of here". Review of Resident #1's last quarterly assessment, dated 04/30/12, revealed the resident had evidence of wandering coded as occurring 1-3 days; however, the facility failed to reassess the resident for the risk of elopement or apply the wander guard device, which would sound an audible alert to staff when the resident attempted to exit the facility. Review of the Behavior care plan, updated on 05/09/12, revealed the resident had wandering behaviors with interventions to observe for changes in mood and behaviors, and report to the nurse or social services. Further review of a Nurse's note, dated 05/19/12, revealed the resident tried to leave through the front doors and the receptionist tried to bring the resident back inside. The resident became combative with staff, hitting and pulling at them. The Nurse's note, dated 05/21/12, revealed the resident had increased behaviors with exit seeking behavior. A Urinalysis was obtained at that time, and the results were negative. The Nurse's note, dated 05/25/12, revealed the resident tried to leave the facility several times. Interview with the MDS Assessment Nurse, on 06/19/12 at 2:45 PM, revealed the Social Services Director was responsible for completion of the Cognition Section of the Comprehensive Assessment; however, stated she did not always attend the care plan meetings. The MDS Assessment Nurse stated the issue with elopement could have been prevented if the resident had been reassessed, and followed through the care plan process with application of a wander guard. Interview with the Social Services Director, on 06/19/12 at 2:30 PM, revealed she was responsible for completion of the Cognition Section of the MDS Assessment, and reviewed for residents who were exit seeking or exhibited behaviors. The Social Services Director stated she previously did not consider pacing to be an exit seeking behavior; however, she had been trained since the elopement, and would consider this behavior in the future. In addition, the Social Services Director stated Resident #1 was noted to be wandering around in April 2012, prior to the elopement, and did not consider this as a risk at that time. The Social Service Director was aware of the policy regarding elopement; however, had not followed the policy related to wandering. Interview with CNA #4, on 06/15/12 at 11:00 PM, revealed she was responsible for Resident #1 on 06/06/12 (11-7 shift) and stated the resident was up all night in the wheelchair, rolling around the facility, and tried to get out on several other nights she worked. CNA #4 stated the resident had to be watched very closely, especially at night. The CNA stated the resident needed a wander guard, but did not know why he/she did not have one. The CNA revealed she last saw the resident around 5:00 AM, because she had to start her rounds, and tried to come out of each room and look for Resident #1. However, at 6:20 AM, the CNA noticed Resident #1 was not on the unit and started to search all units and went to the front lobby, when a Hospice aide was noted returning the resident through the front door. CNA #4 also revealed the front door alarm sounded around 2:00 AM, and she went to reset the front door. She stated she did not hear the door alarm again, because it sounds similar to the call lights, and didn't notice if it was the door alarm or the call light. Interview with Certified Nurse Aide (CNA) #5, on 06/15/12 at 10:30 PM, revealed she had been asked to go to the front door and reset the alarm around 1-2 AM, and did not hear an alarm after that. The CNA stated that all the alarms sound the same. Interview with Licensed Practical Nurse #3, on 06/14/12 at 9:15 PM, revealed she remembered hearing the alarm sound around 2:00 AM; however, stated that alarms sound all night long. She stated she knew how to reset the alarms, and received training on how to reset; however, the alarm sounded again around 4:00 AM, and she was unable to turn off the alarm mechanism at the nurses station. LPN #3 revealed she spoke with the nurse on the C/D Hall, who told her to put a book over the alarm mechanism to muffle the sound; however, stated she did not do this. LPN #3 stated when the Unit Manager came in at 6:00 AM, she also could not get the alarm to turn off, and then called the Maintenance Director. Attempts were made to contact the C/D Nurse, with messages left to call; however, she did not return the call. LPN #3 revealed she should have called the physician and updated the care plan for elopement risk that night, however she did not do it. Both LPN #3 and the C/D Nurse were terminated from employment at the facility. Review of the investigation and interview with Unit Manager #1, on 06/14/12 at 5:15 PM, revealed she received a call from the C/D nurse on 06/06/12, around 6:00 AM, who stated they could see Resident #1 on the cameras, between the glass doors out front. The Unit Manager stated alarms were sounding, but did not distinguish the type of alarm at the time, since the alarms that ring for the call bells sound similar. The Unit Manager stated she did not see any problems with the alarm system at that time. She stated Resident #1 was brought back to his/her room, was assessed, and had no injury. Interview with the Director of Nursing (DON), on 06/14/12 at 12:30 PM, revealed Resident #1 should have been reassessed for elopement after exhibiting exit seeking behaviors beginning on 04/06/12. Further interview revealed both nurses on duty, on 06/06/12, should have called the Maintenance Director, Administrator, or Director of Nursing when the alarm would not silence. Interview further revealed if the resident had been wearing a wander guard device, on 06/06/12, the elopement could have been prevented, because there would have been a different sounding alarm from the door alarm. Per interview, the DON revealed, according to interview with CNA #4, she was with Resident #1 all night long, because of the exit seeking, and did not leave Resident #1 until approximately 5:00 AM to do her rounds. Interview with the Administrator, on 06/14/12 at 2:30 PM, and review of the facility's investigation, revealed the facility utilized the Wander Guard Alert System and the Locking Door Alarm system to provide safety for residents who were evaluated to be at risk for elopement. Per interview and review of the facility's investigation, nursing staff did not hear the door alarm on the AB Hall, on 06/06/12, when Resident #1 exited the facility, because the alarm was already sounding. Further interview revealed the facility's investigation determined the front doors had been reset by staff, after the pharmacy technician exited the building around 1-2 AM; however, staff failed to go back to the AB nurses station, pick up the phone on the alarm system, and replace the receiver in order to shut off the alarming sound, thus allowing the alarm to sound continuously. Interview also revealed both 11-7 nurses were terminated for failure to follow policy, and failure to notify the physician of Resident #1's exit seeking behavior. The facility was not able to provide evidence that the front door alarm system was functional at the time Resident #1 eloped, based on interviews with LPN #3, Unit Manager AB Hall, and CNA #4 and #5 on 06/14/12. Per interview, the night shift nurses were not aware of how to turn off the front door alarm at the AB Nurse's desk, and were waiting for the Maintenance Director to arrive the next morning and reset the alarm. Review of the Allegation of Compliance (AOC) revealed the facility took the following actions: 1. Upon return to the facility on [DATE], Resident #1 was assessed and found to have no injuries. A wander guard bracelet was applied. Resident #1 was reassessed for wandering/elopement behavior. Fifteen minute checks were initiated on 06/06/12, and monitored. The facility initiated an investigation on 06/06/12. 2. All elopement risk assessments which included the resident census of eighty-five (85) were completed on 06/06/12 with care plans and Certified Nurse Aide plans of care updated. All residents were re-assessed for wandering behaviors and wander guards applied for resident safety, by 6/16/12, by Unit Managers, Weekend Supervisor, or Staff development nurse. The facility determined nine (9) residents to be at risk for elopement. 3. The Staff Development Nurse re-trained all nursing staff on 06/06/23, to include Policies on "How to properly assess and supervise the resident at risk for elopement" , " Elopement Policy and Procedure", " Care Plan Policy and procedure", "Wander Guard Policy and Procedure." The Wander Guard Policy was revised on 06/06/12 by the Director of Nursing. 4. Environmental Services Director provided education to all staff on properly resetting and recognizing all door alarms on 06/06/12. An explanation of security measures (i.e. what do door alarms sound like, look like, and proper code) and when and who to notify (Environmental Services Director, DON, or ADM). All door alarm systems were checked, on 06/06/12, by Environmental Services Director to ensure safe response of security measures. The Alarm manufacturer was contacted, on 06/07/12, to discuss and add a voice activated door alarm to the current alarm system. A log of the daily security checks will be documented as evidence of a malfunction, if it should occur. 5. A new Quick Reference Binder was developed, on 06/06/12, to identify all residents assessed at risk for elopement. The binder will identify each resident assessed for elopement with a digital photo of the resident and will also contain policies for Elopement, Wander Guard, and the Door Alarm Systems. 6 . A revision was completed for the Resident at Risk for Elopement Policy on 06/15/12 by the Director Nursing Services, with the new Pre-Assessment Form initiated. All (PRN) 'as needed' staff have been called and notified that they will not be able to work until they receive the in-services. 7. All resident care plans were revised and all care plans updated and ensured that all residents at risk were identified. Through this process Unit Managers and floor nurses will ensure implementation of the care plan interventions. All resident care plans will be audited for proficiency and effectiveness by 6/18/12 by Medical record Staff. 8. The Rehabilitation/Skilled Care Consultant re-educated the MDS Assessment Nurse, on 06/15/12 via conference call, regarding reassessment with change of condition, care planning and behavior interventions. The MDS Assessment Nurse will also complete the Good Samaritan Society's Learning Center courses titled: 1) Dementia: Wandering and Elopement; and 2) Elopement: Do you Know Where Your Resident Is? This was completed on 6/15/12. The Alternate MDS Assessment Nurse was educated on 06/18/12 utilizing the above course titles. 9. The Social Worker Consultant, via telephone conference on 06/15/12, re-educated the Social Services Director regarding need for on-going assessment of resident changes in condition, updating changes in condition on the resident's care plan, and assessment and care planning if the comprehensive assessments are coded for wandering. The Social Services Director will complete the Learning Center courses for: 1) Dementia: Wandering and Elopement; and 2) Elopement: Do you Know Where Your Resident Is? (completed on 06/15/12). The part time Social Services worker was educated on 06/18/12. 10. QA measures were put into place, on 06/06/12 by the Administrator, DON, Social Services Director, Environmental Services Director, along with consultation of the Medical Director, and the Rehabilitation/Skilled Care Consultant. These QA measures included all residents to be reassessed for elopement after the incident, all care plans to be updated, all staff to be trained on the elopement policy, door alarm system, and updating and following care plans. The informal Continuous Quality Improvement (CQI) meeting discussed and devised a plan to ensure the safety of each resident in the facility. This had been discussed on a daily basis since the elopement occurred on 06/06/12. The Director of Nursing, Unit Managers, Weekend Supervisor, or Staff Development nurse will complete chart audits for all residents exhibiting wandering behavior weekly x4, then monthly x 2 to ensure assessments are completed, safety devices are in place. and care plans are updated. An audit tool (unnamed) was developed and will be submitted to Continuous Quality Improvement (CQI)committee for further recommendations. The State Agency validated the AOC as follows: 1. The State Agency validated, through record review, the assessment of Resident #1, dated 06/06/12, was documented in the nurses notes. Observation, on 06/13/12, revealed Resident #1 with a wander guard bracelet attached to the left ankle. The State Agency validated through record review, evidence of 15 minute checks completed for Resident #1, on 06/06/12. Observations of the Resident #1, on 06/13/12 at 10:25 AM, and 10:40 AM, and on 06/14/12 at 11:30 AM, revealed the resident sitting in the common area fully dressed sitting in a wheelchair at the table. The resident had his/her head on the table and appeared to be sleeping. A wander guard, and tab alarm was being utilized by the resident. 2. The State Agency validated through record review, and observation that the nine (9) residents (#1, 2, 3, 7, 8, 9, 10, 11, 12) found to be at risk for elopement on 06/06/12, were reassessed, and care plans developed. This was verified on 06/19/12, with updated care plans for all nine resident determined by the facility to be at risk for elopement. 3. The State Agency validated through record review evidence of education provided to staff which included policies for: Elopement Policy, Assessment and Intervention for residents at risk for elopement, Care Plan Updating, and Supervision of Care. Training was completed on 06/06/12, 06/15/12, 06/16/12, and 06/18/12. The facility staff roster indicted one-hundred and thirty-two (132) of the one-hundred and sixty one (161) total staff had been educated by 06/18/12 on the policies and procedures. The facility provided documentation of a detailed plan to train the remaining thirty-two (32) prior to the date of their return to work. In addition, the State Agency verified through record review and interview, the revision of the Wander Guard Policy revised on 06/06/12 by the DON. This was verified on 06/19/12 during interviews with LPN #1 at 2:00 PM, LPN #6 at 2:45 PM, LPN #7 at 4:35, LPN #8 at 3:20 PM, LPN #9 at 3:40 PM and LPN #10 at 2:00 PM. The State Agency validated through interview with the staff and record review that the revision of the Elopement Policies, Wander Guard Policies, and Door Alarm System Policies were completed and provided to the staff by 06/18/12. This was verified on 06/14/12 by CNA #2 at 10:35 PM, CNA # 3 at 11:05 PM, CNA #4 at 11:00 PM, and CNA # 5 at 10:30 PM. 4. The State Agency validated through record review, that education was provided to all staff on 06/06/12 regarding properly resetting and recognizing all door alarms. Interview with LPN #1 on 06/19/12 at 2:00 PM, LPN #6 at 2:45 PM, LPN #7 at 4:35, LPN #8 at 3:20 PM, LPN #9 at 3:40 PM and LPN #10 at 2:00 PM and interview, on 06/19/12 by CNA #2 at 10:35 PM, CNA # 3 at 11:05 PM, CNA #4 at 11:00 PM, and CNA # 5 at 10:30, verified they had been trained on properly resetting the doors. Review of the daily logs verified daily monitoring of all doors to ensure properly working doors. Interview on 06/19/12, with CNA #2 at 10:35 PM, CNA # 3 at 11:05 PM, CNA #4 at 11:00 PM, and CNA # 5 at 10:30 PM, revealed they had been required to complete a return demonstration regarding resetting of doors. 5. The State Agency validated through record review and interviews with the Receptionist on 06/19/12 at 2:30 PM, and interviews on 06/19/12 with LPN #1 at 2:00 PM, LPN #6 at 2:45 PM, LPN #7 at 4:35, LPN #8 at 3:20 PM, LPN #9 at 3:40 PM, and LPN #10 at 2:00 PM, that a Dark Lavender Quick Reference Binder was located at the front entrance and at both nurse's station. All binders contained photos of all nine residents identified at risk for elopement with policies and procedures regarding elopement procedures, wander guard policy, and operation of the door alarm system, with troubleshooting information. 6. The State Agency validated through record review, and interview on 06/19/12 at 11:45 AM, with the Staff Development Nurse, the revised policy for residents at risk for elopement, revised on 06/15/12 by the DON, with the new Pre-Assessment Form initiated. Review of the 9 residents assessed at risk for elopement verified the new Pre-Assessment Form had been completed for each resident. Documentation reviewed, and interview with the Staff Development Coordinator on 06/19/12 at 11:45 AM, regarding notification of all 'as needed staff' revealed that they would not be able to work until they received the in-services. 7. The State Agency validated through record review that all resident care plans were audited for proficiency and effectiveness by 6/18/12 by Medical Records staff. This was verified on 06/19/12. 8. The State Agency validated through record review and interview with the MDS Assessment Nurse, on 06/19/12 at 2:30 PM, the education was received, on 06/15/12, via conference call with the Rehabilitation/Skilled Care Consultant and the Education Courses, were completed on 6/15/12. Review of training shows the Alternate MDS Assessment Nurse received education on 06/18/12. 9. The State Agency validated re-education of the Social Services Director by the Social Worker Consultant via telephone conference, on 06/15/12, regarding need for on-going assessment of resident changes in condition, updating changes in condition on the resident's care plan, and assessment and care planning if Comprehensive Assessments were coded for wandering. Training Courses were verified, on 06/19/12, and was completed by Social Services Director, on 06/15/12, and the part time Social Services worker was educated on 06/18/12. 10. The State Agency validated through interview with the Administrator, on 06/19/12 at 2:30 PM, and interview with the Director of Nursing, on 06/19/12 at 12:30 PM, and record review revealed the QA measures were put into place, on 06/06/12, by the Administrator, DON, Social Services Director, Environmental Services Director, and Rehabilitation/Skilled Care Consultant. The State Agency verified through interview, on 06/19/12 at 1:00 PM, and record review that the Medical Director was consulted on 06/06/12 via telephone conference. The informal Continuous Quality Improvement (CQI) meeting was verified on 06/19/12, to have occurred on 06/06/12. QA measures included interventions to reassess all residents, identify residents at risk, train all staff on following and updating care plans, were put into place on 06/06/12. The State Agency validated through record review the facility completed an investigation on 06/11/12. The Director of Nursing, Unit Managers, Weekend Supervisor, or Staff Development nurse will complete chart audits for all residents exhibiting wandering behavior weekly x4, then monthly x 2 to ensure assessments are completed and safety devices are in place. The audit tool to be used (unnamed) was reviewed and will be submitted to Continuous Quality Improvement (CQI) committee for further recommendations.

Based on observation of the facility's video taping, interview, review of facility policy, incident report, and the clinical record it was determined the facility failed to provide appropriate assistive devices to prevent accidents for one (1) of three (3) sampled residents. Resident #1, who had a history of [REDACTED]. On 06/03/11, facility staff failed to apply this device to the resident's wheelchair. During a transport, the resident's left foot touched the floor, and the foot and leg bent backward under the wheelchair. On 06/04/11, after family reported Resident #1 was complaining of pain, the nurse assessed the resident and identified the left leg exhibited plus 3 non-pitting edema, was tender to touch, and the left ankle was not in alignment with the upper portion of the lower leg. Resident #1 was transferred to the hospital and diagnosed with [REDACTED]. The findings include: Review of the facility's policy for fallen or injured residents, revised April 2011, revealed the policy focused on falls with injuries rather than other incidents of injury. Review of Resident #1's clinical record revealed the resident was admitted to the nursing facility on 05/27/07 with [DIAGNOSES REDACTED]. Review of the most current MDS (Minimum Data Set) assessment completed on 05/18/11 revealed the facility had assessed the resident to be non-ambulatory with total assistance from staff for locomotion on and off the unit. The facility assessed the resident to have no deficit in memory recall with the resident able to recall all three words with no cues required. Review of the care plan dated 05/25/11 revealed alteration in self care related to CVA, left hemiparesis, weakness, and independently perform own ADLs (activities of daily living). The care plan stated the resident required total assist from staff for wheelchair mobility. Review of a facility's incident detail report, completed on 06/04/11, revealed Resident #1 had an injury of unknown source. The report revealed the resident's left ankle/lower leg was swollen and the ankle "looked dislocated". The report revealed the resident complained of pain and the daughter had reported the leg/foot rest had not been applied for "a great deal of the day" on 06/03/11. Review of the clinical record revealed a nurses' note dated 06/04/11 at 6:15pm where Resident #1's daughter approached the nurse and reported the resident's left foot was "dragging along the ground at times". The daughter informed the nurse that the leg/foot rest had not been attached to the resident's wheelchair for a portion of time on 06/03/11. The daughter stated the resident spent the "entire night of 06/03/11 in pain to the left leg". Upon assessment of the resident's left foot the nurse documented the left leg exhibited plus 3 non-pitting edema, tender to touch, and the left ankle was not in alignment with the upper portion of the lower leg. The physician was notified and the resident was transferred to the emergency room . At 9:00pm, the hospital's emergency room notified the facility the resident was being admitted to the hospital for fracture of the left tibia and fibula. Observation of Resident #1, on 06/09/11 at 8:45am, revealed the resident lying in bed with eyes closed. An immobilizer was applied to the resident's left leg from the knee to the toes. Interview with the resident at the time of the observation revealed the left leg was injured when a lady was pushing the resident's wheelchair and "all at once my leg felt hurt". "The lady stopped and asked if I was hurt and even though my leg was hurting, I told her I would be okay." The resident stated the nurse did not assess the injured leg, only the person pushing the wheelchair. "My daughter came in to visit the next day and saw my foot, she wanted medical care". Interview, on 06/10/11 at 5:15pm, with the nurse who assessed Resident #1 on 06/04/11 revealed the daughter reported the resident's leg was swollen and out of alignment. Upon assessment the nurse found the resident's left foot to be very edematous and was turned inward. She stated the resident did not complain of any pain at that time. The nurse stated she received no report of any incident regarding the residents during shift change report. Interview with Resident's #1's daughter, on 06/09/11 at 11:30am, revealed the daughter visits the resident daily. She revealed the resident was suppose to have a leg/foot rest applied to the left side of the wheelchair since the stroke because of the left sided paralysis and the resident could not propel the wheelchair with the left leg, and this was in place long before this incident. The daughter stated she came to the facility on [DATE] at approximately 10:00am and the resident was in an activity. When the daughter went into the activity to see the resident, she noticed the leg/foot rest was not applied to the resident's wheelchair and she requested the staff to apply. The daughter stated the resident complained of pain while the staff was placing the left leg upon the leg rest but she thought it was "normal aches and pains". The daughter came back to the facility the morning of 06/04/11 and checked the resident's legs for edema, which according to the daughter she did regularly. She stated the left foot didn't look right but the resident was not complaining of pain at that time. The daughter came back to the facility that evening (06/04/11) and found the resident's left ankle/foot swollen and the ankle was not in alignment with the rest of the leg. The daughter informed the nurse who then called the physician. The daughter voiced concern that the resident had been transferred by a mechanical lift where the resident would have to bear weight on the left leg after the incident and may have caused further harm. The daughter stated the resident's injury could have been prevented if the staff had only applied the leg/foot rest and she was upset that she had to be the one who discovered the injury. Interview with the Director of Nursing (DON), on 06/09/11 at 10:30am, revealed the facility became aware of the injury of unknown source on 06/04/11 when the daughter reported the changes to the resident's left leg. During the investigation, it was found the resident's leg/foot rest had not been applied on the morning of 06/03/11. The activity assistant told the activity director that there had been an incident on 06/03/11 where the resident's left foot had caught on the floor and bent backward under the wheelchair. The DON stated upon interview with the activity assistant, it was found the resident's left foot probably was injured when the left foot was bent backward. On 06/09/11 at 9:45am, an interview with the activity assistant revealed she went into the resident's room on 06/03/11 before 10:00am to take the resident to an activity. The resident was already sitting up in the wheelchair. She stated she did not look at the wheelchair to see if the leg/foot rest was applied. When she was pushing the wheelchair across the first dining room, the resident yelled, "Oh!" She stated she stopped and the resident said something like my foot is stuck or ouch my foot hurts. When she pulled the wheelchair back, the resident's foot was bent under the wheelchair. The activity assistant stated she apologized to the resident and asked if the resident was okay. She stated the resident indicated the foot was okay and they proceeded on toward the activity. She stated the resident was in the activity without any signs of pain. She stated the daughter came to the door and asked if she could take the resident. The daughter was upset the leg/foot rest was not on the resident's wheelchair and requested staff to apply the leg/foot rest. The activity assistant stated she didn't realize the leg/foot rest was suppose to be on the resident' wheelchair. She acknowledged she had not asked about the leg/foot rest and did not report the incident to anyone. She stated she thought the resident was fine and didn't realize the resident was really hurt. On 06/10/11 at 8:50am, a review of the facility's security video tape (with the administrator and DON) for the morning of 06/03/11 revealed the resident propelled the wheelchair from the resident's room at 4:45am, down the hallway (D-wing) and into the sitting area outside the C/D dining room. The resident was observed to move the wheelchair with the right foot and right hand. The leg/foot rest was not applied and the resident's left foot was observed to be dangling above the floor. At 5:10am, CNA#4 brought another resident to the sitting area and placed the resident beside Resident #1. Throughout the tape, CNA #4 passed Resident #1 several times and did not identify the resident's leg/foot rest was not applied. Continued review of the facility's video tape revealed on 06/03/11 at 7:55am, LPN #3 pushed Resident#1's wheelchair to the dining room and placed the resident under the table. The nurse did not identify the leg/foot rest was not applied. At 8:57am, LPN #4 removed the resident from the dining room and took the resident back to the room. The video taping revealed the leg/foot rest was not applied. At 10:05am, the activity assistant was observed to go into the resident room and came out pushing Resident #1's wheelchair down the hallway. The wheelchair did not have the leg/foot rest applied. The resident's right foot was resting on top of the left foot. Interview with CNA #4, on 06/09/11 at 10:45pm, revealed on the morning of 06/03/11 she was assisting LPN #4 with a straight cath for urinalysis on Resident #1. She stated the resident requested to get up early (4:30am) so she washed and dressed the resident. She left the resident in the wheelchair in the resident's room and didn't know how the resident got to the sitting area. She confirmed she had not applied the leg/foot rest to the resident's wheelchair. When she conducted the last visual check on the resident, she found the resident sitting in the same area as before. She stated she did not think about the leg/foot rest not being applied. Interview with CNA #3, on 06/10/11 at 10:35am, revealed Resident #1 was already up in the wheelchair when she arrived for work on 06/03/11. The CNA did not notice the leg/foot rest was not applied. Later that morning, she saw the resident with the daughter and the leg/foot rest was applied at that time. CNA #3 stated when she put the resident back to bed at 2:00pm, the resident's left leg was slightly swollen but nothing was alarming because the resident routinely has some edema in the feet. The resident requested to have the left leg elevated and did whimper a little but did not vocalize any pain. Interview with LPN #4, on 06/10/11 at 10:25am, revealed she had pushed Resident #1 in the wheelchair from the dining room to the resident's room after breakfast on 06/03/11. She stated she placed the resident in the room, turned on the television, and gave the resident the call light. She then left the room without applying the leg/foot rest even though she knew the resident required the use of the leg rest. The nurse stated she had not noticed the leg/foot rest was not applied. Review of the hospital's Orthopedic consultation and Radiology report revealed the resident experienced an acute angulated mildly comminuted and impacted fractures at the distal shafts of the tibia and fibula, approximately 5 centimeters above the Morris (ankle) joint. Interview with Resident #1's physician, on 06/09/11 at 11:15am, revealed the injury was consistent with the type of trauma a resident would experience with the left foot caught behind the wheelchair. The physician added the resident was non-ambulatory and demineralization of the bones comes with age causing bones to break easily. Continued interview with the DON, on 06/10/11 at 11:00am, revealed the facility did not use paper CNA care plans. The staff used hand held computer devices that had instructions for the CNAs. Review of the hand held device revealed approaches for Resident #1 was non-weight bearing status, immobilizer to left leg, and assure leg/foot placed on wheelchair when resident is up. She revealed those approaches were not in place prior to the incident; however, staff knew the resident required the leg/foot rest when up in the facility. She stated nursing staff involved had been counseled on the failure to apply the leg/foot rest on Resident #1's wheelchair.