Every finding on record at Landmark of Amarillo Rehabilitation and Nursing Ce

Based on interview and record review the facility failed to ensure the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 6 residents reviewed for accidents and hazards.The facility failed to ensure Resident #1 did not have access to a double-sided razor blade. Resident #1 used the razor blade to cut his left wrist, resulting in a 7 cm laceration on the inside of Resident #1's left wrist which required 23-26 stitches on the night of [DATE].The noncompliance was identified as PNC. The IJ began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the investigator entered the facility.This failure could place residents at risk of harm or death. Findings Included:Record review of Resident #1's admission record dated [DATE] revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, type 2 diabetes mellitus (insufficient production of insulin, causing high blood sugar), nicotine dependence, alcohol dependence in remission, major depressive disorder recurrent severe (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities), alcoholic hepatitis (liver inflammation caused by heavy or prolonged alcohol use), acquired absence of right leg below knee, and acquired absence of left leg below knee.Record review of Resident #1's quarterly MDS assessment completed on [DATE] revealed a BIMS score of 15 which indicated intact cognition. Section D Mood revealed he had little interest or pleasure in doing things 7-11 days of the 14-day look-back period. Section E Behavior revealed Resident #1 had no behaviors during the look-back period. Section GG Functional Abilities revealed he used a walker and limb prosthesis. Resident #1 was independent across all ADLs except bathing where he needed supervision or touching assistance. Section N Medications revealed he was receiving antidepressant medication.Record review of Resident #1's care plan completed on [DATE] revealed he had a positive drug screen for marijuana and he used tobacco. He was care planned for having major depressive disorder. Staff were to Monitor/record/report to MD prn risk for harm to self; suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving away possession or writing a note), intentionally harmed or tried to harm self, refusing to eat or drink, refusing med or therapies, sense of hopelessness or helplessness, impaired judgment or safety awareness. This intervention was initiated on [DATE]. Another intervention was Psychiatric Services [name of provider] discontinued r/t non-adherent with treatment plan.Record review of Resident #1's order summary report dated [DATE] revealed the following orders and corresponding order start dates:[DATE] Discharge for services of [name of psychiatrist's NP] due to resident/responsible party non-adherent with treatment plan[DATE] Sugical [sic] incision to left wrist: clean with wound cleanser/NS.[DATE] Transfer to [name of behavioral health hospital] for inpatient treatment. one time only for 7 Days[DATE] Duloxetine HCI Oral Capsule Delayed Release Sprinkle 60 MG.give 2 capsule by mouth one time a day related to MAJOR DEPRESSIVE DISORDER, RECURRENT SEVERE .Record review of Resident #1's MAR for [DATE] revealed he received his Duloxetine HCI as ordered from [DATE]st to [DATE]th.Record review of Resident #1's progress notes revealed the following notes and corresponding authors and dates/times:[DATE] at 11:50 PM a transfer notification written by CN [Resident #1] was transferred to a hospital on [DATE] 12:15 AM related to Resident was found in his room bleeding from self inflicted wound to left wrist. The resident used a straight razor to slice his wrist.[DATE] at 12:10 AM a note written by RN K This shift nurse was going to assess the resident and check BG level this evening due to low levels found the previous day and a lower level today. This is only a concern due to levels trending out of the norm. Upon entering the residents room, there appeared to be a mess on the floor when the light was turned on it was quickly identified as blood. This shift nurse approached the resident and asked if he was bleeding and pulled covers aside and identified laceration or lacerations to left wrist. This shift nurse grabbed some gauze to apply pressure and called CNA for assistance and called upon other staff members to aide in care. Management and Physicians on call notified as documented. 911 called and awaiting ambulanceXXX[DATE] at 01:40 AM a note written by RN K The ambulance arrived about 0128 (01:28 AM). The paramedic asked about the situation which was addressed by this shift nurse. The resident was loaded onto a granny/gurney. And paperwork given to Paramedic/EMT. The resident was wheeled out and loaded onto ambulance and transported to [initials of hospital].[DATE] at 04:35 AM a note written by RN K [Initials of hospital] representative called facility and stated that the resident was being transferred back. When asked why and why is not being committed to the [name of psychiatric care facility] or such. And the [initials of hospital] representative stated that due to the residents denial of suicidal ideologythat [sic] they had no grounds to commit him for psychiatric evaluation. The resident was transported back by [initials of hospital] transport. Upon arrival he was met in drop off zone by front doors with staff and wheelchair. The resident was returned to his room by wheelchairand [sic] accompanied by staff. Will monitor the resident and await further orders. The resident is in bed resting, bed lowered, bed brakes locked, call light in reach, equal fall and rise chest bilaterally, RR at 17, and denies pain or further needs at this time.[DATE] at 06:08 AM a note written by LVN M Ressident [sic] alert and orientd [sic] very pleasant denies any pain or discomfort, denies any SI, dressing to left wrist intact no new drainage noted. Resident on one on one for supervision .[DATE] at 07:52 AM a note written by RN K This statement is in regards of [Resident #1]. On the night of [DATE] this shift nurse went to check on the resident around 11:30. The reason being is the day before ([DATE]) when BG was checked, it was 62. This was not consistent for the resident. When assessed the evening of [DATE] the residents BG was at 141. So I decided that I would do a check later in the evening to make sure BG wasn't dropping to a critical level. When I entered the room to assess the resident BG level I seen something on the floor. I turned on the residents light and the mess on the floor appeared to be blood. I spoke with a loud tone, '[Resident #1] are you bleeding?' I approached the resident and uncovered him and I could see the resident was bleeding from his left wrist. I said, '[Resident #1] did you cut yourself?' He stated, 'Yes.' I said, 'Why?' He stated, 'Because I'm a fucking dumb ass.' I mediately [sic] went to the cart and grabbed some gauze, returned and applied pressure. At this time the cut did not appear to be bleeding profusely but still needed to apply pressure. I had staff CNA's [sic] assist me' [sic] then called other shift nurses to come help. Together we called management to notify of the situation. Physician was notified and orders were to send out which at this time 911 was called. Family on resident profile was notified. When CNA's [sic] asked the resident what happened he stated, 'I was throwing away the razor blades and slipped and I guess that's when I cut myself. I didn't even notice I cut myself. I just went to bed.' This was the same thing he told the Paramedic, EMT, [initials of hospital] staff and the police. When staff CNA's [sic] were cleaning the resident to transfer out. The CNA's found a metal box with barbers razors and a marijuana vape pen. This was removed, bagged up and placed away for the administrator to inspect. Paramedics had arrived and the resident was taken to the hospital. When the paramedics/EMT asked what happened the resident stated, 'I fell when trying to throw away the razers [sic].' The resident left by ambulance and report was called into the [initials of hospital] ER. [Initials of hospital] representative called and stated they were bringing the resident back. This staff nurse asked. ' Why are they not going to admit him to the [names of two psychiatric units] for help.' The representative stated, ' The resident denied suicidal ideology.' Due to the denial, [initials of hospital] treated the incident as an accident as stated by the resident. Upon arrival I told the resident, ' I understand you told everyone that this was an accident. But from mypoint [sic] of view you were in bed like you do when going to sleep. Prosthetics off, shirt off and in your boxers. But before this you slip, cut your wrist, don't feel it or see yourself bleeding. You don't call for help ring the call light come out of your room for help but manage to undress and get ready for bed. It just doesn't make since [sic]. But if you need help, know that we're here for you.' The resident stated, ' Okay, but I'm good I have [name of friend] why would I kill myself.' On this day the resident didn't show signs of suicidal tendencies. When this staff nurse arrived to work, the resident was sitting in the chair he's always in watching T.V. in the units day room. I walked by and said what's up [Resident #1], gave him a fist bump, and asked, 'You good.' He stated, 'Yeah.' And when asked if he was good it was not because he was giving me signs to be concerned. I generally ask everyone upon arrival if they are ok. And as stated above my only concern was to check BG level because he was trending low. That was my reason for checking on him. Maybe an act of God and good I didn't wait till the morning.[DATE] at 09:13 AM a note written by LVN M Resident continues on one on one supervision no s/s of discomfort or distress noted.[DATE] at 12:07 PM a note written by SW SW and admin met with patient. Although he indicated he was not trying to self-harm, he was agreeable to go to [name of behavioral hospital] to be evaluated and admitted due to the seriousness of his injury and concern of the facility. [Name of behavioral hospital] has accepted the patient and [name of facility] will transport him at 2pm.Record review of Resident #1's hospital discharge instructions revealed he arrived at the hospital on [DATE] at 01:54 AM with a laceration to his left wrist. He was to return in 7-10 days for suture removal.Record review of Resident #1's Discharge Notification dated [DATE] revealed he was discharged to a behavioral health hospital on [DATE] and the discharge was necessary for his welfare, and his needs could not be met in the facility. The discharge further revealed, Resident has an immediate threat to self harm. Resident lacerated his left wrist with a double edged razor blade. Resident was treated in [DATE] for suicidal ideation at [name of behavioral hospital]. In [DATE], resident was sent to hospital for emergency care after an apparent suicide attempt in facility. Resident is being discharged to acute in-patient psychiatric facility, [name of behavioral hospital].During an interview on [DATE] at 05:22 AM CNA A stated she had worked with Resident #1 and had never noted any signs of depression or suicidality. She stated it was not normal for residents to have razor blades in their rooms. CNA A stated if residents wanted to be shaved the CNAs did that for them. She stated a possible negative outcome of a resident having razor blades in their room was they could cut or hurt themselves. She stated since Resident #1 cut himself she had been trained on what was allowed in a resident's room as well as how to recognize and report s/s of depression, anxiety, and suicidal ideation.During an interview on [DATE] at 05:27 AM LVN B stated she had worked with Resident #1 and had never noted any signs of depression or suicidality. She stated it was not normal for residents to have razor blades in their rooms. She stated a possible negative outcome of a resident having razor blades in their room was they could accidentally or intentionally cut themselves. She stated since Resident #1 cut himself she had been trained on what was allowed in a resident's room as well as how to recognize and report s/s of depression, anxiety, and suicidal ideation.During an interview on [DATE] at 05:30 AM CNA C stated residents should not have razor blades in their rooms. She stated they could hurt or cut themselves or step on the razor blades. CNA C stated since Resident #1 cut himself she had been trained on what was allowed in a resident's room as well as how to recognize and report s/s of depression, anxiety, and suicidal ideation.During an interview on [DATE] at 05:36 AM LVN D stated she had worked with Resident #1 and had not noticed any suicidal ideation or depression. She stated Resident #1 interacted with the other residents really well. LVN D stated it was not normal for residents to have razor blades in their rooms. She stated a possible negative outcome of a resident having razor blades in their room was cuts and/or infections. LVN D stated since the incident with Resident #1 she was trained on what was allowed in a resident's room as well as how to recognize and report s/s of depression, anxiety, and suicidal ideation.During an interview on [DATE] at 05:38 AM CNA E stated it was not normal for residents to have razor blades in their rooms. He stated a possible negative outcome of a resident having razor blades in their room was what happened with Resident #1. He stated since the incident he was trained on what was allowed in resident rooms and how to recognize and report s/s of depression, anxiety, and suicidal ideation.During an interview on [DATE] at 05:40 AM CNA F stated it was not normal for residents to have razor blades in their rooms. She stated a possible negative outcome of a resident having razor blades in their room was they could slice somebody's throat or wrist. She stated after the incident with Resident #1 she was trained on what was allowed in resident rooms and how to recognize and report s/s of depression, anxiety, and suicidal ideation.During an interview on [DATE] at 05:42 AM CNA G stated residents should not have razor blades in their rooms. She stated, They are not to have any sharp objects in their rooms. CNA G stated residents could hurt themselves or others. She stated she had been trained on what was allowed in a resident's room and how to recognize and report s/s of depression and suicidal ideation since the incident with Resident #1.During an interview on [DATE] at 05:48 AM DON stated residents were not allowed to have razor blades in their rooms because they could hurt themselves.During an interview on [DATE] at 05:52 AM LVN H stated residents were not to have razor blades in their rooms lest they hurt themselves. She stated she worked occasionally with Resident #1 and never noticed s/s of depression or suicidal ideation from him. She stated following the incident of him cutting himself with a razor blade she was trained on what was allowed in a resident room and on recognizing and reporting s/s of depression and suicidal ideation.During an interview on [DATE] at 05:53 AM CNA I stated residents were not to have razor blades in their rooms lest they hurt themselves. She stated CNAs shaved residents who desired to be shaved. CNA I stated since the incident with Resident #1 she had been trained on recognizing and reporting s/s of depression, anxiety, and suicidal ideation as well as what was allowed in a resident's room.During an interview on [DATE] at 05:57 AM DON stated she provided training to all staff on rotation on [DATE] on recognizing and reporting s/s of anxiety, depression and suicidal ideation as well as what was and was not allowed in a resident's room. She stated a new rotation came on [DATE] and she would train that whole rotation at that time.During an interview on [DATE] at 06:09 AM CNA F stated she was on shift on the evening of [DATE] when Resident #1 cut himself. She stated she and her nurse, LVN J, were on a different unit but when RN K called LVN J to assist him with Resident #1 she (CNA F) went as well. She stated LVN J stopped by a supply closet and got a bandage and the two of them ran to RN K's unit. CNA F stated RN K was holding gauze to Resident #1's left wrist when she and LVN J arrived in Resident #1's room. She stated LVN J began to bandage Resident #1's wrist and she (CNA F) told RN K they could take care of Resident #1 if he (RN K) wanted to start making calls and charting. She stated after LVN J bandaged Resident #1's wrist, she (LVN J) left Resident #1's room to help RN K with notifications and calling 911. She stated she began to clean the blood on Resident #1's floor and table. She stated Resident #1 had his head covered by the blankets. She stated she looked in his drawer and inside the seat of his walker and did not see anything he could have cut himself with. She stated when she took the trash bag out of his trash can it seemed heavy and she prodded around on the bottom of the bag and felt something hard. She stated she discovered a marijuana vape pen and a small metal box of razor blades in the bottom of Resident #1's trash can. She showed the two items to LVN J and after the blood was cleaned off the two items LVN J took a picture for ADM. CNA F stated the blood on Resident #1's floor was beginning to dry around the edges, and it was approximately 8 inches around. She described the blood on his table as just a few inches and oval. CNA F described the blood on Resident #1's bedding as approximately 12 inches in an elongated oval.During an interview on [DATE] at 06:43 AM LVN J stated RN K called for her to assist him after he found Resident #1's cut wrist. She stated she and RN K watched Resident #1 until the ambulance arrived. She stated she had worked with Resident #1 many times and never seen any warning signs of depression or suicidal ideation. She stated, I never seen anything, he is always very friendly. It caught me off guard that that happened.During an interview on [DATE] at 06:49 AM ADM stated Resident #1 had a cut from one side to the other on the inside of his wrist. She stated it was 7 cm long and required 23-26 stitches at the hospital.During an interview on [DATE] at 07:42 AM RN K stated when he arrived on shift on the evening of [DATE] Resident #1 was acting normal. He stated, I didn't notice anything different with him. He stated he had some concern about Resident #1's blood glucose level as it has been low during his last shift on [DATE]. RN K stated at about 11:30 PM on [DATE] he entered Resident #1's room to check his blood glucose and he noticed a mess on the floor of the room. When he turned on the light, he saw it was blood. RN K stated he asked Resident #1 if he was bleeding and he could see blood dripping from Resident #1's bed. RN K stated he pulled the covers back and asked Resident #1 if he cut himself and Resident #1 said he did. RN K stated he asked Resident #1 why he cut himself and Resident #1 stated, Because I am a freaking idiot. RN K stated later when the CNAs asked Resident #1 what happened he told them he was trying to put the razor blades away and he slipped and fell and did not realize he cut himself. RN K stated, That is the story he is sticking with and I don't buy it. He would have had to take off both legs (Resident #1 had two prosthetic legs) and take his shirt and his shorts off all while not noticing he was cut. RN K stated of Resident #1 cutting himself, It really caught me off guard. It really shocked me. I have had rapport with him for a while. RN K stated he had worked with Resident #1 for 3 years. He stated in that three years Resident #1 had shown no s/s of suicidality. RN K stated the size of the pool of blood on Resident #1's floor was approximately 6 inches round with wavy edges. He stated the blood in the bed had soaked into the blanket and sheets and Resident #1 had moved around a lot so it was a mess. RN K stated it was not normal for residents to have razor blades in their rooms. He stated, I have no idea where those came from. RN K stated residents could accidentally cut themselves. He stated the cut on Resident #1's wrist was all the way across the inside of his wrist. RN K stated he had not been back to work since the incident and had not received any trainings regarding the incident, but he expected to be trained before his next shift.During an interview on [DATE] at 08:12 AM CN stated the facility did not have an accidents/hazards policy. She stated the resident's rights policy would cover part of accidents/hazards.During an interview on [DATE] at 09:15 AM CNA L stated she was working on the unit with RN K on the evening of [DATE]. She stated Resident #1 did not show any s/s of depression or act any differently than usual. CNA L stated residents were not supposed to have razor blades in their rooms. She stated they could cut themselves. CNA L stated she had been trained after the incident with Resident #1 regarding recognizing and reporting s/s of depression or suicidal ideation as well as what was allowed in a resident room.During an interview on [DATE] at 09:21 AM FM N stated Resident #1 had always lived with family members and had been in rehabilitation for drugs and alcohol. She stated she did not believe Resident #1 tripped and fell on the razor blade. Family member N stated Resident #1 told her, I didn't try to kill myself, but I want to go home to my [family member]. She stated Resident #1's family member died of cancer in 2012.During an interview on [DATE] at 09:37 AM SW stated when she and ADM performed a trauma screening on Resident #1 on [DATE] after he returned to the facility from the hospital, he kept indicating to her that he did not try to kill himself. She stated he did agree to go the psychiatric hospital. SW stated when she was speaking to the psychiatric hospital to refer him for placement, they told her he had been there before for similar reasons.During an interview on [DATE] at 09:44 AM FM O stated in March of 2025 she and several other family members received a text message from Resident #1 saying he wished he was dead. She stated she alerted the facility and the facility had Resident #1 transferred to the psychiatric hospital where he stayed for 7-10 days. She stated he had never harmed himself before but had talked about it a lot all of his life.During an interview on [DATE] at 09:56 AM LMSW, Resident #1's counselor, stated she had been seeing him weekly since October of 2025. She stated he often declined sessions. LMSW stated Resident #1 did not ever show s/s of suicidal ideation or depression during their sessions. LMSW stated the last time she saw Resident #1 was [DATE] and during that session he did not show any s/s of depression or suicidal ideation.During an interview on [DATE] at 11:03 AM HSK P stated she had been recently trained on recognizing and reporting s/s of depression and suicidal ideation and what was allowed in resident rooms.During an interview on [DATE] at 03:09 PM Resident #1's friend stated she did not have any idea he was planning to hurt himself. She stated they did not have a fight or argument.During an interview on [DATE] at 03:56 PM ADON stated residents were not to have razor blades in their rooms because they could hurt themselves or others. She stated she was trained on recognizing and reporting s/s of depression and suicidal ideation and on what was allowed in resident rooms.Record review of an undated facility policy titled Resident Rights revealed no mention of a safe environment or accidents/hazards. Record review of undated sheet from facility titled Items Not Allowed in Resident Room: revealed the following: . SAFETY HAZARDS: . Razors and blades .Record review of Ad Hoc QAPI meeting revealed it was held on [DATE] and attended by ADM, DON, ADON, MD, BOM, Director of Rehab, CN, Human Resources, MDS nurse, and Housekeeping.Record review of an in-service by DON for all staff dated [DATE] revealed staff were trained on items allowed in a resident's room. Record review of the information covered during this inservice revealed that staff were provided a list of items that were not allowed in a resident's room , which included razors and blades. Record review of an in-service by DON for all staff dated [DATE] revealed staff were trained on recognizing depression and suicide warning signs in residents and how to immediately report said signs. This failure was identified as past noncompliance IJ as the facility had instituted adequate corrective measures to prevent recurrence of the non-compliance.

Based on interviews and record reviews the facility failed to establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave for 1 (Resident #1) of 5 residents reviewed for transfer/discharge rights.The facility failed to allow Resident #1 to return to the facility after he was admitted to a short-term psychiatric hospital following an apparent suicide attempt.This failure could place residents at risk of feelings of instability/insecurity. Findings Included:Record review of Resident #1's admission record dated 05/19/26 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, type 2 diabetes mellitus (insufficient production of insulin, causing high blood sugar), nicotine dependence, alcohol dependence in remission, major depressive disorder recurrent severe (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities), alcoholic hepatitis (liver inflammation caused by heavy or prolonged alcohol use), acquired absence of right leg below knee, and acquired absence of left leg below knee.Record review of Resident #1's quarterly MDS assessment completed on 02/23/26 revealed a BIMS score of 15 which indicated intact cognition. Section D Mood revealed he had little interest or pleasure in doing things 7-11 days of the 14-day look-back period. Section E Behavior revealed Resident #1 had no behaviors during the look-back period. Section GG Functional Abilities revealed he used a walker and limb prosthesis. Resident #1 was independent across all ADLs except bathing where he needed supervision or touching assistance. Section N Medications revealed he was receiving antidepressant medication.Record review of Resident #1's care plan completed on 04/29/26 revealed he had a positive drug screen for marijuana and he used tobacco. He was care planned for having major depressive disorder. Staff were to Monitor/record/report to MD prn risk for harm to self; suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving away possession or writing a note), intentionally harmed or tried to harm self, refusing to eat or drink, refusing med or therapies, sense of hopelessness or helplessness, impaired judgment or safety awareness. This intervention was initiated on 03/21/25. Another intervention was Psychiatric Services [name of provider] discontinued r/t non-adherent with treatment plan.Record review of Resident #1's order summary report dated 05/19/26 revealed the following orders and corresponding order start dates:01/23/26 Discharge for services of [name of psychiatrist's NP] due to resident/responsible party non-adherent with treatment plan05/18/26 Transfer to [name of behavioral health hospital] for inpatient treatment. one time only for 7 DaysRecord review of Resident #1's progress notes revealed the following notes and corresponding authors and dates/times:05/17/26 at 11:50 PM a transfer notification written by CN [Resident #1] was transferred to a hospital on [DATE] 12:15 AM related to Resident was found in his room bleeding from self inflicted wound to left wrist. The resident used a straight razor to slice his wrist. 05/18/26 at 09:13 AM a note written by LVN M Resident continues on one on one supervision no s/s of discomfort or distress noted.05/18/26 at 12:07 PM a note written by SW SW and admin met with patient. Although he indicated he was not trying to self-harm, he was agreeable to go to [name of behavioral hospital] to be evaluated and admitted due to the seriousness of his injury and concern of the facility. [Name of behavioral hospital] has accepted the patient and [name of facility] will transport him at 2pm.05/18/26 at 12:35 PM a note written by LVN M [Resident #1] was transferred to a hospital on [DATE] at 1:48 PM related to Self inflicted wound to left wrist. This is intended to serve as notice of an emergency transfer.Record review of Resident #1's EHR under the MDS tab revealed a Discharge Return Not Anticipated assessment In Progress.Record review of Resident #1's EHR under the MISC tab revealed an Immediate Discharge Notice dated 05/18/26 at 02:05 PM by ADM.Record review of Resident #1's Discharge Notification dated 05/18/26 revealed he was discharged to a behavioral health hospital on [DATE] and the discharge was necessary for his welfare, and his needs could not be met in the facility. The discharge further revealed, Resident has an immediate threat to self harm. Resident lacerated his left wrist with a double edged razor blade. Resident was treated in March 2025 for suicidal ideation at [name of behavioral hospital]. In May 2026, resident was sent to hospital for emergency care after an apparent suicide attempt in facility. Resident is being discharged to acute in-patient psychiatric facility, [name of behavioral hospital].During an interview on 05/19/26 at 08:21 AM OM stated she has received an immediate discharge for Resident #1 and was concerned the facility might not be planning to take him back after he finished his in-patient psychiatric stay.During an interview on 05/19/26 at 02:28 PM CN stated the facility issued an immediate discharge for Resident #1 on 05/18/26 because Resident #1 had not exhibited any signs or symptoms that indicated he was suicidal and the facility did not feel they could keep him safe or meet his needs.During an interview on 05/20/26 at 08:39 AM OM stated she spoke to ADM on 05/19/26 and was informed the facility did not intend to take Resident #1 back after his stay at the behavioral hospital. OM stated ADM told her the decision came from high up in the facility's corporate structure. OM stated, Him (Resident #1) being dumped will likely affect his Medicaid and certainly his NF Medicaid. She stated Resident #1 was enrolled in a program to help him transition to living in the community on his own and that his enrollment could be jeopardized by the facility refusing to take him back.During an interview on 05/20/26 at 10:40 AM ADM stated someone in her corporate structure right below the very top made the decision not to take Resident #1 back. She stated corporate said, We will take the dumping tag.but we are not taking him back. ADM stated she spoke to the behavioral hospital staff and told them she would help them find placement for Resident #1 after his treatment if she needed to. She stated she spoke to his Medicaid case manager about a possible placement at another facility in town and his case manager was planning to visit that facility today to see if they would accept Resident #1 when he finished his treatment at the behavioral hospital.During an interview on 05/20/26 at 10:50 AM DDC stated the immediate discharge the facility did for Resident #1 did not necessarily mean he could not return to the facility until they could find him a more appropriate placement. DDC reiterated, We are not saying we will never take him back in this building. We were in agreement that this discharge option was safest for him and for us and for our facility. I do think this (surveyor's investigation into the appropriateness of Resident #1's discharge) is a little premature since he has not been discharged from [name of behavioral hospital] yet and we are still working to locate an appropriate placement.During an observation and interview on 05/20/26 at 11:37 AM, DDC was seated in ADM's office and ADM was on the phone. The DDC joined this surveyor in the hallway. DDC stated if Resident #1 was ready to be discharged from the behavioral hospital and did not have an appropriate placement the facility would take him back and work to find him an appropriate placement. ADM hung up the phone and this surveyor leaned into her office doorway and asked her if the facility would be willing to take Resident #1 back if, when he was ready to be discharged from the behavioral hospital, he had no other placement options. DDC walked behind this surveyor into ADM's office and stood facing ADM and nodding. ADM looked at DDC and stated, I guess so if they (gestured to DDC) are saying that, then we will.During an interview on 05/20/26 at 01:17 PM ADON stated there was not a negative outcome to Resident #1 if the facility discharged him to a short-term behavioral hospital unless the behavioral hospital would send them (Resident #1) out on the streets.During an interview on 05/20/26 at 01:29 PM IDPA stated when a facility sent a resident to their behavioral hospital and was unwilling to take the resident back, They (residents) don't have anywhere to go and that leaves us trying to find new placement for them so basically what they (facility) did is dumped him on us. She stated the facility did not let the behavioral hospital know they were not taking Resident #1 back until he was already in the behavioral hospital.During an interview on 05/20/26 at 01:45 PM ADM stated the reason Resident #1 was issued an immediate discharge and not simply transferred to the behavioral hospital was because the facility was not intending to take him back. She stated she did not think there was a negative outcome to Resident #1 because his needs were being met so it is not like I kicked him out on the street.During an interview on 05/20/26 at 01:47 PM DDC stated she did not think there was a negative impact on Resident #1. She stated, In this case when we find him an appropriate, safer level of care after psych (psychiatric hospital) we hope it positively impacts his life.During an interview on 05/20/26 at 02:10 PM DDC stated she thought the decision to issue an immediate discharge for Resident #1 was the right decision for Resident #1 and for the facility.Record review of facility policy titled Discharge or Transfer and dated 12/2017 revealed the following: . In the following limited circumstances, this facility may initiate transfers or discharges: A. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; . Emergent Transfers to Acute Care Residents who are sent emergently to the hospital are considered facility-initiated transfers because the residents return is generally expected. When a resident is temporarily transferred on an emergency basis to an acute care facility, this type of transfer is considered to be a facility-initiated transfer. In situations where the facility has decided to discharge the resident while the resident is still hospitalized , the facility will send a notice to a representative of the Office of the State LTC Ombudsman. Permitting Residents to Return This facility will allow residents to return following a hospitalization or leave unless the conditions for discharge are met as explained in this policy. Because this facility was able to care for the resident prior to the hospitalization or therapeutic leave, documentation related to the basis for discharge must clearly show why the facility can no longer care for the resident.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #65) of 17 residents observed for infection control. -Resident #65's oxygen nasal cannula was left on the floor for 23 hours. This deficient practice has the potential to affect residents by exposing them to the spread of infections, tissue breakdown, and feelings of isolation related to poor hygiene.Findings include: Record review of Resident #65's face sheet revealed he was a [AGE] year-old male resident admitted to the facility originally on 11/26/2024 and readmitted on [DATE] with diagnoses to include chronic respiratory failure (a long-term condition lasting over a month where the lungs cannot adequately supply oxygen to the flood or removed carbon dioxide, often resulting from chronic diseases like COPD), asthma (a chronic disease in which the bronchial airways in the lungs become narrowed and swollen, making it difficult to breathe), cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), and dementia (a group of thinking and social symptoms that interfere with daily functioning). Record review of Resident #65's clinical record revealed his last MDS was a quarterly completed 1/30/2026 listing him with a BIMS score of 15 indicating he was cognitively intact and he had a functionality of requiring supervision/touching assistance to partial/moderate assistance with his activities of daily living. Record review of Resident #65's care plan with admission date of 02/13/2025 revealed the following: Focus: The resident has Oxygen Therapy. Date Initiated: 02/03/2026. Record review of Resident #65's Order Summary Report with Active Orders as of 3/26/2026 revealed the following order:- Oxygen LPM: 2-5 L Via: N/C every shift for keep O2 SATS GREATER THAN 88% Assess O2 Sat, Resp. Rate, Pulse, Breath sounds Verbal Active 01/29/2026. Record review of Resident #65's O2 Sats Summary revealed the following: 3/26/2025 02:00AM 92.0% Oxygen via Nasal Cannula 3/23/2025 04:17AM 92.0% Oxygen via Nasal Cannula 3/22/2025 02:09AM 92.0% Oxygen via Nasal Cannula 3/21/2025 04:25AM 92.0% Oxygen via Nasal Cannula During an observation on 03/24/2026 at 08:56 AM Resident #65 was not in his room. Resident #65's nasal cannula was on the floor next to his oxygen concentrator and his bedside dresser with the nasal prongs touching the floor. During an observation on 03/24/2026 at 10:03 AM Resident #65 was observed on the unit, up in his wheelchair. Resident #65 reported no issues. Observation of his room revealed his nasal cannula continued to be on the floor in the same position. During an observation on 03/24/2026 at 11:35 AM of Resident #65's room revealed his nasal cannula continued to be on the floor and the trashcan had been placed over the nasal cannula after the trashcan had been emptied. During an observation and interview on 03/24/2026 at 11:38 AM Resident #65 was observed sitting on the unit in his wheelchair dressed well for the day and he appeared in good condition. Resident #65 reported he had pneumonia about a month ago and required oxygen but only used it at night now. The staff provide for all his needs to include his oxygen care. During an observation on 03/24/2026 at 1:50 PM Resident #65 was in his bed sleeping peacefully with the HOB elevated and not wearing his oxygen. His nasal cannula was still on the floor under his trash can next to the oxygen concentrator. During an observation on 03/24/2026 at 3:20 PM Resident #65's nasal cannula continued to be on the floor under his trash can. During an observation on 03/25/2026 at 8:08 AM Resident #65 had been taken to therapy by staff in his wheelchair and when this surveyor checked his room his nasal cannula was still on the floor with the nasal prongs touching the floor in the same area next to his bedside dresser and his oxygen concentrator, but the trash can had been removed. During an observation and interview on 03/25/2026 at 1:20 PM Resident #65 was observed in his bed with the HOB elevated and he was watching TV. He was noted to have a new nasal cannula in a bag hanging from his oxygen concentrator. Resident #65 reported the nurse discovered the nasal cannula and replaced it. Resident #65 reported he did not need the oxygen last night, he only needs it occasionally, and if he needs it, he will just let the staff know and they will put it on him. Resident #65 was not aware the nasal cannula had been on the floor but reported he was glad it was replaced. During an interview on 03/25/2026 at 2:48 PM LVN I (the nurse providing care for Resident #65 this shift) reported staff should make rounds every 2 hours and they should check the resident's oxygen tubing to make sure it was stored correctly in a bag off the floor. LVN I reported if staff do find the tubing on the floor, then they should replace the tubing before putting it on the resident. LVN I reported she had not replaced Resident #65 oxygen tubing but had replaced his nebulizer tubing, that she would immediately check his room and ensure his oxygen tubing was replaced. LVN I reported Resident #65 will wear oxygen at night but only requires it when his oxygen saturation was below 90%. LVN I did confirm the oxygen tubing and nasal cannula on the floor should have been caught by staff when doing rounds. LVN I reported if a resident used a nasal cannula that had been on the floor, then they could get germs especially if the dirty nasal cannula was not removed and a new one put on. During an interview on 03/26/2026 at 9:12 AM CNA H (the CNA providing care for Resident #65 this shift) reported staff make rounds every 2 hours. CNA H reported if the room had oxygen, then the oxygen tubing and cannula need to be stored off the floor so the residents will not develop an illness. During an interview on 03/26/2026 at 9:49 AM the DON reported staff, especially the CNA's, should make rounds every two hours and they should check the oxygen and make sure the nasal cannula and tubing are stored in a bag off the floor. The DON reported if the nasal cannula and tubing were not stored correctly then it could be contaminated, damaged, or the resident could get caught up in it and trip resulting in a fall. During an interview on 03/26/26 at 09:32 AM the CN stated the facility did not have a policy or procedure specific to nasal cannula storage. The CN provided the Oxygen policy which had no information related to nasal cannula/O2 tubing storage.Record review of the facility provided policy titled, Fundamentals of Infection Control Precautions undated, revealed the following:-A variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the facility.6. Resident care equipment and articles 3. Non-invasive resident care equipment is cleaned daily or as need between use by nursing assistant.

Based on observation, interview, and record review, the facility failed to ensure all residents had a right to a dignified existence for 1 of 24 residents (Resident #56) observed for dining room experience when the facility failed to: Ensure Resident #56 was treated with respect, dignity and consideration when she failed to receive her noon meal at the same time as her table mates. This failure could place residents at risk of feeling neglected or ignored and could negatively impact residents' quality of life. Findings included:Resident #56 was a 95-y o female admitted to the facility on [DATE] with diagnoses of dementia (a decline in mental ability), diabetes ( a condition causing high blood sugar due to insufficient insulin production), dysphagia- oropharyngeal type ( difficulty initiating a swallow, moving food from the mouth to the throat ), Vitamin B deficiency ( ( when the body lacks sufficient B vitamins needed for metabolism, red blood cell production and nerve function), Vitamin D vitamin deficiency causing weak or brittle bones, muscle weakness and chronic fatigue) and Vitamin D deficiency ( when the body lacks sufficient Vitamin D causing weak or brittle bones, muscle weakness and chronic fatigue). A Care Plan dated 1/1/26 documented resident was independent in most ADLs, wanders and is at risk for falls. A Quarterly MDS dated [DATE] documented a BIMS score of 5 out of 15 which indicates cognition is severely impaired. The MDS documented Resident #56 usually understood what was said to her and was usually understood. The MDS documented Resident # 56 was 57 inches tall and weighed 108 pounds. Resident #56 had not had any weight loss in the past 6 months. In an observation on 3/24/26 at 12:00 pm, Resident #56 did not receive her food at the same time as her tablemates. Further observation revealed Resident #56 sat at the table at the same time the other 2 tablemates were seated. The other 2 tablemates received their trays and began eating. Resident # 56 was not served the lunch meal until after the 2 tablemates and 2 other tables of 4 residents each had gotten their food. In an interview on 3/25/26 at 2:50 pm Resident # 56 stated she was in the dining room and the residents at her table all had their food except her. She stated she felt left out and had been wondering why she did not get her food. She stated she thought she might not get to eat.In an interview on 3/26/26 at 10:15 am, the DM stated she had not been aware Resident #56 had not received her tray at the same time as the rest of the residents at her table. The DM stated all residents at a table should be served at the same time. She stated the consequences of not serving all residents at the table at the same time could be residents feeling left out of the group. Record review of the facility's policy titled, ' Nursing Responsibilities at Meal Service ' dated 2012, documented: A tray sequence is used in dining rooms so all residents at a table are served at the same time. Record review of the facility's policy titled, ' Resident Rights documented Residents have the right to be treated with dignity, courtesy, consideration and respect.

Based on observation, interview, and record review, the facility failed to provide a safe and clean environment for 1 (Resident #59) of 17 residents reviewed for environment. -Resident #59 had soiled washcloths left in her room for 29 hours. This failure could place residents at risk for diminished quality of life due to the lack of a well-kept environment.Findings included:Record review of Resident #59's face sheet revealed she was a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), seizures (sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain), hemiplegia (a condition characterized by sever or completed paralysis on once side of the body, typically resulting from brain damage), and depressive disorder (a common, serious mental health condition characterized by persistent sadness, loss of interest in activities, and low energy, lasting at least two weeks). Record review of Resident #59's quarterly MDS assessment completed 2/18/26 listing her with a BIMS of 07 indicating she was severely cognitively impaired, and she had a functionality of being dependent on staff for most of her activities of daily living. Record review of Resident #59's care plan with admission date of 9/01/24 revealed the following: Focus: Resident has a behavior problem: History of finger-painting feces Date Initiated: 05/01/2024Intervention: Check often for position/cleanliness. Date Initiated: 05/01/2024 During an observation on 03/24/2026 at 09:21 AM Resident #59 was in her room, in her bed under her covers. Resident #59 was awake and alert. Resident #59 had difficulty with speech but was able to report she was pleased with her care. Resident #59 then went back to watching TV and did not respond to any further questions. Several used washcloths were observed in a brown bin in the shower in her room. During an observation on 03/24/2026 at 11:37 AM the used washcloths continued to be in the bathroom in the brown bin. They were observed to be white washcloths with a slight brown discoloration. During an observation on 03/24/2026 at 1:54 PM Resident #59 was observed leaving her room by wheelchair with the assistance of a staff member. Upon observation, the used slightly brown stained washcloths continued to be in the shower in her room. Between 03/24/2026 at 3:21 PM and 03/25/2026 at 1:45 PM the slightly brown stained washcloths were observed 3 times in Resident #59's shower in her room. During an observation on 03/25/2026 at 2:24 PM this surveyor observed Resident #59's room/shower with the CN and noted the soiled washcloth to be present in the shower. The CN stated the soiled washcloths were an issue, she did not even know why they were in the shower because this shower was not used for resident care, and they (the soiled washcloths) should have been removed. During an interview on 03/25/2026 at 2:48 PM LVN I (the nurse responsible for providing care for Resident #59 this shift) reported if a resident had dirty washcloths in their room and she saw them she would remove them. LVN I reported the soiled washcloths should have been removed because they were dirty. LVN I reported if they are not removed then cross-contamination can occur, germs can occur, and it was just nasty. During an interview on 03/26/2026 at 9:12 AM CNA H (the CNA responsible for providing care for Resident #59 this shift) reported they make rounds every 2 hours and they check the room for cleanliness. CNA H reported if the room was left unclean then the resident could develop an illness. During an interview on 03/26/2026 at 9:49 AM the DON reported staff, especially the CNAs, should make rounds every two hours and they should make sure that the resident's room was clean, tidy, and had no trash. The DON reported that if the room was not clean it could affect the resident's mental condition and violate infection control. Record review of the facility provided policy titled, Fundamentals of Infection Control Precautions Infection Control Policy & Procedure Manual undated, revealed the following: Linen and laundry:1. All soiled linen will be double bagged at the site that it was generated.2. Soiled linen will be transported to the laundry site by cart. Record review of the facility provided policy titled, Resident Rights undated, revealed the following: The resident has a right to a dignified existence.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.

Based on interview and record review the facility failed to ensure the assessment accurately reflected the resident's status for 2 (Resident #18 and Resident #71) of 18 residents reviewed for accuracy of assessment.The facility inaccurately coded Resident #18 as having a bipolar diagnosis when he did not have a bipolar diagnosis.This failure could place residents at risk of receiving unnecessary care/medication or not receiving necessary care/medication.Findings Included:Record review of Resident #18's admission record dated 03/25/26 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Parkinson's disease (chronic and progressive movement disorder that initially causes tremors in one hand and stiffness or slowing of movement), dementia (a group of thinking and social symptoms that interferes with daily functioning), and anxiety disorder (a group of mental health conditions characterized by excessive and persistent worry, fear, and nervousness that can significantly interfere with daily life). The admission record did not reveal a diagnosis of bipolar disorder.Record review of Resident #18's significant change MDS assessment completed on 01/25/26 revealed a BIMS of 6 which indicated severely impaired cognition. Section I Active Diagnoses in the Last 7 Days revealed he had a diagnosis of bipolar disorder.Record review of Resident #18's care plan completed on 01/25/26 revealed no mention of bipolar disorder.Record review of Resident #18's diagnosis report dated 03/25/26 revealed no mention of bipolar disorder.During an interview on 03/26/26 at 08:58 AM RN D stated MDS RN was responsible for completing MDS assessments. She stated an inaccurate MDS assessment could negatively affect a resident because a lot of times the doctors use it and nurses use it and it can give you an incorrect clinical depiction of your resident. They might not be getting the care they need.During an interview on 03/26/26 at 09:03 AM ADON stated MDS RN was responsible for completing MDS assessments. She stated if an MDS assessment was inaccurate some level of care (for the resident) might be missed.During an interview on 03/26/26 at 09:05 AM DON stated MDS RN was responsible for completing MDS assessments. She stated if an MDS assessment was inaccurate it would cause the care plan to be inaccurate and residents might not receive needed care.During an interview on 03/26/26 at 09:09 AM ADM stated MDS RN was responsible for completing MDS assessments. She stated if an MDS assessment was inaccurate residents might not receive care or services they needed.During an interview on 03/26/26 at 9:10 AM CN stated MDS RN was responsible for completing MDS assessments. She stated if an MDS assessment was inaccurate residents might not receive the care they needed.During an interview on 03/26/26 at 09:17 AM MDS RN stated she was responsible for completing MDS assessments. She stated she used the RAI manual as her policy for completing MDS assessments. The MDS RN stated she was not sure why Resident #18 was coded as having bipolar disorder. MDS RN stated an inaccurate MDS assessment could affect facility funding. She stated she did not believe an inaccurate MDS assessment would negatively affect resident care because the facility would treat the resident regardless of funding.Record review of the facility provided policy titled, Documentation, revealed the following in part. Goal:1. The facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets.Record review of the Long-Term Care Facility RAI 3.0 User's Manual Version 1.20.1 dated October 2025 revealed the following: . SECTION I: ACTIVE DIAGNOSES Intent: The items in this section are intended to code diseases that have a direct relationship to the resident's current functional status, cognitive status, mood, or behavior status, medical treatments, nursing monitoring, or risk of death. One of the important functions of the MDS assessment is to generate an updated, accurate picture of the resident's current health status. Once a diagnosis is identified, it must be determined if the diagnosis is active. Active diagnoses are diagnoses that have a direct relationship to the resident's current functional, cognitive, or mood or behavior status, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period.

Based on interview, and record review the facility failed to refer to the state designated authority all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 1 (Resident #9) of 18 residents reviewed for PASRR.The facility failed to refer Resident #9 to the state designated authority for a PASRR Evaluation due to his diagnosis of Major Depressive Disorder Recurrent Severe.This failure could place residents at risk of not receiving necessary services or of being harmed by residents who have not been screened properly for placement in a nursing home setting.Findings Included:Record review of Resident #9's admission record dated 03/25/26 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, personal history of traumatic brain injury and major depressive disorder recurrent severe (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities).Record review of Resident #9's diagnosis report dated 03/25/26 revealed he received a diagnosis of major depressive disorder recurrent severe on 02/28/25.Record review of Resident #9's quarterly MDS assessment completed on 02/02/26 revealed a BIMS score of 6 which indicated severely impaired cognition. Section I Active Diagnoses revealed he had a diagnosis of depression.Record review of Resident #9's care plan completed on 02/05/26 revealed no mention of major depressive disorder but did note Resident #9 was being monitored for side effects of several medications one of which was antidepressant medication.Record review of Resident #9's active orders dated 03/25/26 revealed no orders for antidepressant medication.Record review of Resident #9's discontinued, struck out, completed orders revealed the following antidepressant medication orders and corresponding start dates:02/28/25 Duloxetine HCI Capsule Delayed Release Particles 60 MG Give 1 capsule by mouth one time a day for depression related to MAJOR DEPRESSIVE DISORDER, RECURRENT SEVERE.03/28/25 Mirtazapine Oral Tablet 15 MG . Give 1 tablet by mouth at bedtime related to MAJOR DEPRESSIVE DISORDER, RECURRENT SEVERE .06/13/25 Mirtazapine Oral Tablet 30 MG . Give 1 tablet by mouth at bedtime for Depression07/11/25 Mirtazapine Oral Tablet 45 MG . Give 45 mg by mouth one time a day related to MAJOR DEPRESSIVE DISORDER, RECURRENT SEVERE .09/20/25 Sertraline HCI Oral Tablet 50 MG . Give 1 tablet by mouth one time a day related to MAJOR DEPRESSIVE DISORDER, RECURRENT SEVERE .10/31/25 Sertraline HCI Oral Tablet 100 MG . Give 100 mg by mouth one time a day related to MAJOR DEPRESSIVE DISORDER, RECURRENT SEVERE .Record review of Resident #9's EHR under the miscellaneous tab revealed one PASRR screening and no Form 1012 (a form used to determine if a resident is eligible for PASRR services based on a new diagnosis).Record review of Resident #9's PASRR Level 1 Screening dated 12/09/24 revealed he was negative for mental illness.During an interview on 03/26/26 at 08:58 AM RN D stated not having a new PASRR screening following a qualifying diagnosis could negatively impact resident care. She stated, We have to reassess and make sure we are meeting their needs.During an interview on 03/26/26 at 09:03 AM ADON stated MDS RN was responsible for ensuring PASRRs were completed. She stated not having a new PASRR screening following a qualifying diagnosis could probably negatively impact resident care. She stated, Their mental health or condition might be overlooked or misunderstood.During an interview on 03/26/26 at 09:05 AM DON stated MDS RN was responsible for ensuring PASRRs were completed. She stated not having a new PASRR screening following a qualifying diagnosis could negatively impact resident care. She stated the care plan might not be as good as it could be if a new PASRR screening was not completed.During an interview on 03/26/26 at 09:09 AM ADM stated MDS RN was responsible for ensuring PASRRs were completed. She stated not having a new PASRR screening following a qualifying diagnosis could negatively impact resident care due to missed care/missed services.During an interview on 03/26/26 at 09:10 AM CN stated not having a new PASRR screening following a qualifying diagnosis could negatively impact resident care. She stated, We could not provide all the services they might quality for.During an interview on 03/26/26 at 09:17 AM MDS RN stated she was responsible for ensuring PASRR screenings were done as needed after admission. She stated she did not think a resident's care would be negatively impacted if they did not receive a new PASRR screening because residents with mental illness received in-house treatment. Regardless of whether or not they have the positive on the PASRR they still receive the services in the building. MDS RN stated without a new PASRR screening the residents would not be offered the opportunity to get outside services.During an interview on 03/26/26 at 09:41 AM PC stated residents might not get needed care if they do not receive a new PASRR screening following a qualifying diagnosis. She stated the facility could enter a change of condition into the system rather than performing a new PASRR screening and that would alert her to call and find out what the change was and if it qualified the resident for services or not.Record review of an undated facility policy titled Form 1012 Policy and Procedure with Instructions revealed the following: . Form 1012 assists nursing facilities (NF) in determining whether a resident with a negative Preadmission Screening and Resident Review (PASRR) Level 1 (PL1) Screening form . needs further evaluation for Mental Illness (MI). When to Prepare The NF completes Form 1012 following: . An individual's diagnosis is changed. Depression, unless diagnosed as major depressive disorder in the medical record by the physician is not considered a mental illness.Record review of facility policy titled, PASRR Level 1 Screen Policy and Procedure and dated 03/06/19 revealed no information on what to do if an individual receives a qualifying diagnosis after admission.

Based on interview and record review the facility failed to perform a preadmission screening for individuals with a mental disorder and individuals with intellectual disability for 1 (Resident #18) of 18 residents reviewed for preadmission screening.The facility failed to ensure an accurate PL1 for Resident #18 prior to her admission on [DATE]. She was coded as not having mental illness when she did have mental illness.This failure could place residents at risk of not receiving needed services.Findings Included:Record review of Resident #18's admission record dated 03/25/26 revealed a [AGE] year-old female admitted to the facility with diagnoses that included, but were not limited to, schizoaffective disorder bipolar type (mental disorder in which a person experiences a combination of symptoms of schizophrenia and mood disorder), generalized anxiety disorder (inability to control constant worrying), and major depressive disorder single episode (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities). The date of her schizoaffective disorder bipolar type diagnosis was 08/12/25. The date of her generalized anxiety disorder diagnosis was 08/14/25. The date of her major depressive disorder single episode diagnosis was 08/14/25.Record review of Resident #18's quarterly MDS completed on 01/24/26 revealed a BIMS of 12 which indicated moderately impaired cognition. Section I Active Diagnoses coded Resident #18 as having anxiety disorder, depression, and schizophrenia.Record review of Resident #18's care plan completed on 02/10/26 revealed the following: The resident has depression r/t SCHIZOPHRENIA . The resident requires antidepressant medication . The resident requires anti-psychotic medications . The resident uses anti-anxiety medications .Record review of Resident #18's active orders dated 03/25/26 revealed the following orders with corresponding start dates:03/11/26 Ariprazole Oral Tablet 30 MG . Give 30 mg by mouth at bedtime related to SCHIZOAFFECTIVE DISORDER, BIPOLAR TYPE .11/11/25 Divalproex Sodium ER Oral Tablet Extended Release 24 Hour 500 MG . Give 3 tablet by mouth at bedtime related to SCHIZOAFFECTIVE DISORDER, BIPOLAR TYPE .Record review of Resident #18's EHR under the miscellaneous tab revealed one PL1.Record review of Resident #18's PL1 revealed it was completed by her family member and she was coded as having no mental illness.During an interview on 03/26/26 at 08:58 AM RN D stated an inaccurate PL1 at admission could negatively impact resident care. She stated, We have to reassess and make sure we are meeting their needs.During an interview on 03/26/26 at 09:03 AM ADON stated MDS RN was responsible for ensuring PASRRs were completed. She stated an inaccurate PL1 at admission could probably negatively impact resident care. She stated, Their mental health or condition might be overlooked or misunderstood.During an interview on 03/26/26 at 09:05 AM DON stated MDS RN was responsible for ensuring PASRRs were completed. She stated an inaccurate PL1 at admission could negatively impact resident care. She stated the care plan might not be as good as it could be if the PL1 at admission was inaccurate.During an interview on 03/26/26 at 09:09 AM ADM stated MDS RN was responsible for ensuring PASRRs were completed. She stated an inaccurate PL1 could negatively impact resident care due to missed care/missed services.During an interview on 03/26/26 at 09:10 AM CN stated an inaccurate PL1 could negatively impact resident care. She stated, We could not provide all the services they might quality for.During an interview on 03/26/26 at 09:17 AM MDS RN stated she and AC were responsible for ensuring PL1s were completed at or prior to admission. She stated she did not think a resident's care would be negatively impacted if their PL1 was inaccurate because residents with mental illness received in-house treatment. Regardless of whether or not they have the positive on the PASRR they still receive the services in the building. MDS RN stated if a PL1 was inaccurate, residents would not be offered the opportunity to get outside services.During an interview on 03/26/26 at 09:26 AM AC stated she gets the PL1 from the RE and sends it with all of the other admission paperwork to MDS RN. AC stated she does not check the PL1 against the resident's diagnoses to ensure accuracy.During an interview on 03/26/26 at 09:41 AM PC stated residents might not get needed care if their PL1 was inaccurately coded.Record review of an undated facility policy titled Form 1012 Policy and Procedure with Instructions revealed the following: .Depression, unless diagnosed as major depressive disorder in the medical record by the physician is not considered a mental illness.Record review of facility policy titled, PASRR Level 1 Screen Policy and Procedure and dated 03/06/19 revealed the following: . Procedure 1. The Facility Admissions process will ensure a PL1 Screening Form is obtained from the RE on day of admission or prior to admission. 3. The Facility will review the PL1 Screening Form for completion and correctness prior to admission . review each item on the PL1 to ensure accuracy and prevent a regulatory problem. 7. The facility will maintain PL1 Best Practices as follows: . Review the PL1 form for completion and correctness before admission.

Based on observation, interview, and record review, the facility failed to ensure that residents who required respiratory care were provided such care consistent with professional standards of practice for 1 (Resident #5) of 18 residents reviewed for respiratory care.Resident #5 did not have physician orders for oxygen therapy. This failure had the potential to affect residents by placing them at risk for respiratory compromise and associated complications, including shortness of breath, confusion, respiratory failure, infection, and exacerbation of their condition.Findings included: Record review of Resident #5's clinical record revealed a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include Chronic Obstructive Pulmonary Disease (COPD refers to a group of diseases that cause airflow blockage and breathing-related problems), type 2 diabetes (a chronic condition that affects the way the body processes blood sugar (glucose), dementia (a group of thinking and social symptoms that interferes with daily functioning), myocardial infarction (heart attack), acute on chronic diastolic (congestive) heart failure (heart failure where the heart muscle is stiff and cannot fill properly) and morbid obesity. Record review of Resident #5's clinical record revealed the most recent MDS, a significant change assessment completed 03/12/2026 indicated a BIMS score of 10, reflecting moderate cognitive impairment. The assessment further indicated that the resident required substantial to maximal assistance with most activities of daily living. Section O (Special Treatments, Procedures, and Programs) documented that Resident #5 was not receiving oxygen therapy while a resident. Record review of the Order Summary, printed on 03/25/2026, revealed no physician orders for oxygen therapy.Record review of the Medication Administration Record, printed on 03/26/2026 for the period of 03/01/2026 through 03/31/2026, revealed no orders or documentation for oxygen administration, including flow rate or dosage.Record review of the O2 Saturation Summary, printed on 03/25/2026 and covering the period of 12/25/2025 through 03/25/2026, revealed documentation on 03/21/2026 through 03/25/2026 indicating oxygen was administered via nasal cannula.Record review of Resident #5's care plan, last reviewed on 03/24/26, revealed the following: Focus: resident has shortness of breath at times related to COPD. Interventions: Give oxygen therapy as ordered by the physician. During an observation and attempted interview on 03/24/26 at 9:17 AM, Resident #5 was observed sitting in a recliner receiving O2 via a N/C at 2 lpm and was unable to answer questions. During an observation on 03/24/26 at 12:05 PM, Resident #5 was observed at lunch receiving O2 via N/C. During an observation on 03/25/26 at 2:52 PM, Resident #5 was observed lying in bed, on her back asleep, receiving O2 via a N/C at 2 lpm. During an observation on 03/26/26 at 9:37 AM Resident #5 was observed lying in bed receiving O2 via a N/C. During an interview on 03/26/26 at 9:39 AM, CNA F stated that she had been working at the facility since 2022 and nurses were responsible for setting flow rates. She stated a potential negative outcome for administering O2 without orders included the resident receiving too much or too little oxygen. During an interview 03/26/26 at 9:41 AM LVN E stated there were no orders for O2 for Resident #5 and that the resident was just put on hospice which may be why there was not an order. She stated that O2 was considered medication and physicians orders were required. LVN E further stated staff would not know the correct flow rate without orders and would be unable to appropriately monitor the resident.During an interview on 03/26/2026 at 9:47 AM, LVN G stated she was the charge nurse for the unit that Resident #5 resided on currently. She stated a potential negative outcome of administering oxygen without an order included adverse reactions due to the absence of a baseline for comparison.During an interview on 03/26/2026 at 9:55 AM, the DON stated oxygen was considered a medication and should not be administered without a physician's order. The DON stated a potential negative outcome included unnecessary oxygen use and possible dependency.Record review of the facility provided policy titled, Oxygen Administration, not dated, revealed the following: The amount of oxygen by percent of concentration or lpm, and the method of administration, is ordered by the physician.Goals:1. The resident will maintain oxygenation with safe and effective delivery of prescribed oxygen. Record review of the facility provided policy titled, Documentation, not dated, revealed the following in part. Goal:1. The facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets.

Based on observation, interview, and record review, the facility failed to prepare, and serve foods using methods to ensure palatability and flavor for 1 of 4 residents with a pureed diet (Resident #56) when they failed to: A. Ensure facility staff prepared pureed foods for meal service using standardized recipes, and nutritive methods to ensure palatability, flavor and meal satisfaction. These failures placed Reside1 of 4 residents who ate food that was pureed and served by the kitchen at risk of meal dissatisfaction and potential weight loss. Findings included: In an interview and observation on 3/24/26 at 11:00 am, [NAME] C measured 4 servings of green beans with juice, 7 ladles of gravy and 6 slices of bread into the blender. During the puree process another 3 slices of bread were added to the puree. [NAME] C pureed the beans then added 2 more slices of bread to the puree before completing the puree. During a taste test of the green beans the green beans tasted like bread with a hint of gravy to this writer. [NAME] C was asked to taste the green beans. She reluctantly tasted the green beans and stated, They are ok. When asked what she would normally use to thicken the food she stated she used gravy because it was already made. [NAME] C stated the thickener made the food taste funny. She stated she used bread to thicken most foods, so the food tasted better. When asked if she reviewed the puree recipes, she said no. An observation of the kitchen preparation area revealed there were no recipes out for review at the time of the food being pureed. In an observation and interview on 3/24/26 at 11:15 am, [NAME] C pureed the BBQ chicken. [NAME] C added more than 4 servings of BBQ chicken and turned the bottle of BBQ sauce upside down into the chicken and added an unmeasured amount of BBQ sauce. [NAME] C pureed the chicken and then added more BBQ sauce and 3 slices of bread to the chicken. [NAME] C pureed the meat again. [NAME] C added more BBQ sauce and 4 more slices of bread before completing the puree. During a taste test the BBQ had a strong overwhelming taste of BBQ sauce. [NAME] C appeared to reluctantly taste the chicken and stated it was ok. In an observation and interview on 3/24/26 at 11:35 am, [NAME] C stated she had finished pureeing the foods for the noon meal. [NAME] C was asked about pureeing the honey kissed rolls that were listed on the menu and that were observed sitting on the counter. [NAME] C stated, They (residents on a pureed diet) don't ask for bread. This writer asked [NAME] C if all the residents should get the same food listed on the menu as all residents on a regular diet. [NAME] C hesitated then stated yes, they should. [NAME] C then got a package of premade rolls and microwaved the package. [NAME] C then put the whole package of rolls into the blender, added 7 scoops of gravy to the rolls and pureed the rolls. [NAME] C added 5 more scoops of gravy and pureed the rolls again. During a taste test the bread tasted like gravy. [NAME] C stated she used gravy because it was already made. When asked what else she could use to puree the bread she stated she would use chicken broth. [NAME] C was asked if she had ever used milk to puree bread and she stated she had not. [NAME] C tasted the bread and stated she thought the bread tasted ok. The pureed bread tasted like gravy. In an interview on 3/25/26 at10:25 am, the RD stated purees should be thinned with chicken broth for chicken, juice from green beans or chicken broth. She stated bread should have milk added to it for thinning. She stated she was not sure about using gravy for green beans or bread. She stated that was not a usual thinner. She stated she was not sure about the taste of the food if gravy had been used. The RD stated measured amounts of liquids should be used to thin a puree only as needed and after an initial puree was conducted. She stated added liquids should be a last resort. The RD stated if green beans were drained properly there would be no need to add gravy or bread. She stated the cooks should use the fork test for consistency. In an interview on 3/25/26 at 2:50 pm Resident # 56, who had a pureed lunch meal, stated the bread had tasted like gravy and the chicken had too much BBQ sauce. She stated she did not like the green beans but ate them anyway. She stated the green beans had tasted like bread. In an interview on 3/26/26 at 10:15 am, the DM stated she had trained all cooks to pureed foods and to taste food after it is prepared to ensure quality. She stated she expected the cooks to taste the food after it was prepared to ensure the quality and taste was palatable. She stated she expected staff to take pride in serving quality meals to all residents. She stated foods should be pureed first with no added liquid and then small, measured amounts of liquid could be added as needed. The DM stated milk should be used for bread when pureeing bread. The DM stated it is preferable that the juices from the cooked foods should be used when possible before bread or gravy was used to ensure flavors were as close as possible to the food cooked. She stated the consequences of not preparing purees properly could be weight loss and meal dissatisfaction. She stated residents could also have poor meal experiences. Record Review of the facility recipe from Menu Manager titled Pureed [NAME] Beans documented:Measure number of servings. Drain well to minimize the use of thickener to obtain appropriate consistency. Puree. Add liquid if needed. Record Review of the facility recipe from Menu Manager titled Pureed BBQ Chicken documented:Measure number of servings. Drain well to minimize the use of thickener to obtain appropriate consistency. Puree. Add liquid if needed. Record Review of the facility recipe from Menu Manager titled Honey Kissed Rolls documented:Measure number of servings. Drain well to minimize the use of thickener to obtain appropriate consistency. Puree. Add liquid if needed. Record review of the facility's policy titled, ' Menus ' dated 2012, documented:Menus are planned to meet the Recommended Dietary Allowances of the Food and Nutrition al Board. The menus will be prepared as written using standardized recipes. Record review of the facility's policy titled, ' Resident Menus ' dated 2012, documented: The menus will be prepared as written using standardized recipes. The DM and cook are trained and responsible for the preparation and service of therapeutic diets as prescribed.

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1of 1 kitchen when they failed to: Ensure facility staff wore hair restraints and beard guards while in the kitchen.These failures placed all residents who ate food served by the kitchen at risk of cross contamination and food-borne illness. Findings included: In an observation on 3/24/26 at 8:15 am, a sign posted on the main door of the kitchen stated, A hairnet must be worn at all times in the kitchen. Do not enter without putting on a hairnet. Do not cross the threshold without one. No Exceptions. In an observation and interview on 3/24/26 at 10:00 am, [NAME] A walked through the kitchen with his beard and sideburns sticking out of his beard cover. The beard cover did not cover the mouth, sideburns or the upper part of his bushy beard. He stated as far as he knew he was supposed to have a beard cover and hair net on while in the kitchen. When asked if the hairnet was supposed to cover all parts of the hair on his face he stated What am I supposed to do about that? In an observation and interview on 3/24/26 at 12:05 pm, [NAME] B walked into the kitchen from the front door and through the kitchen to the staff changing room with no hairnet or beard cover on. When asked he stated I just walked through the kitchen. I am not sure I am supposed to put it on. In an interview on 3/25/26 at 10:25 am, the RD stated she expected all staff to wear hairnets, and beard covers at all times while in the kitchen. She stated she expected hairnets, and beard covers to cover all hair. She stated the consequences of all issues would be food borne illness. In an interview on 3/26/26 at 10:15 am, the DM stated she had trained the staff in their kitchen duties She stated she expected all staff to wear hairnets and beard covers. She stated she was aware all staff had to keep hair, moustache and beards covered while in the kitchen. She stated she had been aware the beard cover had not covered [NAME] B's beard and moustache very well. She stated she had drilled it into everyone's heads not to come to the kitchen without a hairnet. She stated that food borne illness could result from all these issues. Record review of the facility policy titled ' Preventing Foodborne Illness- Employee Hygiene and Sanitary Practices' dated 2001 documented: Hairnets and beard restraints are worn when cooking, preparing or assembling food to keep hair from contacting exposed food, clean equipment, utensils and linens. Record review of the facility's policy titled, ' Dietary Food Service Personnel Policy and Procedures ' dated 2012 documented:Hairnets or hats covering the hairline are worn at all times. [NAME] guards are required for facial hair. Record review of the facility's policy titled, ' Infection Control ' dated 2012, documented:Clean hair is required. It is to be covered with an effective hair restraint. Facial hair is to be closely trimmed and is to be covered with a hair restraint.

Based on observation, interview and record review, the facility failed to establish a system of record of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and determine that drug records were in order and that an account of all controlled drugs were maintained periodically reconciled for 1 of 18 residents (Resident #1) reviewed for pharmacy services. The facility failed to ensure Resident #1's OxyContin Oral Tablet ER 12-hour abuse-deterrent 10mg-28 count was accounted for at the time of receiving from the facility's Pharmacy on 05/02/2025. This failure could place residents at risk of not receiving medication therapy that would be effective for their treatment, resulting in the exacerbation of conditions and disease processes. Findings included: Record review of Resident #1's Admission record dated 05/21/2025 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included Cauda equina syndrome(compression of the nerve roots at the lower end of spinal cord), chronic pain syndrome, displaced fracture of the left tibial and benign prostatic hyperplasia(enlarged prostate). Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1's BIMS score was a 15 out of 15 indicating his cognition was intact. In section J0100 it was documented that Resident #1 received scheduled and Prn pain medication. Record review of Resident #1's care plan dated 05/12/2025 revealed the following: Focus: The resident has opioid pain medication ordered r/t chronic pain with interventions of administer medication as ordered. Record review of Resident #1's active physician orders revealed the following: Orders dated 04/18/2024 OxyContin Oral Tablet ER 12-hour abuse-deterrent 10mg. Give one tablet by mouth every 12 hours for pain. Record review of Medication paper from Pharmacy dated 5/2/25 revealed the following: Patient: Resident #1 Drug Name: Oxycontin Tab 10mg ER Qty filled: 28 Days' supply: 14 Filled date: 5/2/25 Received by: LVN A's signature Driver: Pharmacy Driver's signature Record review of Resident #1's Medication Administration Record dated May 1-21 2025 revealed Resident #1 received pain medication daily. In an interview/observation on 5/21/2025 at 11:22 AM, Resident #1 was lying in his bed, his head slightly raised. Resident #1 stated he had not missed any of his pain medication and had not experienced any distress. In an interview on 05/21/2025 at 11: 40 AM, the ADM stated that she was unsure if Resident #1's medication was received the evening of 5/2/2025 because it was not accurately received by LVN A or accurately dropped off by pharmacy driver. The ADM stated this failure could cause a resident to need his medication and not have it. The ADM stated she was responsible to ensure her staff was aware of accurately receiving medications and was unsure if the medication ever arrived at the facility due to the inproper count of the receipt of medications the night of 5/2/25. In an interview on 5/21/2025 at 6:20 PM, LVN A stated she was the nurse responsible for signing for the OxyContin Oral Tablet ER 12-hour abuse-deterrent 10mg delivered by the Pharmacy. LVN A stated the night on 5/2/2025 the pharmacy driver dropped of the crate with the medications and when she had time she would count the medications against the pharmacy list. LVN A stated the pharmacy driver would come back and pick up the empty crate along with the signed medication check list. LVN A stated the night on 5/2/2025 she and LVN B were the two nurses on duty, she stated they were busy and is unsure what happened. LVN A stated after she would check the medications in, she would put them a plastic bag and she and LVN B would distribute the medications to the unit the resident lived on. LVN A stated she was unsure if the medication was in the bag and is unsure if the medication was even delivered. LVN A stated LVN B was the one responsible for the medications for Resident #1's unit. LVN A stated she did not have LVN B sign any paper that he received the OxyContin Oral Tablet ER 12-hour abuse-deterrent 10mg for Resident #1. LVN A stated a possible negative outcome for not ensuring the medications were distributed accurately would be a resident could go without their medication. LVN A stated she was responsible for this incident because her signature was on the pharmacy checklist as she received it. In an observation on 05/21/2025 at 10:45 PM, LVN A was sitting at the nurses station and the pharmacy driver was standing outside the nurses station observing LVN A count the medications in, she was checking the medication and putting a checkmark next to the medication and the resident's name accounting for that medication. During the counting of the medication, an observation was made of four medications that were on the list but not present and LVN A circled the medication name and wrote missing next to the medication, she had the pharmacy driver initial next to the medication and her note that the medication was missing. In an interview on 05/21/2025 at 11;15 PM, the Pharmacy driver stated that prior to the incident on 5/2/25 he would drop of the crate with the medication to the nurse on duty and would leave the facility and do his other rounds and then on his way back through town he would pick up the empty crate with the list of medication sheet that was signed off by the nurse. The Pharmacy driver stated he did not watch the nurse count in of medications prior to the 05/02/2025. In an interview on 05/22/2025 at 12:15 AM, LVN B stated he had not worked at the facility for very long on the night on 5/2/2025 and stated he did not remember seeing Resident #1's Oxycontin ER and doesn't remember checking it in. LVN B stated he did not sign for any medications(narcotics) given to him by LVN A on 5/2/2025. LVN B stated a possible negative outcome for not having the medication accurately counted in by the pharmacy and having missed medication would be a resident could need his medication and not have it causing the resident to be in pain or distress. In an interview on 05/22/2025 at 11:45 AM, the ADON stated it was the administrative personnel (new DON will not start until later this month) who were responsible to ensure accuracy of receiving medication and their staff were aware of such processes. The ADON stated she was unsure if the medication arrived at the facility due to the inaccurate process of counting in the medication for Resident #1. The ADON stated that a possible negative outcome for not properly processing the medication when it arrived at the facility would be a resident would not have their medication and possible be hospitalized . Record review of Controlled Medication-Ordering and receipt, not dated reflected the following: Medication included in the Drug Enforcement Administration classification as controlled substances, and medications classified as controlled substance by state law or subject to special ordering, receipt, and recording requirements in the facility, in accordance with federal and state laws and regulations. Procedure: A controlled medication accountability record is prepared when receiving or checking in a controlled substance medication for a resident .

Based on interview and record review, the facility failed to provide pharmaceutical services to include the accurate dispensing and administering of drugs to meet the needs for 1 of 7 residents (Resident #1) reviewed for physician orders. The facility failed to accurately enter physician orders for Lamotrigine (a medication that is used to treat epilepsy and bipolar disorder) for Resident #1. The deficient practice could affect residents in the facility resulting in not receiving needed care to maintain optimum health and placing them at risk for injury and/or deterioration in their condition. Findings included: Record Review of Resident #1's face sheet dated 02/27/2025 revealed a [AGE] year-old female admitted to the facility from the hospital on 02/05/2025 and was sent back to the hospital on 02/08/2025 and readmitted to the facility on [DATE] with diagnosis to include but not limited to other specified local infections of the skin and subcutaneous tissue, other seizures, mild cognitive impairment of uncertain or unknown etiology, laceration without foreign body of scalp, subsequent encounter, epilepsy (disorder that causes abnormal brain function, seizures) unspecified, abrasion of scalp, altered mental status (change in brain function), unspecified, and polyneuropathy (malfunction of many peripheral nerves throughout the body). The face sheet also revealed that Resident #1 was her own responsible party. Record Review of Resident #1's last completed Admission MDS assessment dated [DATE] revealed Resident #1 had a BIMS score of 15 out of 15 indicating that her cognition was intact. Resident #1's functionality was independent from sitting to lying down and eating, set up assistance for oral hygiene, toileting, and upper body dressing and was supervision or touching assistance for showering, lower body dressing, sit to stand, chair/bed-to-chair transfer, and toilet transfers. Supervision or touching assistance was also needed for walking 10 feet and walking 50 feet with two turns. Resident #1 was continent of bowel and bladder. Record Review of Resident #1's care plan start date 02/05/2025 revised on 02/18/2025 revealed that Resident #1 had a history of a seizure disorder with interventions to give seizure medication as ordered by doctor. Also, to monitor/document side effects and effectiveness as well as a precaution to not leave resident alone during a seizure. Record review of Resident #1's orders listed as Active orders entered on 02/14/2025 revealed the following: lamoTRIgine Oral Tablet 100 MG-Give 2.5 tablet by mouth one time a day related to other seizures. lamoTRIgine Oral Tablet 150 MG-Give 2 tablet by mouth one time a day related to other seizures. Record review of Resident #1's Medication Administration Record dated 02/1/2025-02/28/2025 revealed that Resident #1 was ordered lamoTRIgine Oral Tablet 200 mg. Give 2.5 tablet by mouth one time a day. Resident #1 was given that medication dosage on 02/05/25, 02/06/25, 02/07/25, & 02/08/25 in the morning. The MAR further revealed that the order was discontinued on 02/14/25. The MAR indicated that Resident #1 was given lamoTRIgine Oral Tablet 100 mg, 2.5 tablet by mouth one time a day on dates 02/15/25-02/27/25 in the morning. The MAR also revealed Resident #1 was given lamoTRIgine Oral Tablet 150 mg-Give 2 tablet by mouth one time a day on 02/05/25-02/07/25 in the evenings and that dosage was given on dates 02/15-02/26 in the evenings. Record review of Resident #1's Lab result from the hospital dated 02/08/25 stated Lamotrigine Level (abnormal). Specimen: Blood. Result: 21.1 2.0-20.0 ug/mL normal range During an interview on 02/27/25 at 10:32 AM, Resident #1 stated that she had only been living in the facility a brief time and had no concerns with her care whatsoever. She stated she recently moved into the facility after leaving the hospital because of difficulties with her seizures. During an interview on 02/27/25 at 10:43 AM, the ADON stated that the charge nurses were responsible for putting new orders in for new admissions, but that she helped put them in and the DON would review them. ADON stated that on, 02/05/25 when Resident #1 was admitted to the facility, she put her admission medications into PCC and they were correct as follows: Lamotrigine 250 mg every morning and Lamotrigine 300 mg every night. The ADON stated because that medication only came in 100 or 200 mg tabs, the pharmacy called and wanted her to put in the order for the morning dose as 100 mg, 2.5 tabs. She stated that she made a mistake by not changing the dosage to 100 mg, she left it at 200 mg in the MAR, so Resident #1 had gotten a 500 mg dose for her morning dosage on dates 02/05/25, 02/06/25, 02/07/25, and 02/08/25. The ADON stated that Resident #1 was sent back to the hospital on 02/08/25 because her head wound had started bleeding again. She stated that she was not sure what reaction a person could experience by having too much Lamotrigine, so she looked it up on the internet and stated that it could make someone have a rash or be lethargic. The ADON stated that a possible negative outcome for giving a wrong dosage to a resident could be that it could make them lethargic or have a rash. During a phone interview on 02/27/25 at 11:15 AM, the Pharmacist for the facility stated that if a resident had 250 mg more Lamotrigine daily than was ordered, it could not cause a resident to be hospitalized . She stated that that drug would not build up in the system but excretes in urine with a rapid peak of 1-5 hours. The Pharmacist went on to state that the amount given could cause a skin rash in extreme cases, or nausea. She stated it could not cause bleeding. The Pharmacist stated that Lamotrigine, with the dosage being a little bit over would not cause any issues. The Pharmacist was told that Resident #1's Lamotrigine blood level was checked at the hospital and the lab came back one point above the normal range. She stated it would not cause any issues being that close to the normal range. During an interview on 02/27/25 at 1:15 PM, the DON stated that her expectations of medications being put in at admission was that either the charge nurse or the ADON would take discharge papers from hospital or orders from the PCP, wherever the resident was admitting from, and put the orders in correctly and timely. She stated that a possible negative outcome for putting medications in incorrectly, upon admission, could be a medication error. If the medication was the wrong dose, either too low or too high, the medication could be too effective or not effective enough. Record Review of the facility's policy titled, Receiving a New Medication Order, dated 2/2024 revealed in part, the following: . The nurse that receives a new medication order, should be responsible for the following: Order received is accurate and includes all necessary information. Order must be transcribed accurately to the MAR sheet unless electronic MAR's are used by the facility .

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1of 1 kitchens when they failed to: A. Ensure stored food was properly labeled and dated. B. Ensure hairnets were worn. C. Ensure frozen foods were properly stored according to the label. These failures could place residents who ate food served by the kitchen at risk of cross contamination and food-borne illness. Findings included: In an observation and interview on 1/13/25 at 8:20 am, DA was observed in the kitchen dishwashing room, washing the dishes with no hairnet on. DA stated she had no hairnet on because she could not find any hairnets that morning. She stated all kitchen staff were to wear hairnets while in the kitchen. She stated the consequences of not wearing a hairnet in the kitchen were cross contamination. DA stated the DM had trained her to always wear a hairnet in the kitchen. An observation on 1/13/25 at 8:25 am, of the cooler located in the kitchen preparation area the following was observed: 1. An opened box of crinkle cut fries with 3 bags in the box. The box was opened. The box label stated to Keep food frozen. The bags of crinkle cut fries were soft to the touch and were not frozen. 2. A box of corndogs uncovered and open to air. The box stated Keep Frozen. The corndogs were soft to the touch and not frozen. . An observation of the walk-in freezer on 1/13/25 at 8:30 am, revealed the following: 1. 1 box of cherry pie bites, opened to air. 2. 7 plastic bags of biscuits, unlabeled, undated and not in original box 3. A cooked pumpkin pie dated 12/31/24 was uncovered and open to air. An observation on 1/14/25 at 10:25 am of the cooler located in the kitchen preparation area the following was observed: 1. An opened box of crinkle cut fries with 3 bags in the box. The box was opened. The box label stated to Keep food frozen. The bags of crinkle cut fries were soft to the touch and were not frozen. 2. A box of corndogs uncovered and open to air. The box stated Keep Frozen. The corndogs were soft to the touch and not frozen. An observation of the walk-in freezer on 1/14/25 at 10:30 am, revealed the following: 1. 1 box of cherry pie bites, opened to air. 2. 7 plastic bags of biscuits, unlabeled and not in original box 3. A cooked pumpkin pie uncovered and open to air. In an observation and interview on 1/15/25 at 10:05 am, the DM stated of the frozen bread in the freezer that it should have been labeled and dated. She stated the uncovered food should have been tightly covered. She stated she expected all staff to label and date all foods. She stated the pie should have been covered completely and would be thrown out. Observation of the cooler with potatoes and corndogs revealed the temperature of the cooler was 41 degrees. The DM stated the cooler was a freezer and the foods should have been kept frozen. She stated the foods would be thrown out and she would get the cooler fixed. The DM stated the consequences of the issues in the kitchen would be cross contamination. She stated she had been trained by the Dietician and she trained all staff in their kitchen duties. The DM stated she expected all staff to wear hairnets and beard covers while in the kitchen. She stated she expected all staff to exhibit cleanliness in the kitchen. Record review for the facility's policy titled Dietary Food Service Personnel Policy and Procedures dated 2012, documented: All employees receive instruction in sanitation during orientation and through in-service training programs. Hair nets or hats covering the hair are to be worn at all times. [NAME] guards are required for facial hair. All unused foods must be securely covered. All items are to be dated and labeled as to their contents All foods must be kept at the safest temperature. Record review for the facility's policy titled Food Storage and Supplies dated 2012, documented: Perishable foods that are refrigerated are dated once opened and used within 7 days. Opened packages of food are stored in closed containers with covers or in sealed bags and dated as to when opened.

Based on observation, interview, and record review, it was determined the facility failed to ensure drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions, and the expiration date when applicable on 3 of 3 medication carts and 1 of 2 medication rooms reviewed for medication storage. -LVN F left medications for Resident #4 unattended on top of her medication cart. -2C South medication cart contained 2 insulins for Resident #68 that were expired. Lantus and Humalog insulin both had open dates of 12/10/2024. -2C South Medication room refrigerator contained Acetaminophen 650mg suppositories for Resident #71 with an expiration date of 10/2024. -1C North Medication cart contained 1 loose pill identified as Benzonatate 100mg for Resident #45. -1C South medication cart contained the following: *1 loose pill identified as Citalopram 20ng for Resident #73, Arnuity Ellipta for Resident #73 with no open date written on inhaler or tray. *Trelegy Aero for Resident #21 with no open date written on inhaler or tray, *Breo Ellipta for Resident #55 with no open date written on inhaler or tray, Admelog inj. for resident #55 with an open date of 12/08/2024. *Breo Ellipta for resident #47 with no open date written on inhaler or tray. -Medication cup with white pill was left on Resident #27's bedside table. The facility's failures could place residents receiving medication at risk for drug diversion, lack of drug efficacy, and adverse reactions. Findings included: During an observation on 01/13/25 at 08:56 AM LVN F left 2 medications unattended on the top of a medication cart while she went into Resident # 4's room. Other residents were in the common area where the medication cart was located. During an interview on 01/13/25 at 09:16 AM LVN F stated that the negative outcome for leaving medications unattended would be that another resident could get a hold of them. During an observation and interview on 01/13/25 at 09:59 AM 2C South medication cart revealed Lantus Solostar for Resident #68 with an open date of 12/10/2024 and a Humalog with an open date of 12/10/2024. RN D stated that Lantus was given on 01/11/2025 and 01/12/2025 at 09:00pm. RN D then stated that the Humalog was given to the resident on 01/11/2025 at 8:30pm and 01/13/2025 Resident #68 received 2 units. During an interview on 01/13/2025 at 10:10AM RN D stated that a negative outcome for giving expired medications could lead to a negative outcome. During an observation and interview on 01/13/25 at 10:12 AM Medication room for 2 C south revealed an Acetaminophen 650mg suppository for Resident #71 that had expired 10/2024. RN D stated that Resident #71 received the medication on January 4th, 2025. During an observation on 01/13/25 at 10:23AM Medication cart for 1C North revealed 1 loose pill identified as Benzonatate 100mg for Resident #45. Pill was identified by RN E. During an interview on 01/13/25 at 10:35AM RN E stated that a negative outcome for having loose medications could lead to a resident missing a dose of medication. During an observation on 01/13/25 at 10:39 AM Medication cart for 1 C south revealed 1 loose pill identified by LVN A as Citalopram 20mg for Resident #73. Multiple inhalers were not dated with the date of opening on them. 1. Trelegy Aero 100mcg for Resident #21 had a date medication of 11/06/2024, discard date should have been 12/18/2024. 2. Breo Ellipta for Resident #55 had no date written on medication to indicate when medication was opened. 3. Arnuity Ellipta for Resident #73 had no open date written on medication to indicate when medication was opened. 4. Breo Ellipta for resident #47 had a date of 11/07/2024 when medication was opened, discard date should have been 12/19/2024. Insulin was discovered for Resident #55- Admelog inj. 100U/ml with an open date of 12/08/2024, medication should have been discarded on 01/05/2025. During an interview on 01/13/25 at 10:58 AM LVN A stated that a negative outcome for having a loose pill in medication cart was that You don't know what it is, and it could have an adverse reaction for the resident. LVN A stated that giving medications that are expired could lead to the medication not working appropriately. During an interview on 01/14/25 at 02:01 PM DON stated that a negative outcome for giving a resident a medication with no open date on it was, Giving an expired med a med that is past the manufacturer's good date. During an observation on 01/14/25 at 04:13 PM revealed medication cup with an unidentified medication in a medication cup on Resident #27's bedside table. CNA I said she did not know what the medication was During an interview on 01/14/25 at 04:15 PM LVN A stated that she knew what the medication cup was on Resident #27's bedside table. From the doorway of Resident 27's room, LVN A stated that it was a Gabapentin. LVN A was asked how she knew that and LVN A stated, Well, I gave it to him. LVN A stated that she did not witness the resident taking the medication. LVN A stated that a negative outcome for not staying with the resident until he consumed the medication would be that he didn't take it, and I guess I will have to stand over him now. During an interview on 01/14/25 at 04:22 PM ADON stated that a negative outcome for not staying with a resident during the medication administration could lead to the resident not taking the medication (s) correctly or at all. During an interview on 01/15/25 at 10:08 AM ADON stated that a negative outcome for administering expired medications would lead to adverse reactions, no reactions at all and the medication would not be effective. During an interview on 01/15/25 at 10:13 AM DON stated that a negative outcome for administering expired medications would be that the medication would not have an effective therapeutic level. DON stated that the negative outcome of not writing the open date on medications could lead to the medication being used after it has expired. During an interview on 01/15/25 at 10:18 AM CRN stated that a negative outcome for administering expired medications or medications with no open date was that the resident would not get the full effect of the medication. Record review of the facility provided policy titled, Discontinued Medications, dated 2003, revealed the following: The nurse that receives the order to discontinue a medication is responsible for: . .Removing the medication from the medication storage . Record review of the facility provided policy titled, Recommended Medication Storage, dated 07/2012, revealed the following: Medications that require an open date as directed by the manufacturer should be dated when opened in a manner that is clear when the medication was opened. No medication cart or med room storage policy was provided.

Based on interviews and record review, the facility failed to ensure residents who were trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 of 18 residents (Resident #18) reviewed for trauma-informed care. The facility did not ensure Resident #18 had a trauma screening that identified possible triggers when Resident #18 had a history of trauma. These failures could put residents at an increased risk for severe psychological distress due to re-traumatization. The findings included: Record review of the face sheet, dated 01/15/2025, indicated Resident #18 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses of unspecified Dementia (disease that destroys memory and other important mental functions), post-traumatic stress disorder ( a mental health condition that can develop in people who experience or witness a traumatic event), generalized anxiety disorder ( condition in which a person has excessive worry and feelings of fear, dread, and uneasiness). Record review of the quarterly MDS assessment, dated 11/14/2024 , revealed Resident #18 had a BIMS of 02, which indicated severe cognitive impairment. The MDS Assessment revealed Resident #18 had PTSD as an active diagnosis. Record review of the comprehensive care plan, revised on 11/14/2024, had no documentation of Resident #18's post-traumatic stress disorder. Record review of Assessments in Resident #18's clinical filed revealed no Trauma Informed Care Assessment. During an interview on 01/14/2025 at 10:05 AM, LVN B stated a Trauma Assessment should be documented in the resident's clinical file including the care plan and stated a possible negative outcome for not having documentation would be a resident could be triggered by an event. During an interview on 01/14/2025 at 4:53 PM, the SW stated she was responsible for ensuring trauma assessments were done on admission, however, the company that owned the facility prior to the current owners took documents with them and she was not sure if the assessment was completed. During an interview on 1/15/2025 at 10:20 AM, the DON stated she expected trauma assessments to be done on admission or anytime the need arises. The DON stated the trauma assessment was the social services responsibility. The DON stated the trauma assessment was important because it allows the staff to give the resident the best possible care. The DON stated the interventions should be in the resident's care plan and stated the failure of not having a trauma assessment could cause the resident to be retraumatized. During an interview on 1/15/2025 at 10:28 AM, the CRN stated trauma assessments were to be done on admission and documented in the resident's clinical file. The SW was responsible for ensuring the assessments were completed. The CRN said a possible negative outcome for not having the assessment would be a resident could be retraumatized. During an interview on 1/15/2025 at 10:46 AM, the ADON stated trauma assessments were to be done at admission and the SW or the charge nurse on duty was responsible for ensuring the assessment was completed. The ADON stated the interventions should be documented in the care plan. The ADON said a possible negative outcome for not having the assessment would be staff wouldn't know what the resident's triggers were and the resident could be retraumatized . Record review of the facility's policy titled Trauma-Informed Care revised on 10/2022, indicated: The facility should collaborate with resident trauma survivors and as appropriate, the family or friends and implement individualized interventions. Resident specific approaches must be developed and included in the residents care plan. Facilities must monitor the effects of their approaches to ensure they are implemented as intended and are having the desired effect to achieve the measurable objectives and the resident's goals for care. For residents with a history of trauma, in particular, facilities must evaluate whether the interventions mitigate or reduce the impact of identified triggers.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communication diseases and infections for 2 (Resident #11, and Resident #27) of 18 Residents in that: 1. The facility failed to ensure Resident #27's catheter bag and tubing were kept off the floor and below the level of his waist. 2. The facility failed to ensure CNA G performed hand hygiene and a glove change during incontinent care of Resident #11. 3. The facility failed to ensure CNA C performed hand hygiene and glove changes while performing catheter care for Resident #27 as well as cross contaminating Resident #27's belongings. These failures had the potential to affect residents in the facility by placing them at risk of contracting, spreading, and/or exposing them to bacterial or viral infections that could lead to the spread of communicable diseases. Findings included: Resident #11: Record Review of Resident #11's admission record dated 01/14/2025 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, neuromuscular dysfunction of bladder, need for assistance with personal care, retention of urine. Record review of Resident #11's most current MDS completed on 12/06/2024 revealed the following: Section C: Resident #11 had a BIMS score of 09 which indicated moderately impaired cognition. During an observation on 01/14/25 at 02:56 PM Foley catheter and incontinent care was performed by CNAG and CNA H. CNA G was observed cleaning the buttocks of Resident #11 then proceeded to take a clean brief and place it under Res #11 and then removed her gloves and performed HH. Hand Hygiene and glove change was not performed between the dirty (cleaning soiled buttocks) and placing a clean brief under this resident. During an interview on 01/14/25 at 03:13 PM CNA G stated that not performing HH and a glove change in between dirty (cleaning soiled buttocks) and placing a clean brief on resident could cause an infection for the resident. Resident #27: Record review of Resident #27's admission record dated 01/13/25 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, cognitive communication deficit, need for assistance with personal care, benign prostatic hyperplasia without lower urinary tract symptoms, and neuromuscular dysfunction of bladder. Record review of Resident #27's quarterly MDS completed on 11/10/24 revealed the following: Section C: Resident #27 had a BIMS score of 15 which indicated intact cognition. Record review of Resident #27's care plan completed on 11/10/24 revealed no mention of staff educating him regarding catheter care and no mention of him having negative behaviors when educated regarding catheter care. The care plan noted Resident #27 preferred to empty his own catheter bag, staff should ensure the catheter bag was kept below waist level, and staff should ensure the catheter bag and tubing were kept off the floor. The care plan noted Resident #27 was on enhanced barrier precautions and the associated goal was there would not be any transmission of infection from or to Resident #27. Record review of Resident #27's order summary report dated 01/13/25 revealed the following orders: Order with start date of 01/31/21 to Monitor foley catheter q shift for secured tubing and location to prevent displacement/trauma, tubing may not be on floor, privacy bag as needed. [sic] every shift. During an observation on 01/13/25 at 09:53 AM Resident #27 was seated in a motorized wheelchair in his room. In front of the wheelchair on the floor was his catheter bag and approximately 1.5 feet of tubing. The tubing ran from the bottom of his pants leg on his right leg onto the floor of his room. Resident #27 was buckling the seatbelt of his wheelchair and when he finished, he reached down and grabbed his catheter bag and hung it on the handle of his wheelchair with the tubing pointing up in an arch approximately 6 inches in length. The tubing and the catheter bag were above waist level. During an observation and interview on 01/14/25 at 10:41 AM Resident #27 was lying on his back in his bed covered with a large coat. His wheelchair was next to his bed and his catheter bag was lying on the seat of the wheelchair. The bag was not below waist level. Resident #27 stated staff had not educated him to keep his catheter bag and tubing off the floor to prevent infection. He stated staff had not educated him to keep his catheter bag below the level of his waist to enable urine to drain to gravity and to avoid infection. He said, They don't say nothing here! During an interview on 01/14/24 at 11:30 AM LVN A stated Resident #27 knew he was supposed to keep his catheter bag and tubing off the floor and below waist level. She stated, He is very difficult and does things his own way. He screams and yells when we try to redirect him. She stated a possible negative outcome of a catheter bag and tubing on the floor and/or not below waist level was all kinds of infection, big time infection and UTI. LVN A stated, We [staff and Resident #27] talk about it [proper catheter bag and tubing positioning] all the time. It is behaviors and choices; he chooses to act this way. During an interview on 01/14/25 at 01:39 PM DON stated a possible negative outcome of catheter bag and/or tubing on the floor was the tubing could be stepped on or kinked. She stated having a catheter bag and/or tubing above the waist of the resident could cause backflow [of urine in the tubing toward the bladder] and can cause UTI. During an observation on 01/14/25 at 04:18 PM Foley catheter care and incontinent care of Resident # 27 was performed by CNA I and CNA C. CNA C removed her gloves to look for more incontinent wipes for Resident #27. CNA C picked a brief up off of the floor and placed the brief on the bedside table for later use. CNA C was observed not performing hand hygiene after removing and placing clean gloves back on to assist CNA I with the continuation of foley catheter care for Resident #27. During an interview on 01/14/25 at 04:32 PM CNA C stated that a negative outcome for not performing hand hygiene in between glove changes could lead to cross contamination and stated that she would throw the brief away that was on the floor so that it doesn't get used. During an interview on 01/15/25 at 10:08 AM ADON stated that a negative outcome for not performing HH and glove changes at the appropriate times during incontinent care could lead to lack of infection control. During an interview on 01/15/25 at 10:13 AM DON stated that a negative outcome for not performing HH and glove changes at the appropriate times during incontinent care could lead to lack of infection control. During an interview on 01/15/25 at 10:18 AM CRN stated that a negative outcome for not performing HH and glove changes at the appropriate times during incontinent care could lead to lack of infection control. Record review of the facility provided policy titled, Infection control plan: Overview, dated 2019, revealed the following: .Preventing the spread of Infection . (3) the facility will require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. Record review of facility policy titled Catheter Care and dated February 13, 2007 revealed the following: . 4. When the resident is ambulatory the bag must be held lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. 5. Check the resident frequently . Keep tubing off floor . 9. Review the resident's plan of care daily for changes. 10. Be sure the catheter tubing and drainage bag are kept off the floor. No Hand hygiene policy provided. 47854

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen observed. The facility failed to ensure that all staff were wearing proper protective hair restraints in the kitchen. This failure placed residents who ate food served by the kitchen at risk of food contamination caused by fallen hair. Findings included: An observation and interview on 02/06/2024 at 11:35 AM revealed the DM was in the kitchen prep area without a hair restraint; her hair was long and went past her shoulders. The DM stated that she was in her office and heard State was at the kitchen door and got nervous and forgot to put on her hair restraint. The DM's hair was down past her shoulders, the front half was pulled back in a hair tie. The DM stated everyone was supposed to wear a hair restraint while in the kitchen. The DM did not have an answer about a possible negative outcome. During an observation and interview on 02/06/2024 at 3:35 PM, the DA was in the kitchen prep area without a hair restraint. The DA stated that he did not think he had to wear a restraint because his hair was short . The DA said he did not always wear a hair restraint. Observation of DA's hair was short, close to his scalp. The DA stated that a possible negative outcome for staff not wearing hair restraints would be that hair would get into the residents food. During an interview with the ADON on 02/06/2024 at 4:40 PM, the ADON stated that a possible negative outcome for staff in the kitchen not wearing hair restraints would be that hair could get into the resident's food and that would be gross. During an interview with the DON on 02/06/2024 at 4:40 PM, the DON stated that a possible negative outcome for staff in the kitchen not wearing hair restraints would be that if a staff member had lice or any other types of bugs in their hair that it could get into the resident's food. Record Review of Dietary Service Policy and Procedure Manual 2012 revealed the following: Sanitation and Food Handling: .Hair nets or hats covering the hairline are worn at all times . Record Review of 2022 Food Code/U.S. Food and Drug Administration/January 18, 2023 Version revealed the following: Section 2-402 Hair Restraints .Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens .

Based on observation, interview and record review the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 18 residents (Resident # 4) reviewed for pressure ulcers. The facility failed to prevent the development of one facility-acquired Stage III pressure injury for Resident #4. This failure could place residents at risk for worsening of an ulcer, infection, and a decreased quality of life. Findings included: Record review of Resident #4's face sheet reflected a [AGE] year-old female who was readmitted to the facility on [DATE]. Resident #4 was admitted with diagnoses which included: Other Cerebral Palsy Other Acute Kidney Failure Type 2 Diabetes Mellitus Without Complications Other Seizures Mild Intellectual Disabilities Mild Protein-Calorie Malnutrition Morbid (Severe) Obesity Due to Excess Calories Schizoaffective Disorder, Depressive Type (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania). Other Neuromuscular Dysfunction of Bladder (The name given to several urinary conditions in people who lack bladder control due to a brain, spinal cord or nerve problems). Other Recurrent Depressive Disorders Diabetes Insipidus (a rare disorder that causes the body to make too much urine-up to 20 quarts per day). Other Specified Anxiety Disorders Colostomy Status (an operation that creates an opening for the colon, or large intestine, through the abdomen). Gastro-Esophageal Reflux Disease Without Esophagitis Intermittent Explosive Disorder Essential (Primary) Hypertension Malignant Neoplasm Of Colon, Unspecified Cyst Of Bartholin's Gland (The Bartholin's glands are located on each side of the vaginal opening. They secrete fluid that helps lubricate the vagina. Sometimes the ducts of these glands become obstructed and fluid backs up, forming a cyst. Personal History Of Urinary (Tract) Infections Record review of Resident #4's Quarterly Care Plan, dated 9/30/23, indicated Resident #4 had potential for pressure ulcer development related to self-care deficit. Resident #4 did at times refuse to be repositioned while in her bed and was prone to redness in her skin folds. The goal for Resident #4 was to be free of preventable skin breakdown through the next review date of 12/24/23. The intervention for Resident #4 was to be monitored and reported to physician, any changes in skin condition, status, appearance, color, and impairment. Pressure relieving devices were to be used as ordered, repositioning as allowed and weekly skin checks for redness, circulatory problems, pressure sores, open areas, and other changes to skin integrity were to be reported to the physician. Record Review of Resident #4's skin assessment, dated 7/20/23, reflected a sacral pressure ulcer (the bottom of the spine that lies between the fifth segment of the lumbar spine (L5) and the coccyx (tailbone)) had been discovered and was categorized as an in-house acquired with no staging, undermining, tunneling or Sinus Tract (abscess) identified. There was no exudate (fluid that leaks out of blood vessels into surrounding tissues) and the skin was red, but cool to the touch. Record review of Resident #4's physician order, dated 7/20/23, was daily cleansing with Dakins Solution (sodium hypochlorite (0.4% to 0.5%) and boric acid (4%) diluted in water) and packing with alginate (a naturally occurring anionic polymer obtained from brown seaweed). The preventative intervention was pressure redistribution mattress, specific turning/repositioning program, positioning devices and heel boots. Resident #4 would be turned every 2 hours for repositioning; position would be documented every 2 hours and resident would be up in her Geri Chair 3 times per day to assist with wound healing and offload of pressure. Record review of Resident #4's clinical record reflected there was no additional documentation of Resident #4's sacral ulcer until 8/18/23. Record review of Resident #4's progress notes, dated 08/18/2023 at 5:39 PM, reflected Resident #4 received a bed bath but refused repositioning afterward. Wound care was provided, and education was given on the importance of repositioning. There was no documentation that Resident #4 refused to get out of bed. Record review of Resident #4's progress notes, dated 08/19/2023 at 2:52 PM, reflected Resident #4 refused repositioning and wound care was completed. There was no documentation that Resident #4 refused to get out of bed. Record review of Resident #4's progress notes, dated 08/20/2023 at 6:22 PM, reflected Resident #4's wound care was completed, and the facility wound care nurse was notified of copious amounts of drainage. Resident #4 refused to be repositioned. There was no documentation Resident #4 refused to get out of bed. Record review of Resident #4's progress notes, dated 08/23/2023 at 3:55 PM, reflected Resident #4's wound care was completed. Resident #4's mattress was exchanged for a new air mattress. Resident #4 was given education on the importance of repositioning. Resident #4 refused to reposition. There was no documentation Resident #4 refused to get out of bed. Record review of Resident #4's progress notes, dated 08/24/2023 at 12:51 PM, reflected Resident #4 received a bed bath and wound care was completed. Resident #4 continued to refuse repositioning. There was no documentation Resident #4 refused to get out of bed. Record review of Resident #4's progress notes, dated 08/28/2023 at 1:58 PM reflected Resident #4 was seen by the Wound Care Nurse Practitioner. No new wound care order was completed. Resident #4 refused to reposition. There was no documentation Resident #4 refused to get out of bed. Record review of Resident #4's progress note, dated 09/03/2023 at 5:06 PM, reflected Resident #4 received a bed bath PRN related to colostomy bag mess. Dressing was changed to buttocks. Resident #4 continued to decline to turn and reposition. Education was provided. There was no documentation Resident #4 refused to get out of bed. Record review of Resident #4's progress notes, dated 09/07/2023 at 10:43 AM, reflected Resident #4 had a dressing change to the coccyx due to the dressing being soiled with drainage. Resident #4 continued to decline to participate in turning and repositioning. Education was provided on the importance of turning and repositioning and the resident continued to decline. There was no documentation Resident #4 refused to get out of bed. Record review of Resident #4's progress notes, dated 09/13/2023 at 03:10 AM, reflected the wound care services' Nurse Practitioner performed rounds on Resident #4 to assess a PU to the sacrum which measured 5.5 centimeters by 2.3 centimeters by 1.3 centimeters. The ulcer was cleansed with wound cleanser and patted dry with 4X4 gauze pad. Alginate with silver was applied to the wound bed and covered with foam dressing. Continued heavy drainage. The NP obtained a wound culture. Education was provided to the resident regarding turning and repositioning. Resident #4 voiced understanding but continued with non-compliance. No other concern; continue to monitor. There was no documentation Resident #4 refused to get out of bed. Record review of Resident #4's progress notes, dated 09/25/2023, reflected Resident #4 continued antibiotic for wound infection. The resident's central dressing was CDI. Resident continued to refuse to turn and reposition. Education was provided, but the resident continued to decline. There was no documentation Resident #4 refused to get out of bed. Record review of Resident #4's wound report, dated 9/28/23, reflected a facility acquired sacral ulcer with a length of 5.5 centimeters, width of 4 centimeters and depth of 2 centimeters. There was moderate drainage which was purulent (discharging pus) with a foul smell. The treatment was cleansing with Dakins solution and treating with alginate. Record review of Resident #4's skin assessment, dated 10/9/23, categorized the sacral ulcer for Resident #4 as in-house acquired, Stage III, (full thickness tissue loss) with a length of 5.5 centimeters, width of 4 centimeters and depth of 2 centimeters. There was no tunneling, undermining or Sinus Tract identified. The exudate was moderate and purulent with a thick, tenacious (clinging) consistency and foul odor. The wound color was red with defined margins and weeping surrounding skin. Record review of Resident #4's progress notes, dated 10/09/2023 reflected Resident #4's IV to right side of neck Central line was intact with no signs or symptoms of infection noted, no redness, no swelling, and no pain. Wound care was performed with a dressing change. The NP rounded and no new orders were received. Resident #4 continued to refuse to turn or reposition. Resident #4 received education on the importance of turning and repositioning, but the resident continued to decline. There was no documentation Resident #4 refused to get out of bed. Record review of Resident #4's physician order, dated 10/9/23, reflected cleansing with Dakins Solution 25% strength, patting dry with 4x4 gauze, packing with alginate, and covering with dry dressing. The preventative intervention was pressure redistribution mattress, specific turning/repositioning program, positioning devices and heel boots. The wound was determined to be infected, and Resident #4 was placed on contact precautions with antibiotic therapy. Record review of Resident #4's progress notes, dated 10/14/2023 at 09:32AM, reflected Resident #4 was tolerating antibiotics, central line was clean/dry/intact. No signs or symptoms of infection, swelling, redness, no complaints of pain or discomfort. Central line was patent. Resident #4 continued to refuse turning and repositioning. Education was provided and the resident continued to decline. There was no documentation Resident #4 refused to get out of bed. Record review of Resident #4's progress notes, dated 10/15/2023 at 09:34 AM, reflected Resident #4 was not having any adverse reactions to the antibiotics. Central line to right side of the neck was clean/dry/intact. No signs or symptoms of infection, redness, swelling, no complaints of pain or discomfort. Central line was patent. Resident #4 continued to refuse to turn or reposition. Education was provided, but resident declined. There was no documentation Resident #4 refused to get out of bed. Record review of Resident #4's skin assessment, dated 10/16/23, categorized the sacral ulcer as in-house acquired, Stage III, with a length of 5.5 centimeters, width of 4.0 centimeters and depth of 1.5 centimeters. There was no tunneling, undermining or Sinus Tract identified. The exudate was moderate and serosanguineous (producing serum with small amounts of blood present) with a thin, watery consistency and no odor present. The wound color was pink and red and was erythematic (abnormal redness of the skin due to the accumulation of blood in dilated capillaries). The wound margins were undefined. Record review of Resident #4's physician order, dated 10/16/23, reflected cleansing with Dakins Solution, packing with collagen particles and alginate with silver rope and covering with a silicone foam dressing. The preventative intervention was pressure redistribution mattress, nutritional supplements, vitamin supplements, positioning devices and protein supplements. Record review of Resident #4's progress notes, dated 10/16/2023 at 10:36AM, reflected Resident #4 was receiving Cefepime HCL intravenous solution 2gm/100ml. No adverse reactions noted, wound care completed by wound nurse. Continued to encourage resident to turn. There was no documentation Resident #4 refused to get out of bed. Record review of Resident #4's skin assessment, dated 10/23/23, categorized the sacral ulcer as in-house acquired, Stage III, with a length of 5.0 centimeters, width of 3.0 centimeters and depth of 2.0 centimeters. There was no tunneling, undermining or Sinus Tract identified. The exudate was moderate and serosanguineous with a thin, watery consistency and no odor present. The wound color was pink and black and was erythematic. The wound margins were undefined. Record review of Resident #4's physician order, dated 10/23/23, reflected cleansing with Dakins Solution, packing with collagen particles and alginate with silver rope and covering with a silicone foam dressing. The preventative intervention was pressure redistribution mattress, vitamin supplements and protein supplements. Record review of Resident #4's progress notes, dated 10/23/23 at 3:35 PM, indicated reflected Resident #4 did not want to be repositioned at that time. Resident #4 also declined being turned at 5:14 PM and 8:50 PM. There was no documentation Resident #4 refused to get out of bed. Record review of Resident #4's progress notes, dated 10/24/23 at 12:27 AM, indicated Resident #4 did not want to be turned at that time. Resident #4 cooperated with repositioning at 3:00 AM and 12:50 PM. At 3:17 PM, Resident #4 was given a bed bath and did not want to be repositioned afterward. There was no documentation Resident #4 refused to get out of bed. Record review of Resident #4's progress notes, dated 10/25/23 at 5:45AM, indicated Resident #4 did not want to be turned at that time. There was no documentation Resident #4 refused to get out of bed. Record review of Resident #4's progress notes, dated 10/26/23 at 10:25PM, indicated Resident #4 was comfortable and lying on her left side. Record review of Resident #4's progress notes, dated 10/27/23, indicated Resident #4 did not want to be repositioned at 8:50 AM, 12:57 PM, 5:35 PM, 9:17 PM and 11:03 PM. There was no documentation Resident #4 refused to get out of bed. Record review of Resident #4's progress notes, dated 10/28/23, indicated Resident #4 did not want to be repositioned at 5:02 AM and 1:16 PM. There was no documentation Resident #4 refused to get out of bed. Record review of skin assessment for Resident #4, dated 11/1/23, categorized the sacral ulcer as in-house acquired, Stage III, with a length of 5.5 centimeters, width of 5.0 centimeters and depth of 2.0 centimeters. There was no tunneling, undermining or Sinus Tract identified. The exudate was moderate and serosanguineous with a thin, watery consistency and foul odor present. The wound color was red and black and was erythematic. The wound margins were undefined. Record review of Resident #4's physician order, dated 11/1/23, reflected cleansing with Dakins Solution, packing with collagen particles and alginate with silver rope, covering with silicone foam dressing. The preventative intervention was pressure redistribution mattress, nutritional supplements, and vitamin supplements. The dietician was notified of the need for additional nutritional assessment. Record review of Resident #4's skin assessment, dated 11/8/23, categorized the sacral ulcer as in-house acquired, Stage III, with a length of 5.5 centimeters, width of 3.0 centimeters and depth of 2.0 centimeters. There was no tunneling, undermining or Sinus Tract identified. The exudate was moderate and serosanguineous with a thin, watery consistency and foul odor present. The wound color was red and black and was erythematic. Record review of Resident #4's physician order, dated 11/8/23, reflected cleansing with Dakins Solution, packing with collagen particles and alginate with silver rope, covering with a silicone foam dressing. An interview with CNA I on 11/7/23 at 1:14 PM revealed there was no Geri Chair big enough for Resident #4 on Unit C-1S, nor was there a Hoyer Lift. Equipment was shared by Unit C-1S and Unit C-1N. CNA stated that Resident #4 is very large and cannot transfer herself, so she cannot get out of bed on her own. CNA I stated there was not enough room on Unit C-1S to store a Hoyer Lift or Geri Chair. She stated she would ask the therapy department for help in finding equipment. An observation and interview on 11/7/23 at 1:18 PM of Resident #4's room revealed a manual bariatric wheelchair pushed against the wall of her room. Resident #4 stated the staff didn't like to get her out of bed and into her chair, because she was too hard to lift. Resident #4 stated staff were supposed to get her out of bed three times a day and were to reposition her every 2 hours, bet this was not being done. An observation and interview on 11/7/23 at 1:42 PM revealed Resident #4 in the same position in bed, as earlier today. She stated she had not gotten out of bed because staff had not come to reposition her or get her out of bed. An interview with LVN H on 11/7/23 at 2:07 PM revealed equipment was shared by Unit C-1S and Unit C-1N and the Hoyer Lift stayed on the North Unit because they had more space. LVN H stated she did not know of a Geri Chair large enough for Resident #4, that was not already being used by another resident. CNA I stated she told me yesterday she would ask the therapy department if they had equipment that was not being used. LVN H stated Resident #4 didn't like to get up from her bed. CNA I stated she had not gotten Resident #4 out of bed today, due to lack of equipment. An interview with Resident #4 on 11/7/23 at 2:29 PM revealed she wanted to get out of bed every day and would go to an activity if she could get up. An interview with the DON on 11/8/23 at 2:35 PM revealed the negative outcome of not following a doctor's order to get a resident up with the Hoyer lift and into a Geri Chair x 3/day, would result in the resident getting stiff joints, which reduces ADLs. The resident would develop a pressure ulcer in the places that touched the bed all day. The DON stated Resident #4 frequently refused to get out of bed and when this happened, the staff did not make her reposition or get out of bed, due to her size. DON was asked for documentation of the resident's refusal to get out of bed, but no documentation was produced. An interview with CNA J on 11/16/23 at 3:24 PM revealed Resident #4 refused to get out of bed frequently. She thought documentation was done on the resident's screen (on computer) under locomotion but was not positive. She would have to ask a nurse where the documentation was supposed to be done. CNA J stated she did not always document. CNA J stated Resident #4 liked her bed baths on Tuesday, Thursday and Saturday and was cooperative. An interview with LVN L on 11/16/23 at 3:28 PM revealed nursing documented any refusal of a resident refusing to get out of bed. She stated she should have documented on Resident #4 since she got up so infrequently, but she was used to this behavior, so it was not documented. LVN L stated Resident #4 was comfortable in a chair for about 30 minutes. Resident #4 wanted to be in bed all the time. Resident #4 was cooperative with bathing. An interview with CNA K on 11/16/23 at 3:35 PM revealed Resident #4 frequently refused to be repositioned. It was hard to get Resident #4 up due to the fact she was a 2-person assist and had to use a Hoyer lift. When they were busy, it was hard to get 2 people to help with a Hoyer lift, because some were helping other residents or taking residents outside to smoke. CNA K stated there was a place to document refusal by Resident #4 in the resident's chart, but she didn't document due to Resident #4 getting up so infrequently. An observation and interview on 11/16/23 at 3:45 PM revealed Resident #4 was sitting in a Geri chair watching television by the nurse's station. She stated her bottom hurt if she sat in the chair for too long. Resident #4 stated it was nice to be in up out of bed and in the chair, today. She had participated in an activity, which she had enjoyed. This occurred after surveyor intervention on behalf of Resident #1.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure foods were properly stored, labeled, and dated. 2. The facility failed to ensure general cleanliness was maintained in the kitchen. 3. The facility failed to ensure beard covers were worn. These failures could place residents who ate food served by the kitchen at risk of food-borne illness. Findings include: Observation of the freezer on 11/6/23 @ 8:40 AM revealed the following: 1. (1) box of pancakes, open to air. 2. (1) box of frozen sugar cookie dough, open to air. 3. (1) baggie of biscuits, not in original package, no label or date. 4. (1) box of dinner rolls, open to air. 5. Several baggies of meat, no label or date, not in original box. 6. (1) bag of biscuits, no label or date, not in original box. Observation of the kitchen food prep area and the Traulsen Cooler in the kitchen prep area on 11/6/23 at 8:45 am revealed the following: 1. 1 baggie of burritos open to air, no label, not in original package. 2. 1 baggie of corn dogs open to air, no label, not in original package. 3. 4 boxes of pork egg roles in cooler. Label stated, Keep Frozen. 4. 1 ziplock baggie of pastry, no label or date, open to air, not in original package. Observation of the pantry area on 11/6/23 at 8:47 am, revealed food debris and dirt on 4 plastic trays holding packages of gravy mix. Observation of the kitchen food prep area on 11/6/23 at 8:50 am revealed plastic containers of flour, sugar and rice were sticky and grimy to the touch. The container lids had food crumbs on the top and were sticky to the touch. The lids were not secured. Observation on 11/6/23 at 8:55 am revealed Cook A was in the kitchen prep area with no beard cover. Observation of the kitchen on 11/6/23 at 9:00 am revealed there was no cleaning schedule posted. In an Observation and an interview on 11/6/23 at 9:30 am, Cook A was observed in the kitchen prep area with no beard cover. Cook A stated he had just come back to the kitchen from delivering snacks. There was no move to get a beard cover. Observation on 11/6/23 at 11:30 am revealed Cook A was in the kitchen prep area preparing food for the noon meal. Cook A had no beard cover on. Observation of the pantry area on 11/7/23 at 8:45 AM revealed food debris and dirt on 4 plastic trays holding packages of gravy mix. Observation of the freezer on 11/7/23 at 8:50 AM revealed the following: 1. (1) box of pancakes, open to air. 2. (1) box of frozen sugar cookie dough, open to air. 3. (1) baggie of biscuits, not in original package, no label or date. 4. (1) box of dinner rolls, open to air. 5. Several baggies of meat, no label or date. 6. (1) bag of biscuits, no label or date, not in original box. Observation of the kitchen food prep area and the refrigerator on 11/7/23 at 8:55 am revealed the following: 1. 1 baggie of burritos open to air, no label, not in original package. 2. 1 baggie of corn dogs open to air, no label, not in original package. 3. 4 boxes of pork egg rolls in cooler. Label stated, Keep Frozen. 4. 1 ziplock baggie of pastry, no label or date, open to air, not in original package. Observation of the kitchen food prep area on 11/7/23 at 9:00 am revealed plastic containers of flour, sugar and rice were sticky and grimy to the touch. The container lids had food crumbs on the top and were sticky to the touch. The lids were not secured. Observation on 11/7/23 at 9:05 am revealed Cook A was washing dishes in the kitchen dishwashing area with no beard cover. Observation and interview on 11/7/23 at 9:45 am revealed Cook B was washing dishes in the kitchen dishwashing area with no beard cover. Cook B stated he did not know he was supposed to wear a beard cover. Observation on 11/7/23 at 9:50 am revealed there was no cleaning schedule posted. Observation on 11/7/23 at 9:55 am revealed Cook A was preparing food in the kitchen with no beard cover. Observation and interview of the kitchen on 11/7/23 at 2:25 pm revealed Cook C was in the kitchen putting foods in the cooler and did not have a beard cover. Cook C stated he did not know he was supposed to wear a beard cover. In an interview and a walk through with the DM on 11/7/23 at 2:30 pm, the DM stated of the issues with the food grime and crumbs on the containers of sugar rice and flour and the food particles on the trays in the pantry that she is sorry they have missed it and she will get it cleaned. The DM stated she expects all staff to be cleaning daily. The DM stated she has been out of the facility, and it was just missed. The Dietary Manager stated she does not have cleaning schedule sheets and did not know she was to keep them for at least one year. The DM stated she trains the staff on cleaning practices and the labeling and dating of foods. The DM stated she expects all staff to close all packages of food after they use the package. The DM stated the consequences of not labeling and dating foods could cause residents to have food borne illnesses. The DM stated the consequences of not storing food properly would possibly make the residents sick if consumed. She further stated residents could get sick from the food not being covered or refrigerated after being opened. The DM stated she did not have cleaning sheets for review. The DM stated she was not aware male staff with beards were to wear beard covers. The DM stated she did not have any beard covers and will order the beard covers. The DM stated a consequence of not having beards would be hair in the food and on kitchen surfaces. Record Review of the policy dated 3/27/12, titled Dress Code documented: Beard guards must be used for employees with facial hair. Record Review of the policy dated 11/2/17, titled Infection Control Guidelines documented: open foods are labeled and dated with content, opened on date and use by date according to guidelines. Opened refrigerated foods will be covered, labeled and dated. Equipment and counters will be cleaned and sanitized after each use. Record Review of the policy dated 3/26/12, titled Dry Food Storage documented: Foods will be stored in a clean, cool, dry area. Opened food items will be stored in clean, dry, sealed containers with content noted and opened on dates. Foods stored in bins will be clean with tight fitting lids to prevent contamination. Record Review of the policy dated 3/26/12, titled Cold Storage Areas documented: Date label and properly secure all food products. Record Review of the policy dated 3/25/12, titled Cleaning and Sanitation documented: The Food and Nutrition Director will develop, implement and monitor schedules for cleaning, sanitizing and maintenance and keep record for 1year. Cleaning schedules designate cleaning for each position and are posted in an accessible area.

Based on interview and record review, the facility failed to ensure the residents received treatment and care in accordance with professional standards of practice for 1 of 3 residents (Resident #1) reviewed for wound care. The facility failed to follow policy stating the residents with wounds will have weekly skin assessments performed. The deficient practice could affect all residents currently residing in the facility resulting in not receiving needed care to maintain optimum health and placing them at risk for injury and/or deterioration in their condition. Findings include: Record review of the clinical record for Resident #1 revealed at [AGE] year-old female resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. other Orthopedic Aftercare, Phlebitis and [MEDICAL CONDITION] of Superficial Vessels and UTI. Record review of Resident #1's last MDS dated [DATE], revealed Resident #1 had a BIMS of 10 indicating she is cognitively intact with only mild cognitive impairment, and Section G-Functional Status that revealed Resident #1 needed extensive two-person assistance with all ADLs. Section H revealed that Resident #1 was incontinent of bowel and bladder. Record review of Resident #1's progress notes revealed that on 11-12-2020, Resident #1 was sent to the hospital due to altered mental status. Record review of Resident #1's evaluations reveal that a skin assessment was done on 10-17-2020. Skin assessment stated that there was no existing loss of skin integrity even though the resident had a [DEVICE] to the left lower leg. The next skin assessment was not done until 11-2-2020 (more than 2 weeks later). Record review of a head to toe assessment, dated 11-9-2020, revealed this was the first time wounds were noted to the buttock region showing a facility acquired wound as described wound to LLE; wound vac in place. wounds to buttocks; TX in place. redness to bilateral heels; TX. No documentation of the wound being infected was noted. No size of the wound was documented, no smell of the wound was documented. Record review of head to toe assessment, dated 11-12-2020 at 9:51 AM, revealed only redness to the groin and buttock, no wound or wound description. During an interview on 11-14-2020 at 9:30 AM, RN A was asked about Resident #1's wound. RN A stated he last saw Resident #1 on 10-17-2020 during the weekly skin assessment. RN A stated that he remembered the resident had a red area over the Coccyx/Sacrum, but that there was no skin breakdown. RN A contracted COVID and was gone from the facility for 2 weeks. He did not return to the facility until 11-5-2020. RN A stated he did not see the resident before she was taken to the hospital. After reviewing the facility's electronic records, RN A confirmed there was no documentation of a skin assessment done from 10-17-2020 until 11-2-2020. RN A stated the resident also had COVID during that time and that might be why there was no other skin assessments done. RN A confirmed nurses on the COVID unit should be capable of performing a skin assessment, as an assessment is a basic nursing skill. RN A confirmed no action or assessment was done during the time Resident #1 was in the COVID unit. During an interview on 11-14-2020 at 10:12 AM, COM B stated the Resident #1 came into the ER lethargic with altered LOC. COM B confirmed the resident had what she would describe as a stage II pressure ulcer to her coccyx/sacrum area. COM B stated the wound was weeping purulent (pus-like yellow-green) drainage that had a very malodorous smell to it. COM B stated the wound was covered with some tap over gauze and was soaked through with urine and feces. COM B stated there was no way this had happened recently. COM B stated Resident #1 had a severe rash and breakdown around her brief, and her brief was soiled with feces that appeared to have been there for some time. COM B stated Resident #1 was admitted to the hospital to treat the infection of the wound. During an interview on 11-14-2020 at 4:30 PM, DON confirmed Resident #1 should have had a more thorough skin assessment done. DON confirmed it was her expectation that all nursing staff should be able to complete a skin assessment as it was a basic nursing skill. Record review of facility provided policy tilted Clinical Manual -Patient Care, not dated, revealed in part: 8. The Wound Care Professional will make rounds weekly assessing skin, would healing and providing wound care interventions. Documentation of these rounds will occur on the wound management documents. 10. Routine assessment and wound care may (be) provided by the patients assigned nurse each shift. Documentation will be on the twenty for hour nursing flow sheet.

Based on interview and record review it was determined the facility failed to ensure all residents were free from neglect for 3 of 23 residents reviewed for neglect (Resident #25, Resident #47 and Resident #49). LVN A incorrectly inserted a suprapubic catheter (a catheter to drain urine that inserts a few inches through a stoma on the abdomen into the bladder) and threaded the catheter 16.5cm (almost 6.5 inches) too far and inflated the catheter bulb in Resident #49's penis. Resident #49 required transfer to the local emergency room for treatment and admission on 11/5/18 through 11/8/18. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 2/23/18 that occurred on 11/5/17. While the IJ was removed on 2/26/18, the facility remained out of compliance at a severity of actual harm with a scope identified as pattern. The facility was continuing to monitor to ensure catheter care in accordance with professional standards for all residents. Non-IJ: Resident #25 was prescribed the blood thinner Eliquis. She has a history of [MEDICAL CONDITION], requiring blood [MEDICAL CONDITION]. The facility failed to ensure Resident #25's critical lab values indicating severe [MEDICAL CONDITION] were immediately reported to the physician. The facility failed to implement Resident #47's physician orders [REDACTED]. The facility's failure to ensure all residents were free from neglect could place 9 residents requiring catheter care at risk for pain, [MEDICAL CONDITION], genital-urinary trauma, [MEDICAL CONDITION], blood loss, shock, and death; 65 residents requiring oral medications at risk for medication errors, lack of medical treatment, improper medical treatment, [MEDICAL CONDITION], toxic or non-therapeutic medication levels, and death; and 65 residents requiring routine or stat labwork at risk for medication errors, lack of medical treatment, improper medical treatment, [MEDICAL CONDITION], toxic or non-therapeutic medication levels,[MEDICAL CONDITION], and death. Findings include: Record Review of Resident #49's clinical record revealed: Resident #49 is a [AGE] year old male with an admission date of [DATE], a readmission date of [DATE], and was transferred to another nursing facility on 2/22/18. He had [DIAGNOSES REDACTED]. Record Review of the care plan for Resident #49, dated 1/22/18, stated: Resident #49 has limited mobility, requires a Hoyer lift for transfers, has an ADL deficit requiring at least 2 person assist, has pain, depression, requires adaptive equipment to assist with eating, has a suprapubic catheter, is at risk for injuries related to diabetes and hypertension, and is at risk for weight loss and pressure sores. Record Review of Resident #49's MDS, dated [DATE], stated: Resident #49 has BIMS-15, indicating no cognitive impairment; Depression-8; no behaviors; requires total 2 person assist for all bed mobility, transfers, dressing, toileting, ADLs, and bathing; requires extensive 1 person assist for hygiene; requires a wheelchair of mobility; has bilateral upper and lower extremity impairment; has an indwelling catheter; is always continent of bowel; has occasional complaints of pain requiring medication; and is at risk pressure sores. During an interview on 2/20/18 at 3:27 p.m., Resident #49 was asked about any care issues during his stay at the facility. He stated he had some problems and stated, one of the nurses came in on the weekend (11/5/17), and she changed (the suprapubic catheter) around lunch time, but she didn't do it right. I had to go to the hospital, and I was there for 4 days for bleeding and an infection in my bladder. During an interview on 2/23/18 at 11:20 a.m., LVN A stated she wasn't comfortable changing that (suprapubic) catheter because Resident #49 was having bladder spasms. She confirmed there was a standing order to change the catheter as needed. She stated she contacted the on call provider and received an order for [REDACTED].#49 had severe pelvic pain and blood in his urine. She stated the facility had not provided any additional training on inserting, changing or care of suprapubic catheters. When asked if she had changed suprapubic catheters before, she stated, I'm not new to this. When asked how far the suprapubic catheter tubing should be inserted, she stated, 1.5 to 2 inches is the normal length. LVN A was informed the catheter had been inserted and the CT Scan showed the catheter bulb was inflated in his penis, and the catheter required retracting 16.5 cm. She stated, Wow, I didn't know that. It wasn't that way when he went out. LVN A confirmed she was not the nurse that transferred Resident #49 to the ER. Review of Facility Nurses' Notes revealed: 11/5/2017 at 6:38 p.m.: Nursing Progress Note: 2:24 p.m. Contacted NP due to patient complaining of severe bladder spasms, pain scale 10/10, yelling for help and called wife crying. NP gave orders to give [MEDICATION NAME] 10mg one by mouth every 12 hours. Resident given Tylenol #3 at 3:00 p.m., was effective with pain management, pain scale 4/10 after 30 minutes of administration. No further complaints of pain at this time. 6:48 p.m. Patient did receive catheter change per their (Resident and his ex-wife) demand. Patient thought it would stop bladder spasms, they continue with leakage of urine tinged pink blood. At 5:41 p.m., NP notified of bladder spasms continue with urine tinged pink blood approximately size of 8-9 sock on sheet noted. (This is how the nurse described the size of the blood.) NP advised to continue to monitor, bleeding should stop on its own in a couple of days, if becomes red staff to contact provider. (Resident #49's daughter) notified of bladder spasms continue with leakage of urine with tinged pink blood and NP notified. (Sic)- LVN A 11/5/2017 at 9:58 p.m.: Nursing Progress Note: Resident called this nurse into his room at 7:15 p.m. this evening complaining of severe bladder spasm's pain scale 8/10 resident is crying and asking for help this nurse called nurse practitioner on call and received orders to send resident out to emergency room (ER) wife at bedside agreed that she does want resident to go to ER. This nurse called non emergent (EMS) at 7:30 p.m. they arrived on unit at 7:46 p.m. and left facility at 8:00 p.m. will continue to monitor closely. (Sic) - LVN B Review of Resident #49's Hospital Medical Record revealed: Record Review of the Physician History and Physical, dated 11/5/17, revealed: Chief Complaint: Problems with urinary catheter pain after placement. History of present illness: This is a [AGE] year old very pleasant gentleman who has [MEDICAL CONDITION] and is in a nursing home. He is non-ambulatory apparently has a suprapubic catheter and this was replaced today at the nursing home, then he had problems with pain eventually calling EMS to send him to the emergency room . On arrival there, EMS noted that there was no drainage from the catheter, he was brought to the ER and evaluation revealed a suprapubic catheter was actually placed in the suprapubic opening and then went into the penile urethra. This was repositioned. A CT scan was performed that showed this, and he was noted to have a (kidney stone). There was a significant amount of bleeding associated with the repositioning of the catheter, as the balloon was blown up partially in the penile urethra. The patient was noted to have a significant amount of pyuria and bacteriuria, which you would expect from a chronic indwelling catheter, but he also had a 20,000 white count. He has not had any fever, chills or associated symptoms. (Sic). Impression/Plan: 1. UTI present on admission. The patient has a chronic suprapubic catheter, but has a 20,000 white count that seems like the only source of his urine .He also has a UTI with [MEDICATION NAME]. 2. Malpositioned suprapubic catheter: This has been repositioned. If problems with drainage, it may need to be flushed. 3. Staghorn calculus in the left kidney. (Sic). Record Review of the ER Nurses' Notes, dated 11/5/17, revealed: 8:19 p.m.: Patient to ER 35 via EMS stretcher. 8:35 p.m.: To CT via stretcher. 10:00 p.m.: Catheter balloon emptied and catheter pulled back slightly to remove from urethra. Per Dr. orders. Catheter flushed and blood with clots came out of penis. Catheter flushed 2 more times with 20 ml of sterile water until blood and clots removed from Foley tubing. Balloon reinflated with removed fluid from deflation. Record Review of CT Cystogram Pelvis Report, dated 11/6/17, revealed: Findings: CT images demonstrate the presence of a suprapubic catheter. The catheter extends through the lumen of the urinary bladder and into the base of the penis. The Foley balloon tipped has been inflated at the base of the penis and repositioning is recommended. Conclusion: 1. Distal tip of the suprapubic catheter extends into the base of the penis. The balloon is insufflated (inflated). Recommend deflation and withdrawal of the catheter by approximately 16.5 cm. Record Review of Physician Consultation Report, dated 11/6/17, revealed: History of present illness: [AGE] year old male who was admitted for UTI. He was noted to have a non-draining suprapubic tube. It previously had been replaced yesterday at the nursing home. It never drained well. A CT scan showed the suprapubic tube had tracked down the penile urethra. The balloon was deflated, repositioned and it is draining now. He states his pain has resolved. Record Review of the Physician Discharge Summary, dated 11/9/17, revealed: Admitting Diagnoses: [REDACTED].>1. Urinary tract infection present on admission, complicated. 2. Malpositioned suprapubic catheter. 3. Left Kidney Stone. Hospital Course: The patient was admitted to the floor on broad-spectrum antibiotics therapy .Final cultures revealed Pseudomonas aeruginosa, Proteus mirabilis and [MEDICATION NAME] feacalis (Note: bacteria typically found in fecal material) .(Resident's Urologist) was consulted regarding the kidney stone and a suprapubic catheter malplacement. A CT scan ordered to evaluate suprapubic catheter did demonstrate malpositioning and high density material in the bladder, likely blood products. After repositioning he does have a left kidney (stone) but will need an outpatient [MEDICAL CONDITION] preoperative clearance prior to considering nephrolithotripsy. During an interview on 2/22/18 at 9:32 a.m., WCD denied knowledge that Resident #49's catheter had been inserted improperly. He stated he had heard something about the catheter being pulled down into the urethra, but (he didn't) remember much about it. He confirmed the nursing documentation regarding the catheter change was lacking because it failed to clearly document the time of the change, whether there was resistance during the insertion, or urine return upon insertion. When asked how far a suprapubic catheter should be inserted, he stated, 2-4 inches. When asked if bleeding, severe pain, and no urine output are signs of an improperly placed catheter, he stated, yes. When shown the CT Scan Report requesting the catheter be retracted 16.5cm (almost 6.5 inches) and asked whether the catheter was incorrectly placed, he stated, yeah, I guess it would be .substantially too far. It's safe to say. It's common sense. When asked in his nursing judgment if there was any way the catheter balloon being inflated in the penis could happen other than improper placement, he denied knowledge of any other causes. He confirmed he had not seen the hospital medical records. He confirmed the facility had not investigated the incident. He confirmed he investigates nursing issues related to care and neglect. During an interview on 2/22/18 at 10:24 a.m., DON confirmed she was unaware of any complications with catheters in the facility. She confirmed nursing documentation should include whether there was resistance during the insertion, or urine return upon insertion. When asked how far a suprapubic catheter should be inserted, she stated, look for some urine, you don't need to go in very far. It's right there .3-4 inches in. When asked what are the complications of an improperly placed catheter, she stated, pain, a lot of pain, and no urine. When asked what a prudent nurse should do if presented with pain, bleeding, and no urine output, she stated, stop what you are doing, and call and get help .the nurse practitioner, doctor, another nurse, somebody. When shown the CT Scan Report recommended retracting the suprapubic catheter 16.5 cm and asked if that indicated the catheter was inserted way too far, she stated, yes. When asked what complications can result from inflation of the catheter bulb in the penis, she stated, pain, inability to urinate, a lot of distention, risk of infection and necrosis (death of the urethra and penile tissue). She confirmed he had not seen the hospital medical records. She confirmed the facility had not investigated the incident. During an interview on 2/22/18 at 2:38 p.m., MD denied being informed by administration about ER findings when Resident #49 was sent to the hospital. He stated he found out that the suprapubic catheter had been placed incorrectly by a floor nurse several days after Resident #49 arrived back at the facility. He confirmed at a minimum he should have been informed by administration that Resident #49 required admission to the hospital and treatment for [REDACTED]. During an interview on 2/23/18 at 9:16 a.m., LVN G confirmed the facility provided no formal training on suprapubic catheter care, maintenance or insertion. She denied a skills check off during orientation, and she denied caring for a resident with a suprapubic catheter during her orientation. She stated she was not familiar with the term suprapubic catheter and does not know the difference between suprapubic and indwelling catheter. During an interview on 2/23/18 at 9:18 a.m., WCD confirmed the facility provided no additional training for suprapubic catheters, except during the 3 day orientation that nurses receive. He confirmed no check-off training had occurred because nurses are taught in school. He stated the facility was aware Resident #49 had went to the hospital on [DATE] because hospitalization s are covered in the morning administrative meeting. He stated he found out in the morning meeting way after he went to the hospital they thought the catheter put in and blown up in the penis. He stated, he dismissed the idea because it would have to be improperly inserted to have been so far in that the bulb was inflated in his penis. He stated had he known he would have done an in-service immediately. As far as he knew, Resident #49 was fine when he got back. He confirmed he had no idea how far the catheter was inserted into Resident #49, the bulb was inflated in his penis, or that he had a kidney stone until the Survey Team presented the hospital CT Scan Report on 2/22/18. During an interview on 2/23/18 at 9:55 a.m., LVN H denied any formal facility-provided training regarding suprapubic catheters. She stated the only training provided was three days of orientation, and she stated she did not care for a resident with a suprapubic catheter. During an interview on 2/26/18 at 10:36 a.m., LVN B stated she was the night nurse that relieved LVN A. She stated LVN A had reported that she had changed Resident #49's suprapubic catheter, and subsequent to the catheter change, he had pain, bleeding, and decreased urine output. She stated, as soon as I got report, his wife came and got me. He was having significant pain, and I contacted the provider and transferred him quickly. She denied knowledge of the ultimate disposition of Resident #49 because he was admitted . When informed that the catheter had been threaded into and inflated in his penis. LVN B gasped, and stated, oh my. When asked if pain, bleeding, and decreased urine output were symptoms of an improperly inserted catheter, she stated, Yes, they are. When asked if the only way the catheter bulb could be inflated in the penis was that it was the catheter was improperly inserted, she stated, definitely. When asked if retracting the catheter 16.5 cm shows that the catheter was inserted improperly, she stated further, I have changed his suprapubic several times, you only have to insert it 2-3 inches. Record Review of the facility's policy for Supra-Pubic Catheter Care, dated 9/24/11, stated: Policy: To cleanse and maintain hygiene of suprapubic catheter stoma. To remove mucous from around supra-pubic catheter to prevent excoriation, inflammation and discomfort. Record review of the facility's policy for Supra-Pubic Catheter Reinsertion, dated 9/24/11, stated: Policy: Supra-pubic catheter will be reinserted into the bladder to resume continuous urinary drainage in accordance with a physician order. Procedure: 12. Insert lubricated tip of catheter approximately 1 ½ inches into the opening. Do not force if there is resistance. Notify MD if resistance is identified. 13. When urine has ceased flowing, insert amount of sterile water needed to inflate the balloon. Note: -This procedure should not be painful. If the resident experiences pain, stop the procedure until the source of pain is discovered. -The Supra-pubic catheter and drainage bag is a closed sterile system. This system must remain closed as much as possible. Record Review of the facility's policy for Reporting Abuse to Facility Management, dated 12/2013, stated: It is the responsibility of our employees .to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source .to facility management. Policy Interpretation and Implementation 2f. Neglect is defined as failure to provide goods or services necessary to avoid physical harm, mental anguish, or mental illness. Record Review of the facility's policy for Abuse Investigations, dated 4/2014, stated: All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. Policy Interpretation and Implementation 1. Should an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident. 3. The individual conducting the investigation will, as a minimum: b. Review the resident's medical record to determine events leading up to the incident; c. Interview the person(s) reporting the incident; d. Interview any witnesses to the incident; e. Interview the resident; f. Interview the resident's Attending Medical Physician as needed to determine the resident's current level of cognitive function and medical condition; g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; h. Interview the resident's roommate, family members, and visitors; j. Review all events leading up to the incident. 5. Witness reports will be obtained in writing. The facility DON was notified on 2/23/18 at 11:40 a.m. that an Immediate Jeopardy situation had been identified due to the above failures. During an interview on 2/27/18 at 10:35 a.m., DON was asked How do you think this incident (Immediate Jeopardy) related to catheter care came about? She stated, I have never had an IJ. I don't think it happened. I don't think it happened. I have known this nurse for years. She said she didn't insert it in that far. I believe her. DON was asked What resources are available for the staff and facility to ensure proper suprapubic catheter care? She stated, To be truthful, we never thought about it being an issue. All this time it wasn't an issue; it only became an issue when he was discharged . There was never a grievance filed. They (Resident #49 and his ex-wife) never complained when he returned from the hospital. Maybe we should have done some training, but they learn that in school. The facility submitted their Plan of Removal on 2/23/18 at 5:16 p.m. and it was accepted on 2/26/18 at 10:00 a.m. The Plan of Removal documented the following: Plumcreek Residence Amarillo, name changed to Landmark of Amarillo No Suprapubic catheters will be changed in this facility. If catheter needs to be changed resident will be taken to urologist for procedure. All nurses are currently being inserviced on new procedure/policy and will complete competency evaluations for catheter care within 24 hours beginning at 1300 (1:00 pm) on Friday, February 23rd. Failure to complete this requirement will result in removal from schedule until above stated requirements are met. The specific resident affected, and the single resident who had a suprapubic catheter is no longer in the facility. The incident occurred in November with no complain or concerns voiced by resident or family at that time. There are 8 residents currently in the facility who have foley catheters. ADON's are assessing them related to their catheters and the catheter care at this time. The assessments will be completed by 1400 (2:00 pm), Friday February 23rd. The Policy concerning catheter care is currently being revised to address that this facility will no longer change suprapubic catheters and will transport to urologist or ER for this care. Orientation of new hire nurses will include specific instructions about not changing suprapubic catheters and instructions and competency checkoffs for other urinary catheters before being released to work on the floors and within 3 days of floor orientation. Affirmation that all current nursing staff have completed the competency checkoff and have been inserviced about not changing suprapubic catheters will be confirmed by the signature of every nurse on said forms which will be reviewed by the DON or designed by 1500 (3:00 pm) Saturday February 23rd. Affirmation that all new hire nurses have been inserviced on the policy and checked off on the competency form will also be confirmed by each signature. This will be monitored by the DON or designee. Anytime a nurse perceives that there may be an issue or event concerning a catheter, he/she will notify the ADON or ADON on call. The ADON will instruct the nurse on how to proceed or contact the DON or designee for directions. All nursing staff will be trained to assess for potential negative reactions to improperly inserted catheters, malfunction of catheter, displacement of cathter or other anomalies related to catheter and care including urinary tract infections, [MEDICATION NAME], urethral injury, blood infection, bacteriuria, blood in the urine, injury to the urethra, kidney damage, and or [MEDICAL CONDITION]. This training will be completed by March 1st, 2018. Any time an unusual event occurs or a nurse does not feel comfortable or does not feel that she/he has adequate training for the task needing to be completed, that nurse should contact the ADON for that unit or after hours the ADON on call before proceeding. The ADON will then immediately contact the DON or designee. The survey Team confirmed that the facility's plan of removal was implemented on 2/26/18 as evidenced by: 1) Interviews with 5 licensed nurses and registered nurses to confirm the additional training regarding catheters had been performed. 2) Interviews with 2 administrative staff to confirm the LVN A had been trained regarding catheter care, changes, positioning and new policy implementation. 3) Interviews with 5 licensed nurses and registered nurses to confirm they had been educated on the implementation of the new policy to send residents to the emergency room for catheter changes. During an interview on 2/26/18 at 10:30 a.m., DON was informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm with a scope identified as pattern. The facility was continuing to monitor to ensure assessments for side rails were accurate for all residents. The facility was continuing to monitor to ensure catheter care in accordance with professional standards for all residents. Non-IJ Findings: Resident #25: Record Review of Resident #25's clinical record revealed: Resident #25 is a [AGE] year old female with an admission date of [DATE]. She has [DIAGNOSES REDACTED]. Record Review of the care plan for Resident #25, dated 1/15/18, stated: Resident #25 has on ADL deficit, has pain, depression, is at risk for injuries related to heart failure, arrhythmia and hypertension, and is at risk for contracture, thrombus, falls and pressure sores. Record Review of Resident #25's Physician Orders, dated 8/29/17, stated: Eliquis 5mg by mouth 2 times a day for blood thinner. Record Review of Resident #25's MAR, dated 8/30/17 to present, stated: Eliquis 5mg by mouth 2 times a day for blood thinner has been given on a consistent twice a day basis. Record Review of Resident #25's Complete Blood Count, dated 12/2/17, stated: Red Blood Cells: 3.32 (Low) Normal Range: 4.8-10.1 Hemoglobin: 8.7 (Low) Normal Range: 12.0-16.0 Hematocrit: 28.2 (Low) Normal Range: 37.0-47.0 (Note: NP initialed and dated lab report 12/27/18, indicating labwork was reviewed 25 days after reported to the facility.) Record Review of the Nurses' Notes for 12/2/17 - 12/27/17 do not indicate Resident #25's physician was notified of the critical lab results indicating severe [MEDICAL CONDITION]. During an interview on 2/22/18 at 11:23 a.m., DON confirmed Reviewed #25's past facility [DIAGNOSES REDACTED]. She confirmed the order dated and signed 8/29/17 by Resident #25's Physician for Eliquis 5mg by mouth twice daily and current MAR for continued administration of the medication. When asked about the lab results reported to the facility on [DATE] with red blood cell count of 3.32, hemoglobin of 8.7, and hematocrit of 28.2 that was addressed by NP on 12/27/17, she responded, That sounds like she needed a fill up-(blood) transfusion. When asked what the process is to handle lab results, she stated, They are put in a folder and left at the nurses stations. The nurse practitioners are supposed to look at them when they come in. During an interview on 2/22/18 at 2:39 p.m., MD was asked about the lab work indicating severe [MEDICAL CONDITION] on 12/2/18, and the failure to notify the physician for 25 days. He stated, I would have to review my notes and look at that situation plus review if her cardiologist is involved. I will have my PA come up and address it probably later this week or the first of next week. During an interview on 2/23/18 at 8:48 a.m., DON notified Survey Team that PA visited resident last night and discussed the issue with her and new orders were received. During an interview on 2/23/18 at 9:14 a.m., Resident #25 stated the PA saw her last night and discussed her blood loss. She stated, It's been a long time problem for me. I usually have to have 2-3 transfusion each year because of it. It can be a real problem because I tend to get weak from it, and my back will hurt more. I have never been asked about it here, especially by MD. When asked about treatment for [REDACTED]. (PA) said, 'he is going to restart it'. When asked if she has had repeat lab work drawn today, she stated, No. During an interview on 2/23/18 at 10:25 a.m., DON verified that she stated yesterday that they handle the lab reports by putting them in a folder and leaving them at the nurses station for the PA or NP to evaluated when they come in. She stated Yes, that is exactly what we do. When asked if they have an official policy regarding this procedure, she stated, she Wasn't sure. She would have to check with the management company and see if they had one and get if faxed over. Resident #47 Record Review of Resident #47's clinical record revealed: Resident #47 is a [AGE] year old male with an admission date of [DATE], a readmission date of [DATE]. He has [DIAGNOSES REDACTED]. Record Review of Resident #47's Care Plans from 8/29/17 do not address Resident #47's [MEDICAL CONDITION]. Record Review of Resident #47's Dietary Consult Form, dated 1/4/18, stated: Concerns: Abnormal Labs: Hemaglobin-13.1 and Hematocrit-40.3 MD Approval: Dated and signed order by NP on 1/15/17 for Iron Sulfate 325mg by mouth once daily. Record Review of Resident #47's MAR from 1/15/18 to present, stated: No implementation or administration of Iron Sulfate 325mg by mouth once daily. During an interview on 2/22/18 at 11:21 a.m., DON verified the order for Iron Sulfate 325mg by mouth every day ordered on [DATE] by NP for the [DIAGNOSES REDACTED]. After verifying my information and checking her records in her office, she stated, I do not have a record of that anywhere. I cannot answer that (why it was not started). It should have been done. Record Review of the facility's policy for Reporting Abuse to Facility Management, dated 12/2013, stated: It is the responsibility of our employees .to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source .to facility management. Policy Interpretation and Implementation 2f. Neglect is defined as failure to provide goods or services necessary to avoid physical harm, mental anguish, or mental illness. Record Review of the facility's policy for Abuse Investigations, dated 4/2014, stated: All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. Policy Interpretation and Implementation 1. Should an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident. 3. The individual conducting the investigation will, as a minimum: b. Review the resident's medical record to determine events leading up to the incident; c. Interview the person(s) reporting the incident; d. Interview any witnesses to the incident; e. Interview the resident; f. Interview the resident's Attending Medical Physician as needed to determine the resident's current level of cognitive function and medical condition; g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; h. Interview the resident's roommate, family members, and visitors; j. Review all events leading up to the incident. 5. Witness reports will be obtained in writing. Record Review of the facility's policy for Lab Order Protocol, dated 1/16/12, stated: Protocol 7. The lab reports results of the lab to the facility. 8. Facility relays the results of abnormal labs to the physician for any new orders. Record Review of the facility's policy for Telephone Order Protocol, dated 1/16/12, stated: Protocol 1. Licensed nurse contacts the physician via telephone and reports change of condition, labs, and other pertinent information regarding the resident's care. Record Review of the facility's Policy for Administering Oral Medications, dated 10/2010, stated: Preparation 1. Verify there is a physician's medication order for this procedure. Review of the

Based on interview and record review it was determined the facility failed to ensure that allegations of neglect are thoroughly investigated for 1 of 23 residents reviewed for neglect (Resident #49). LVN A incorrectly inserted a suprapubic catheter (a catheter to drain urine that inserts a few inches through a stoma on the abdomen into the bladder) and threaded the catheter 16.5cm (almost 6.5 inches) too far and inflated the catheter bulb in Resident #49's penis. Resident #49 required transfer to the local emergency room for treatment and admission on 11/5/18 through 11/8/18. This incident was not reported to the Administration and therefore was not investigated for potential Neglect. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 2/23/18 that occurred on 11/5/17. While the IJ was removed on 2/26/18, the facility remained out of compliance at a severity of actual harm with a scope identified as pattern. The facility was continuing to monitor to ensure catheter care in accordance with professional standards for all residents. The facility's to ensure that allegations of neglect are thoroughly investigated could place 9 residents requiring catheter care at risk for pain, [MEDICAL CONDITION], genital-urinary trauma, [MEDICAL CONDITION], blood loss, shock, and death. Findings include: Record Review of the facility's policy for Reporting Abuse to Facility Management, dated 12/2013, stated: It is the responsibility of our employees .to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source .to facility management. Policy Interpretation and Implementation 2f. Neglect is defined as failure to provide goods or services necessary to avoid physical harm, mental anguish, or mental illness. Record Review of the facility's policy for Abuse Investigations, dated 4/2014, stated: All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. Policy Interpretation and Implementation 1. Should an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident. 3. The individual conducting the investigation will, as a minimum: b. Review the resident's medical record to determine events leading up to the incident; c. Interview the person(s) reporting the incident; d. Interview any witnesses to the incident; e. Interview the resident; f. Interview the resident's Attending Medical Physician as needed to determine the resident's current level of cognitive function and medical condition; g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; h. Interview the resident's roommate, family members, and visitors; j. Review all events leading up to the incident. 5. Witness reports will be obtained in writing. Record Review of Resident #49's clinical record revealed: Resident #49 is a [AGE] year old male with an admission date of [DATE], a readmission date of [DATE], and was transferred to another nursing facility on 2/22/18. He had [DIAGNOSES REDACTED]. Record Review of the care plan for Resident #49, dated 1/22/18, stated: Resident #49 has limited mobility, requires a Hoyer lift for transfers, has an ADL deficit requiring at least 2 person assist, has pain, depression, requires adaptive equipment to assist with eating, has a suprapubic catheter, is at risk for injuries related to diabetes and hypertension, and is at risk for weight loss and pressure sores. Record Review of Resident #49's MDS, dated [DATE], stated: Resident #49 has BIMS-15, indicating no cognitive impairment; Depression-8; no behaviors; requires total 2 person assist for all bed mobility, transfers, dressing, toileting, ADLs, and bathing; requires extensive 1 person assist for hygiene; requires a wheelchair of mobility; has bilateral upper and lower extremity impairment; has an indwelling catheter; is always continent of bowel; has occasional complaints of pain requiring medication; and is at risk pressure sores. During an interview on 2/20/18 at 3:27 p.m., Resident #49 was asked about any care issues during his stay at the facility. He stated he had some problems and stated, one of the nurses came in on the weekend (11/5/17), and she changed (the suprapubic catheter) around lunch time, but she didn't do it right. I had to go to the hospital, and I was there for 4 days for bleeding and an infection in my bladder. During an interview on 2/23/18 at 11:20 a.m., LVN A stated she wasn't comfortable changing that (suprapubic) catheter because Resident #49 was having bladder spasms. She confirmed there was a standing order to change the catheter as needed. She stated she contacted the on call provider and received an order for [REDACTED].#49 had severe pelvic pain and blood in his urine. She stated the facility had not provided any additional training on inserting, changing or care of suprapubic catheters. When asked if she had changed suprapubic catheters before, she stated, I'm not new to this. When asked how far the suprapubic catheter tubing should be inserted, she stated, 1.5 to 2 inches is the normal length. LVN A was informed the catheter had been inserted and the CT Scan showed the catheter bulb was inflated in his penis, and the catheter required retracting 16.5 cm. She stated, Wow, I didn't know that. It wasn't that way when he went out. LVN A confirmed she was not the nurse who transferred Resident #49 to the ER. Review of Facility Nurses' Notes revealed: 11/5/2017 at 6:38 p.m.: Nursing Progress Note: 2:24 p.m. Contacted NP due to patient complaining of severe bladder spasms, pain scale 10/10, yelling for help and called wife crying. NP gave orders to give [MEDICATION NAME] 10mg one by mouth every 12 hours. Resident given Tylenol #3 at 3:00 p.m., was effective with pain management, pain scale 4/10 after 30 minutes of administration. No further complaints of pain at this time. 6:48 p.m. Patient did receive catheter change per their (Resident and his ex-wife) demand. Patient thought it would stop bladder spasms, they continue with leakage of urine tinged pink blood. At 5:41 p.m., NP notified of bladder spasms continue with urine tinged pink blood approximately size of 8-9 sock on sheet noted. (This is how the nurse described the size of the blood.) NP advised to continue to monitor, bleeding should stop on its own in a couple of days, if becomes red staff to contact provider. (Resident #49's daughter) notified of bladder spasms continue with leakage of urine with tinged pink blood and NP notified. (Sic)- LVN A 11/5/2017 at 9:58 p.m.: Nursing Progress Note: Resident called this nurse into his room at 7:15 p.m. this evening complaining of severe bladder spasm's pain scale 8/10 resident is crying and asking for help this nurse called nurse practitioner on call and received orders to send resident out to emergency room (ER) wife at bedside agreed that she does want resident to go to ER. This nurse called non emergent (EMS) at 7:30 p.m. they arrived on unit at 7:46 p.m. and left facility at 8:00 p.m. will continue to monitor closely. (Sic) - LVN B Review of Resident #49's Hospital Medical Record revealed: Record Review of the Physician History and Physical, dated 11/5/17, revealed: Chief Complaint: Problems with urinary catheter pain after placement. History of present illness: This is a [AGE] year old very pleasant gentleman who has [MEDICAL CONDITION] and is in a nursing home. He is non-ambulatory apparently has a suprapubic catheter and this was replaced today at the nursing home, then he had problems with pain eventually calling EMS to send him to the emergency room . On arrival there, EMS noted that there was no drainage from the catheter, he was brought to the ER and evaluation revealed a suprapubic catheter was actually placed in the suprapubic opening and then went into the penile urethra. This was repositioned. A CT scan was performed that showed this, and he was noted to have a (kidney stone). There was a significant amount of bleeding associated with the repositioning of the catheter, as the balloon was blown up partially in the penile urethra. The patient was noted to have a significant amount of pyuria and bacteriuria, which you would expect from a chronic indwelling catheter, but he also had a 20,000 white count. He has not had any fever, chills or associated symptoms. (Sic). Impression/Plan: 1. UTI present on admission. The patient has a chronic suprapubic catheter, but has a 20,000 white count that seems like the only source of his urine .He also has a UTI with [MEDICATION NAME]. 2. Malpositioned suprapubic catheter: This has been repositioned. If problems with drainage, it may need to be flushed. 3. Staghorn calculus in the left kidney. (Sic). Record Review of the ER Nurses' Notes, dated 11/5/17, revealed: 8:19 p.m.: Patient to ER 35 via EMS stretcher. 8:35 p.m.: To CT via stretcher. 10:00 p.m.: Catheter balloon emptied and catheter pulled back slightly to remove from urethra. Per Dr. orders. Catheter flushed and blood with clots came out of penis. Catheter flushed 2 more times with 20 ml of sterile water until blood and clots removed from Foley tubing. Balloon reinflated with removed fluid from deflation. Record Review of CT Cystogram Pelvis Report, dated 11/6/17, revealed: Findings: CT images demonstrate the presence of a suprapubic catheter. The catheter extends through the lumen of the urinary bladder and into the base of the penis. The Foley balloon tipped has been inflated at the base of the penis and repositioning is recommended. Conclusion: 1. Distal tip of the suprapubic catheter extends into the base of the penis. The balloon is insufflated (inflated). Recommend deflation and withdrawal of the catheter by approximately 16.5 cm. Record Review of Physician Consultation Report, dated 11/6/17, revealed: History of present illness: [AGE] year old male who was admitted for UTI. He was noted to have a non-draining suprapubic tube. It previously had been replaced yesterday at the nursing home. It never drained well. A CT scan showed the suprapubic tube had tracked down the penile urethra. The balloon was deflated, repositioned and it is draining now. He states his pain has resolved. Record Review of the Physician Discharge Summary, dated 11/9/17, revealed: Admitting Diagnoses: [REDACTED].>1. Urinary tract infection present on admission, complicated. 2. Malpositioned suprapubic catheter. 3. Left Kidney Stone. Hospital Course: The patient was admitted to the floor on broad-spectrum antibiotics therapy .Final cultures revealed Pseudomonas aeruginosa, Proteus mirabilis and [MEDICATION NAME] feacalis (Note: bacteria typically found in fecal material) .(Resident's Urologist) was consulted regarding the kidney stone and a suprapubic catheter malplacement. A CT scan ordered to evaluate suprapubic catheter did demonstrate malpositioning and high density material in the bladder, likely blood products. After repositioning he does have a left kidney (stone) but will need an outpatient [MEDICAL CONDITION] preoperative clearance prior to considering nephrolithotripsy. During an interview on 2/22/18 at 9:32 a.m., WCD denied knowledge that Resident #49's catheter had been inserted improperly. He stated he had heard something about the catheter being pulled down into the urethra, but (he didn't) remember much about it. He confirmed the nursing documentation regarding the catheter change was lacking because it failed to clearly document the time of the change, whether there was resistance during the insertion, or urine return upon insertion. When asked how far a suprapubic catheter should be inserted, he stated, 2-4 inches. When asked if bleeding, severe pain, and no urine output are signs of an improperly placed catheter, he stated, yes. When shown the CT Scan Report requesting the catheter be retracted 16.5cm (almost 6.5 inches) and asked whether the catheter was incorrectly placed, he stated, yeah, I guess it would be .substantially too far. It's safe to say. It's common sense. When asked in his nursing judgment if there was any way the catheter balloon being inflated in the penis could happen other than improper placement, he denied knowledge of any other causes. He confirmed he had not seen the hospital medical records. He confirmed the facility had not investigated the incident. He confirmed he investigates nursing issues related to care and neglect. During an interview on 2/22/18 at 10:24 a.m., DON confirmed she was unaware of any complications with catheters in the facility. She confirmed nursing documentation should include whether there was resistance during the insertion, or urine return upon insertion. When asked how far a suprapubic catheter should be inserted, she stated, look for some urine, you don't need to go in very far. It's right there .3-4 inches in. When asked what are the complications of an improperly placed catheter, she stated, pain, a lot of pain, and no urine. When asked what a prudent nurse should do if presented with pain, bleeding, and no urine output, she stated, stop what you are doing, and call and get help .the nurse practitioner, doctor, another nurse, somebody. When shown the CT Scan Report recommended retracting the suprapubic catheter 16.5 cm and asked if that indicated the catheter was inserted way too far, she stated, yes. When asked what complications can result from inflation of the catheter bulb in the penis, she stated, pain, inability to urinate, a lot of distention, risk of infection and necrosis (death of the urethra and penile tissue). She confirmed he had not seen the hospital medical records. She confirmed the facility had not investigated the incident. During an interview on 2/22/18 at 2:38 p.m., MD denied being informed by administration about ER findings when Resident # 49 was sent to the hospital. He stated he found out that the suprapubic catheter had been placed incorrectly by a floor nurse several days after Resident # 49 arrived back at the facility. He confirmed at a minimum he should have been informed by administration that Resident #49 required admission to the hospital and treatment for [REDACTED]. During an interview on 2/23/18 at 9:16 a.m., LVN G confirmed the facility provided no formal training on suprapubic catheter care, maintenance or insertion. She denied a skills check off during orientation, and she denied caring for a resident with a suprapubic catheter during her orientation. She stated she was not familiar with the term suprapubic catheter and does not know the difference between suprapubic and indwelling catheter. During an interview on 2/23/18 at 9:18 a.m., WCD confirmed the facility provided no additional training for suprapubic catheters, except during the 3 day orientation that nurses receive. He confirmed no check-off training had occurred because nurses are taught in school. He stated the facility was aware Resident #49 had went to the hospital on [DATE] because hospitalization s are covered in the morning administrative meeting. He stated he found out in the morning meeting way after he went to the hospital they thought the catheter put in and blown up in the penis. He stated, he dismissed the idea because it would have to be improperly inserted to have been so far in that the bulb was inflated in his penis. He stated had he known he would have done an in-service immediately. As far as he knew, Resident #49 was fine when he got back. He confirmed he had no idea how far the catheter was inserted into Resident #49, the bulb was inflated in his penis, or that he had a kidney stone until the Survey Team presented the hospital CT Scan Report on 2/22/18. During an interview on 2/23/18 at 9:55 a.m., LVN H denied any formal facility-provided training regarding suprapubic catheters. She stated the only training provided was three days of orientation, and she stated she did not care for a resident with a suprapubic catheter. During an interview on 2/26/18 at 10:36 a.m., LVN B stated she was the night nurse that relieved LVN A. She stated LVN A had reported that she had changed Resident # 49's suprapubic catheter, and subsequent to the catheter change, he had pain, bleeding, and decreased urine output. She stated, as soon as I got report, his wife came and got me. He was having significant pain, and I contacted the provider and transferred him quickly. She denied knowledge of the ultimate disposition of Resident #49 because he was admitted . When informed that the catheter had been threaded into and inflated in his penis. LVN B gasped, and stated, oh my. When asked if pain, bleeding, and decreased urine output were symptoms of an improperly inserted catheter, she stated, Yes, they are. When asked if the only way the catheter bulb could be inflated in the penis was that it was the catheter was improperly inserted, she stated, definitely. When asked if retracting the catheter 16.5 cm shows that the catheter was inserted improperly, she stated further, I have changed his suprapubic several times, you only have to insert it 2-3 inches. Record Review of the facility's policy for Supra-Pubic Catheter Care, dated 9/24/11, stated: Policy: To cleanse and maintain hygiene of suprapubic catheter stoma. To remove mucous from around supra-pubic catheter to prevent excoriation, inflammation and discomfort. Record review of the facility's policy for Supra-Pubic Catheter Reinsertion, dated 9/24/11, stated: Policy: Supra-pubic catheter will be reinserted into the bladder to resume continuous urinary drainage in accordance with a physician order. Procedure: 12. Insert lubricated tip of catheter approximately 1 ½ inches into the opening. Do not force if there is resistance. Notify MD if resistance is identified. 13. When urine has ceased flowing, insert amount of sterile water needed to inflate the balloon. Note: -This procedure should not be painful. If the resident experiences pain, stop the procedure until the source of pain is discovered. -The Supra-pubic catheter and drainage bag is a closed sterile system. This system must remain closed as much as possible. The facility DON was notified on 2/23/18 at 11:40 a.m. that an Immediate Jeopardy situation had been identified due to the above failures. During an interview on 2/27/18 at 10:35 a.m., DON was asked How do you think this incident (Immediate Jeopardy) related to catheter care came about? She stated, I have never had an IJ. I don't think it happened. I don't think it happened. I have known this nurse for years. She said she didn't insert it in that far. I believe her. DON was asked What resources are available for the staff and facility to ensure proper suprapubic catheter care? She stated, To be truthful, we never thought about it being an issue. All this time it wasn't an issue; it only became an issue when he was discharged . There was never a grievance filed. They (Resident #49 and his ex-wife) never complained when he returned from the hospital. Maybe we should have done some training, but they learn that in school. The facility submitted their Plan of Removal on 2/23/18 at 5:16 p.m. and it was accepted on 2/26/18 at 10:00 a.m. The Plan of Removal documented the following: Plumcreek Residence Amarillo, name changed to Landmark of Amarillo No Suprapubic catheters will be changed in this facility. If catheter needs to be changed resident will be taken to urologist for procedure. All nurses are currently being inserviced on new procedure/policy and will complete competency evaluations for catheter care within 24 hours beginning at 1300 (1:00 pm) on Friday, February 23rd. Failure to complete this requirement will result in removal from schedule until above stated requirements are met. The specific resident affected, and the single resident who had a suprapubic catheter is no longer in the facility. The incident occurred in November with no complain or concerns voiced by resident or family at that time. There are 8 residents currently in the facility who have foley catheters. ADON's are assessing them related to their catheters and the catheter care at this time. The assessments will be completed by 1400 (2:00 pm), Friday February 23rd. The Policy concerning catheter care is currently being revised to address that this facility will no longer change suprapubic catheters and will transport to urologist or ER for this care. Orientation of new hire nurses will include specific instructions about not changing suprapubic catheters and instructions and competency checkoffs for other urinary catheters before being released to work on the floors and within 3 days of floor orientation. Affirmation that all current nursing staff have completed the competency checkoff and have been inserviced about not changing suprapubic catheters will be confirmed by the signature of every nurse on said forms which will be reviewed by the DON or designed by 1500 (3:00 pm) Saturday February 23rd. Affirmation that all new hire nurses have been inserviced on the policy and checked off on the competency form will also be confirmed by each signature. This will be monitored by the DON or designee. Anytime a nurse perceives that there may be an issue or event concerning a catheter, he/she will notify the ADON or ADON on call. The ADON will instruct the nurse on how to proceed or contact the DON or designee for directions. All nursing staff will be trained to assess for potential negative reactions to improperly inserted catheters, malfunction of catheter, displacement of cathter or other anomalies related to catheter and care including urinary tract infections, [MEDICATION NAME], urethral injury, blood infection, bacteriuria, blood in the urine, injury to the urethra, kidney damage, and or [MEDICAL CONDITION]. This training will be completed by March 1st, 2018. Any time an unusual event occurs or a nurse does not feel comfortable or does not feel that she/he has adequate training for the task needing to be completed, that nurse should contact the ADON for that unit or after hours the ADON on call before proceeding. The ADON will then immediately contact the DON or designee. The survey Team confirmed that the facility's plan of removal was implemented on 2/26/18 as evidenced by: 1) Interviews with 5 licensed nurses and registered nurses to confirm the additional training regarding catheters had been performed. 2) Interviews with 2 administrative staff to confirm the LVN A had been trained regarding catheter care, changes, positioning and new policy implementation. 3) Interviews with 5 licensed nurses and registered nurses to confirm they had been educated on the implementation of the new policy to send residents to the emergency room for catheter changes. During an interview on 2/26/18 at 10:30 a.m., DON was informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm with a scope identified as pattern. The facility was continuing to monitor to ensure assessments for side rails were accurate for all residents. The facility was continuing to monitor to ensure catheter care in accordance with professional standards for all residents. Review of the facility provided CMS form 802 Roster/Sample Matrix, dated 2/20/18, documented 9 residents with catheters.

Based on interview and record review it was determined the facility failed to, based on the comprehensive assessment of a resident, ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 4 of 23 residents reviewed for Quality of Care (Resident #25, Resident #47, Resident #49 and Resident #61). LVN A incorrectly inserted a suprapubic catheter (a catheter to drain urine that inserts a few inches through a stoma on the abdomen into the bladder) and threaded the catheter 16.5cm (6.5 inches) too far and inflated the catheter bulb in Resident #49's penis causing pain, bleeding, and decreased urinary output. Resident #49 required transfer to the local emergency room for treatment and admission on 11/5/18 through 11/8/18. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 2/23/18 that occurred on 11/5/17. While the IJ was removed on 2/26/18, the facility remained out of compliance at a severity of actual harm with a scope identified as pattern. The facility was continuing to monitor to ensure catheter care in accordance with professional standards for all residents. Non IJ: Resident #25 was prescribed the blood thinner Eliquis. She has a history of [MEDICAL CONDITION], requiring blood [MEDICAL CONDITION]. The facility failed to ensure Resident #25's critical lab values indicating severe [MEDICAL CONDITION] were immediately reported to the physician. The facility failed to implement Resident #47's physician orders [REDACTED]. Resident #61's breathing treatments were not administered as ordered, and he was observed with wheezing and shortness of breath. The facility's failure to ensure each resident received the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being could place 9 residents requiring catheter care at risk for pain, [MEDICAL CONDITION], genital-urinary trauma, [MEDICAL CONDITION], blood loss, shock, and death; 65 residents requiring oral medications at risk for medication errors, lack of medical treatment, improper medical treatment, [MEDICAL CONDITION], toxic or non-therapeutic medication levels, and death; 65 residents requiring routine or stat lab work at risk for medication errors, lack of medical treatment, improper medical treatment, [MEDICAL CONDITION], toxic or non-therapeutic medication levels,[MEDICAL CONDITION], and death; and 12 residents receiving respiratory therapy at risk for shortness of breath, respiratory infections, low blood oxygen levels, [MEDICAL CONDITION], cardiac arrhythmias, and death. Findings include: Record Review of Resident #49's clinical record revealed: Resident #49 is a [AGE] year old male with an admission date of [DATE], a readmission date of [DATE], and was transferred to another nursing facility on 2/22/18. He had [DIAGNOSES REDACTED]. Record Review of the care plan for Resident #49, dated 1/22/18, stated: Resident #49 has limited mobility, requires a Hoyer lift for transfers, has an ADL deficit requiring at least 2 person assist, has pain, depression, requires adaptive equipment to assist with eating, has a suprapubic catheter, is at risk for injuries related to diabetes and hypertension, and is at risk for weight loss and pressure sores. Record Review of Resident #49's MDS, dated [DATE], stated: Resident #49 has BIMS-15, indicating no cognitive impairment; Depression-8; no behaviors; requires total 2 person assist for all bed mobility, transfers, dressing, toileting, ADLs, and bathing; requires extensive 1 person assist for hygiene; requires a wheelchair of mobility; has bilateral upper and lower extremity impairment; has an indwelling catheter; is always continent of bowel; has occasional complaints of pain requiring medication; and is at risk pressure sores. During an interview on 2/20/18 at 3:27 p.m., Resident #49 was asked about any care issues during his stay at the facility. He stated he had some problems and stated, one of the nurses came in on the weekend (11/5/17), and she changed (the suprapubic catheter) around lunch time, but she didn't do it right. I had to go to the hospital, and I was there for 4 days for bleeding and an infection in my bladder. During an interview on 2/23/18 at 11:20 a.m., LVN A stated she wasn't comfortable changing that (suprapubic) catheter because Resident #49 was having bladder spasms. She confirmed there was a standing order to change the catheter as needed. She stated she contacted the on call provider and received an order for [REDACTED].#49 had severe pelvic pain and blood in his urine. She stated the facility had not provided any additional training on inserting, changing or care of suprapubic catheters. When asked if she had changed suprapubic catheters before, she stated, I'm not new to this. When asked how far the suprapubic catheter tubing should be inserted, she stated, 1.5 to 2 inches is the normal length. LVN A was informed the catheter had been inserted and the CT Scan showed the catheter bulb was inflated in his penis, and the catheter required retracting 16.5 cm. She stated, Wow, I didn't know that. It wasn't that way when he went out. LVN A confirmed she was not the nurse who transferred Resident #49 to the ER. Review of Facility Nurses' Notes revealed: 11/5/2017 at 6:38 p.m.: Nursing Progress Note: 2:24 p.m. Contacted NP due to patient complaining of severe bladder spasms, pain scale 10/10, yelling for help and called wife crying. NP gave orders to give [MEDICATION NAME] 10mg one by mouth every 12 hours. Resident given Tylenol #3 at 3:00 p.m., was effective with pain management, pain scale 4/10 after 30 minutes of administration. No further complaints of pain at this time. 6:48 p.m. Patient did receive catheter change per their (Resident and his ex-wife) demand. Patient thought it would stop bladder spasms, they continue with leakage of urine tinged pink blood. At 5:41 p.m., NP notified of bladder spasms continue with urine tinged pink blood approximately size of 8-9 sock on sheet noted. (This is how the nurse described the size of the blood.) NP advised to continue to monitor, bleeding should stop on its own in a couple of days, if becomes red staff to contact provider. (Resident #49's daughter) notified of bladder spasms continue with leakage of urine with tinged pink blood and NP notified. (Sic)- LVN A 11/5/2017 at 9:58 p.m.: Nursing Progress Note: Resident called this nurse into his room at 7:15 p.m. this evening complaining of severe bladder spasm's pain scale 8/10 resident is crying and asking for help this nurse called nurse practitioner on call and received orders to send resident out to emergency room (ER) wife at bedside agreed that she does want resident to go to ER. This nurse called non emergent (EMS) at 7:30 p.m. they arrived on unit at 7:46 p.m. and left facility at 8:00 p.m. will continue to monitor closely. (Sic) - LVN B Review of Resident #49's Hospital Medical Record revealed: Record Review of the Physician History and Physical, dated 11/5/17, revealed: Chief Complaint: Problems with urinary catheter pain after placement. History of present illness: This is a [AGE] year old very pleasant gentleman who has [MEDICAL CONDITION] and is in a nursing home. He is non-ambulatory apparently has a suprapubic catheter and this was replaced today at the nursing home, then he had problems with pain eventually calling EMS to send him to the emergency room . On arrival there, EMS noted that there was no drainage from the catheter, he was brought to the ER and evaluation revealed a suprapubic catheter was actually placed in the suprapubic opening and then went into the penile urethra. This was repositioned. A CT scan was performed that showed this, and he was noted to have a (kidney stone). There was a significant amount of bleeding associated with the repositioning of the catheter, as the balloon was blown up partially in the penile urethra. The patient was noted to have a significant amount of pyuria and bacteriuria, which you would expect from a chronic indwelling catheter, but he also had a 20,000 white count. He has not had any fever, chills or associated symptoms. (Sic). Impression/Plan: 1. UTI present on admission. The patient has a chronic suprapubic catheter, but has a 20,000 white count that seems like the only source of his urine .He also has a UTI with [MEDICATION NAME]. 2. Malpositioned suprapubic catheter: This has been repositioned. If problems with drainage, it may need to be flushed. 3. Staghorn calculus in the left kidney. (Sic). Record Review of the ER Nurses' Notes, dated 11/5/17, revealed: 8:19 p.m.: Patient to ER 35 via EMS stretcher. 8:35 p.m.: To CT via stretcher. 10:00 p.m.: Catheter balloon emptied and catheter pulled back slightly to remove from urethra. Per Dr. orders. Catheter flushed and blood with clots came out of penis. Catheter flushed 2 more times with 20 ml of sterile water until blood and clots removed from Foley tubing. Balloon reinflated with removed fluid from deflation. Record Review of CT Cystogram Pelvis Report, dated 11/6/17, revealed: Findings: CT images demonstrate the presence of a suprapubic catheter. The catheter extends through the lumen of the urinary bladder and into the base of the penis. The Foley balloon tipped has been inflated at the base of the penis and repositioning is recommended. Conclusion: 1. Distal tip of the suprapubic catheter extends into the base of the penis. The balloon is insufflated (inflated). Recommend deflation and withdrawal of the catheter by approximately 16.5 cm. Record Review of Physician Consultation Report, dated 11/6/17, revealed: History of present illness: [AGE] year old male who was admitted for UTI. He was noted to have a non-draining suprapubic tube. It previously had been replaced yesterday at the nursing home. It never drained well. A CT scan showed the suprapubic tube had tracked down the penile urethra. The balloon was deflated, repositioned and it is draining now. He states his pain has resolved. Record Review of the Physician Discharge Summary, dated 11/9/17, revealed: Admitting Diagnoses: [REDACTED].>1. Urinary tract infection present on admission, complicated. 2. Malpositioned suprapubic catheter. 3. Left Kidney Stone. Hospital Course: The patient was admitted to the floor on broad-spectrum antibiotics therapy .Final cultures revealed Pseudomonas aeruginosa, Proteus mirabilis and [MEDICATION NAME] feacalis (Note: bacteria typically found in fecal material) .(Resident's Urologist) was consulted regarding the kidney stone and a suprapubic catheter malplacement. A CT scan ordered to evaluate suprapubic catheter did demonstrate malpositioning and high density material in the bladder, likely blood products. After repositioning he does have a left kidney (stone) but will need an outpatient [MEDICAL CONDITION] preoperative clearance prior to considering nephrolithotripsy. During an interview on 2/22/18 at 9:32 a.m., WCD denied knowledge that Resident #49's catheter had been inserted improperly. He stated he had heard something about the catheter being pulled down into the urethra, but (he didn't) remember much about it. He confirmed the nursing documentation regarding the catheter change was lacking because it failed to clearly document the time of the change, whether there was resistance during the insertion, or urine return upon insertion. When asked how far a suprapubic catheter should be inserted, he stated, 2-4 inches. When asked if bleeding, severe pain, and no urine output are signs of an improperly placed catheter, he stated, yes. When shown the CT Scan Report requesting the catheter be retracted 16.5cm (almost 6.5 inches) and asked whether the catheter was incorrectly placed, he stated, yeah, I guess it would be .substantially too far. It's safe to say. It's common sense. When asked in his nursing judgment if there was any way the catheter balloon being inflated in the penis could happen other than improper placement, he denied knowledge of any other causes. He confirmed he had not seen the hospital medical records. During an interview on 2/22/18 at 10:24 a.m., DON confirmed she was unaware of any complications with catheters in the facility. She confirmed nursing documentation should include whether there was resistance during the insertion, or urine return upon insertion. When asked how far a suprapubic catheter should be inserted, she stated, look for some urine, you don't need to go in very far. It's right there .3-4 inches in. When asked what are the complications of an improperly placed catheter, she stated, pain, a lot of pain, and no urine. When asked what a prudent nurse should do if presented with pain, bleeding, and no urine output, she stated, stop what you are doing, and call and get help .the nurse practitioner, doctor, another nurse, somebody. When shown the CT Scan Report recommended retracting the suprapubic catheter 16.5 cm and asked if that indicated the catheter was inserted way too far, she stated, yes. When asked what complications can result from inflation of the catheter bulb in the penis, she stated, pain, inability to urinate, a lot of distention, risk of infection and necrosis (death of the urethra and penile tissue). She confirmed he had not seen the hospital medical records. During an interview on 2/22/18 at 2:38 p.m., MD denied being informed by administration about ER findings when Resident #49 was sent to the hospital. He stated he found out that the suprapubic catheter had been placed incorrectly by a floor nurse several days after Resident #49 arrived back at the facility. He confirmed at a minimum he should have been informed by administration that Resident #49 required admission to the hospital and treatment for [REDACTED]. During an interview on 2/23/18 at 9:16 a.m., LVN G confirmed the facility provided no formal training on suprapubic catheter care, maintenance or insertion. She denied a skills check off during orientation, and she denied caring for a resident with a suprapubic catheter during her orientation. She stated she was not familiar with the term suprapubic catheter and does not know the difference between suprapubic and indwelling catheter. During an interview on 2/23/18 at 9:18 a.m., WCD confirmed the facility provided no additional training for suprapubic catheters, except during the 3 day orientation that nurses receive. He confirmed no check-off training had occurred because nurses are taught in school. He stated the facility was aware Resident #49 had went to the hospital on [DATE] because hospitalization s are covered in the morning administrative meeting. He stated he found out in the morning meeting way after he went to the hospital they thought the catheter put in and blown up in the penis. He stated, he dismissed the idea because it would have to be improperly inserted to have been so far in that the bulb was inflated in his penis. He stated had he known he would have done an in-service immediately. As far as he knew, Resident #49 was fine when he got back. He confirmed he had no idea how far the catheter was inserted into Resident #49, the bulb was inflated in his penis, or that he had a kidney stone until the Survey Team presented the hospital CT Scan Report on 2/22/18. During an interview on 2/23/18 at 9:55 a.m., LVN H denied any formal facility-provided training regarding suprapubic catheters. She stated the only training provided was three days of orientation, and she stated she did not care for a resident with a suprapubic catheter. During an interview on 2/26/18 at 10:36 a.m., LVN B stated she was the night nurse that relieved LVN A. She stated LVN A had reported that she had changed Resident #49's suprapubic catheter, and subsequent to the catheter change, he had pain, bleeding, and decreased urine output. She stated, as soon as I got report, his wife came and got me. He was having significant pain, and I contacted the provider and transferred him quickly. She denied knowledge of the ultimate disposition of Resident #49 because he was admitted . When informed that the catheter had been threaded into and inflated in his penis. LVN B gasped, and stated, oh my. When asked if pain, bleeding, and decreased urine output were symptoms of an improperly inserted catheter, she stated, Yes, they are. When asked if the only way the catheter bulb could be inflated in the penis was that it was the catheter was improperly inserted, she stated, definitely. When asked if retracting the catheter 16.5 cm shows that the catheter was inserted improperly, she stated further, I have changed his suprapubic several times, you only have to insert it 2-3 inches. Record Review of the facility's policy for Supra-Pubic Catheter Care, dated 9/24/11, stated: Policy: To cleanse and maintain hygiene of suprapubic catheter stoma. To remove mucous from around supra-pubic catheter to prevent excoriation, inflammation and discomfort. Record review of the facility's policy for Supra-Pubic Catheter Reinsertion, dated 9/24/11, stated: Policy: Supra-pubic catheter will be reinserted into the bladder to resume continuous urinary drainage in accordance with a physician order. Procedure: 12. Insert lubricated tip of catheter approximately 1 ½ inches into the opening. Do not force if there is resistance. Notify MD if resistance is identified. 13. When urine has ceased flowing, insert amount of sterile water needed to inflate the balloon. Note: -This procedure should not be painful. If the resident experiences pain, stop the procedure until the source of pain is discovered. -The Supra-pubic catheter and drainage bag is a closed sterile system. This system must remain closed as much as possible. The facility DON was notified on 2/23/18 at 11:40 a.m. that an Immediate Jeopardy situation had been identified due to the above failures. During an interview on 2/27/18 at 10:35 a.m., DON was asked How do you think this incident (Immediate Jeopardy) related to catheter care came about? She stated, I have never had an IJ. I don't think it happened. I don't think it happened. I have known this nurse for years. She said she didn't insert it in that far. I believe her. DON was asked What resources are available for the staff and facility to ensure proper suprapubic catheter care? She stated, To be truthful, we never thought about it being an issue. All this time it wasn't an issue; it only became an issue when he was discharged . There was never a grievance filed. They (Resident #49 and his ex-wife) never complained when he returned from the hospital. Maybe we should have done some training, but they learn that in school. The facility submitted their Plan of Removal on 2/23/18 at 5:16 p.m. and it was accepted on 2/26/18 at 10:00 a.m. The Plan of Removal documented the following: Plumcreek Residence Amarillo, name changed to Landmark of Amarillo No Suprapubic catheters will be changed in this facility. If catheter needs to be changed resident will be taken to urologist for procedure. All nurses are currently being inserviced on new procedure/policy and will complete competency evaluations for catheter care within 24 hours beginning at 1300 (1:00 pm) on Friday, February 23rd. Failure to complete this requirement will result in removal from schedule until above stated requirements are met. The specific resident affected, and the single resident who had a suprapubic catheter is no longer in the facility. The incident occurred in November with no complain or concerns voiced by resident or family at that time. There are 8 residents currently in the facility who have foley catheters. ADON's are assessing them related to their catheters and the catheter care at this time. The assessments will be completed by 1400 (2:00 pm), Friday February 23rd. The Policy concerning catheter care is currently being revised to address that this facility will no longer change suprapubic catheters and will transport to urologist or ER for this care. Orientation of new hire nurses will include specific instructions about not changing suprapubic catheters and instructions and competency checkoffs for other urinary catheters before being released to work on the floors and within 3 days of floor orientation. Affirmation that all current nursing staff have completed the competency checkoff and have been inserviced about not changing suprapubic catheters will be confirmed by the signature of every nurse on said forms which will be reviewed by the DON or designed by 1500 (3:00 pm) Saturday February 23rd. Affirmation that all new hire nurses have been inserviced on the policy and checked off on the competency form will also be confirmed by each signature. This will be monitored by the DON or designee. Anytime a nurse perceives that there may be an issue or event concerning a catheter, he/she will notify the ADON or ADON on call. The ADON will instruct the nurse on how to proceed or contact the DON or designee for directions. All nursing staff will be trained to assess for potential negative reactions to improperly inserted catheters, malfunction of catheter, displacement of cathter or other anomalies related to catheter and care including urinary tract infections, [MEDICATION NAME], urethral injury, blood infection, bacteriuria, blood in the urine, injury to the urethra, kidney damage, and or [MEDICAL CONDITION]. This training will be completed by March 1st, 2018. Any time an unusual event occurs or a nurse does not feel comfortable or does not feel that she/he has adequate training for the task needing to be completed, that nurse should contact the ADON for that unit or after hours the ADON on call before proceeding. The ADON will then immediately contact the DON or designee. The survey Team confirmed that the facility's plan of removal was implemented on 2/26/18 as evidenced by: 1) Interviews with 5 licensed nurses and registered nurses to confirm the additional training regarding catheters had been performed. 2) Interviews with 2 administrative staff to confirm the LVN A had been trained regarding catheter care, changes, positioning and new policy implementation. 3) Interviews with 5 licensed nurses and registered nurses to confirm they had been educated on the implementation of the new policy to send residents to the emergency room for catheter changes. During an interview on 2/26/18 at 10:30 a.m., DON was informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm with a scope identified as pattern. The facility was continuing to monitor to ensure assessments for side rails were accurate for all residents. The facility was continuing to monitor to ensure catheter care in accordance with professional standards for all residents. Non-IJ Findings: Resident #25 Record Review of Resident #25's clinical record revealed: Resident #25 is a [AGE] year old female with an admission date of [DATE]. She has [DIAGNOSES REDACTED]. Record Review of the care plan for Resident #25, dated 1/15/18, stated: Resident #25 has on ADL deficit, has pain, depression, is at risk for injuries related to heart failure, arrhythmia and hypertension, and is at risk for contracture, thrombus, falls and pressure sores. Record Review of Resident #25's Physician Orders, dated 8/29/17, stated: Eliquis 5mg by mouth 2 times a day for blood thinner. Record Review of Resident #25's MAR, dated 8/30/17 to present, stated: Eliquis 5mg by mouth 2 times a day for blood thinner has been given on a consistent twice a day basis. Record Review of Resident #25's Complete Blood Count, dated 12/2/17, stated: Red Blood Cells: 3.32 (Low) Normal Range: 4.8-10.1 Hemoglobin: 8.7 (Low) Normal Range: 12.0-16.0 Hematocrit: 28.2 (Low) Normal Range: 37.0-47.0 (Note: NP initialed and dated lab report 12/27/18, indicating labwork was reviewed 25 days after reported to the facility.) Record Review of the Nurses' Notes for 12/2/17 - 12/27/17 do not indicate Resident #25's physician was notified of the critical lab results indicating severe [MEDICAL CONDITION]. During an interview on 2/22/18 at 11:23 a.m., DON confirmed Reviewed #25's past facility [DIAGNOSES REDACTED]. She confirmed the order dated and signed 8/29/17 by Resident #25's Physician for Eliquis 5mg by mouth twice daily and current MAR for continued administration of the medication. When asked about the lab results reported to the facility on [DATE] with red blood cell count of 3.32, hemoglobin of 8.7, and hematocrit of 28.2 that was addressed by NP on 12/27/17, she responded, That sounds like she needed a fill up-(blood) transfusion. When asked what the process is to handle lab results, she stated, They are put in a folder and left at the nurses stations. The nurse practitioners are supposed to look at them when they come in. During an interview on 2/22/18 at 2:39 p.m., MD was asked about the lab work indicating severe [MEDICAL CONDITION] on 12/2/18, and the failure to notify the physician for 25 days. He stated, I would have to review my notes and look at that situation plus review if her cardiologist is involved. I will have my PA come up and address it probably later this week or the first of next week. During an interview on 2/23/18 at 8:48 a.m., DON notified Survey Team that PA visited resident last night and discussed the issue with her and new orders were received. During an interview on 2/23/18 at 9:14 a.m., Resident #25 stated the PA saw her last night and discussed her blood loss. She stated, It's been a long time problem for me. I usually have to have 2-3 transfusion each year because of it. It can be a real problem because I tend to get weak from it, and my back will hurt more. I have never been asked about it here, especially by MD. When asked about treatment for [REDACTED]. (PA) said, 'he is going to restart it'. When asked if she has had repeat lab work drawn today, she stated, No. During an interview on 2/23/18 at 10:25 a.m., DON verified that she stated yesterday that they handle the lab reports by putting them in a folder and leaving them at the nurses station for the PA or NP to evaluated when they come in. She stated Yes, that is exactly what we do. When asked if they have an official policy regarding this procedure, she stated, she Wasn't sure. She would have to check with the management company and see if they had one and get if faxed over. Resident #47: Record Review of Resident #47's clinical record revealed: Resident #47 is a [AGE] year old male with an admission date of [DATE], a readmission date of [DATE]. He has [DIAGNOSES REDACTED]. Record Review of Resident #47's Care Plans from 8/29/17 do not address Resident #47's [MEDICAL CONDITION]. Record Review of Resident #47's Dietary Consult Form, dated 1/4/18, stated: Concerns: Abnormal Labs: Hemaglobin-13.1 and Hematocrit-40.3 MD Approval: Dated and signed order by NP on 1/15/17 for Iron Sulfate 325mg by mouth once daily. Record Review of Resident #47's MAR from 1/15/18 to present, stated: No implementation or administration of Iron Sulfate 325mg by mouth once daily. During an interview on 2/22/18 at 11:21 a.m., DON verified the order for Iron Sulfate 325mg by mouth every day ordered on [DATE] by NP for the [DIAGNOSES REDACTED]. After verifying my information and checking her records in her office, she stated, I do not have a record of that anywhere. I cannot answer that (why it was not started). It should have been done. Resident #61: Record Review of Resident #61's clinical record revealed: Resident #61 is a [AGE] year old male with an admission date of [DATE] with a readmission date of [DATE]. He has [DIAGNOSES REDACTED]. Record Review of Resident #61's MDS, dated [DATE], stated: Resident #61 has a BIMS-15, indicating no cognitive deficit; Depression-2; requires extensive 1 person assist for all ADL's, dressing, hygiene, transfers and bathing; uses a wheelchair for mobility; has occasional complaints of pain requiring medication; and at risk for weight loss and pressure sores. Record Review of Resident #61's Care Plan, dated 12/29/17, stated: Resident #61 has impaired cognition, occasionally refuses care, depression, has profound [MEDICAL CONDITION] requiring a brain stimulator and medication, has weight loss, has pain, anxiety, and falls, has an ADL deficit requiring at least 1 person assist, and is at risk for falls, choking, dehydration and pressure sores. Record Review of Resident #61's Physician Orders, dated 2/1/18 - 2/28/18, stated: [MEDICATION NAME]-[MEDICATION NAME] Solution 0.5/2.5 (3mg/3ml) 3ml inhale orally every 6 hours. Record Review of Resident #61's MAR indicated [REDACTED] [MEDICATION NAME]-[MEDICATION NAME] Solution 0.5/2.5 (3mg/3ml) 3ml inhale orally every 6 hours at midnight, 6:00 a.m., 12:00 p.m., and 6:00 p.m. On 2/1/18 - 2/9/18, the MAR indicated [REDACTED]. On 2/3/18 and 2/4/18, the MAR indicated [REDACTED] On 2/9/18, the MAR indicated [REDACTED] On 2/14/18 and 2/16/18, the MAR indicated [REDACTED]. All other doses are documented as administered at the appropriate time. No breathing treatment was documented as given on 2/20/18 at 9:55 a.m. Record Review of Resident #61's Nebulizer Missed Doses, dated 2/1/18 - 2/28/18, stated: 2/6/18 - 2/9/18 indicate Resident #61 refused the treatments. No other documentation of refusal of treatments was found. During an observation on initial tour on 2/20/18 at 9:40 a.m., Resident #61 was having wheezing and accessory muscle usage, indicating shortness of breath. During a simultaneous interview, Resident #61 complained of shortness of breath. When asked when his last breathing treatment was, he stated he has not had a breathing treatment since yesterday evening. He stated his family member infirmed the nurse of his shortness of breath. During an observation on 2/20/18 at 10:10 a.m., Resident #61 was receiving a breathing treatment. He confirmed the breathing treatment began at 9:55 a.m. During an interview on 2/20/18 10:20 AM Spoke with LVN H and she stated Resident #61 was given breathing treatment about 10 till 10. She confirmed this was the first breathing treatment given today. During an interview on 2/21/18 at 11:15 a.m., LVN Q confirmed the Nebulizer Treatment Record and TAR are the only places that breathing treatments are charted. When asked about the process if a treatment is missed, she stated the time should be circled, and documentation why the treatment was missed written on the back page of the nebulizer treatment record. During an interview on 2/21/18 at 11:47 a.m., MA N was shown the nebulizer treatment record and asked about the blank spaced. She confirmed nurses give breathing treatments, not the medication aides. When shown the blank spots, she stated, The nurses aren't giving the treatments at those times. During a simultaneous Record Review of Resident #61's T (TRUNCATED)

Based on interview and record review it was determined the facility failed to ensure residents who are incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 23 residents reviewed for catheters (Resident #49). LVN A incorrectly inserted a suprapubic catheter (a catheter to drain urine that inserts a few inches through a stoma on the abdomen into the bladder) and threaded the catheter 16.5cm (almost 6.5 inches) too far and inflated the catheter bulb in Resident #49's penis. Resident #49 required transfer to the local emergency room for treatment and admission on 11/5/18 through 11/8/18. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 2/23/18 that occurred on 11/5/17. While the IJ was removed on 2/26/18, the facility remained out of compliance at a severity of actual harm with a scope identified as pattern. The facility was continuing to monitor to ensure catheter care in accordance with professional standards for all residents. The facility's failure to ensure all residents were free from neglect could place 9 residents requiring catheter care at risk for pain, [MEDICAL CONDITION], genital-urinary trauma, [MEDICAL CONDITION], blood loss, shock, and death. Findings include: Record Review of Resident #49's clinical record revealed: Resident #49 is a [AGE] year old male with an admission date of [DATE], a readmission date of [DATE], and was transferred to another nursing facility on 2/22/18. He had [DIAGNOSES REDACTED]. Record Review of the care plan for Resident #49, dated 1/22/18, stated: Resident #49 has limited mobility, requires a Hoyer lift for transfers, has an ADL deficit requiring at least 2 person assist, has pain, depression, requires adaptive equipment to assist with eating, has a suprapubic catheter, is at risk for injuries related to diabetes and hypertension, and is at risk for weight loss and pressure sores. Record Review of Resident #49's MDS, dated [DATE], stated: Resident #49 has BIMS-15, indicating no cognitive impairment; Depression-8; no behaviors; requires total 2 person assist for all bed mobility, transfers, dressing, toileting, ADLs, and bathing; requires extensive 1 person assist for hygiene; requires a wheelchair of mobility; has bilateral upper and lower extremity impairment; has an indwelling catheter; is always continent of bowel; has occasional complaints of pain requiring medication; and is at risk pressure sores. During an interview on 2/20/18 at 3:27 p.m., Resident #49 was asked about any care issues during his stay at the facility. He stated he had some problems and stated, one of the nurses came in on the weekend (11/5/17), and she changed (the suprapubic catheter) around lunch time, but she didn't do it right. I had to go to the hospital, and I was there for 4 days for bleeding and an infection in my bladder. During an interview on 2/23/18 at 11:20 a.m., LVN A stated she wasn't comfortable changing that (suprapubic) catheter because Resident #49 was having bladder spasms. She confirmed there was a standing order to change the catheter as needed. She stated she contacted the on call provider and received an order for [REDACTED].#49 had severe pelvic pain and blood in his urine. She stated the facility had not provided any additional training on inserting, changing or care of suprapubic catheters. When asked if she had changed suprapubic catheters before, she stated, I'm not new to this. When asked how far the suprapubic catheter tubing should be inserted, she stated, 1.5 to 2 inches is the normal length. LVN A was informed the catheter had been inserted and the CT Scan showed the catheter bulb was inflated in his penis, and the catheter required retracting 16.5 cm. She stated, Wow, I didn't know that. It wasn't that way when he went out. LVN A confirmed she was not the nurse who transferred Resident #49 to the ER. Review of Facility Nurses' Notes revealed: 11/5/2017 at 6:38 p.m.: Nursing Progress Note: 2:24 p.m. Contacted NP due to patient complaining of severe bladder spasms, pain scale 10/10, yelling for help and called wife crying. NP gave orders to give [MEDICATION NAME] 10mg one by mouth every 12 hours. Resident given Tylenol #3 at 3:00 p.m., was effective with pain management, pain scale 4/10 after 30 minutes of administration. No further complaints of pain at this time. 6:48 p.m. Patient did receive catheter change per their (Resident and his ex-wife) demand. Patient thought it would stop bladder spasms, they continue with leakage of urine tinged pink blood. At 5:41 p.m., NP notified of bladder spasms continue with urine tinged pink blood approximately size of 8-9 sock on sheet noted. (This is how the nurse described the size of the blood.) NP advised to continue to monitor, bleeding should stop on its own in a couple of days, if becomes red staff to contact provider. (Resident #49's daughter) notified of bladder spasms continue with leakage of urine with tinged pink blood and NP notified. (Sic)- LVN A 11/5/2017 at 9:58 p.m.: Nursing Progress Note: Resident called this nurse into his room at 7:15 p.m. this evening complaining of severe bladder spasm's pain scale 8/10 resident is crying and asking for help this nurse called nurse practitioner on call and received orders to send resident out to emergency room (ER) wife at bedside agreed that she does want resident to go to ER. This nurse called non emergent (EMS) at 7:30 p.m. they arrived on unit at 7:46 p.m. and left facility at 8:00 p.m. will continue to monitor closely. (Sic) - LVN B Review of Resident #49's Hospital Medical Record revealed: Record Review of the Physician History and Physical, dated 11/5/17, revealed: Chief Complaint: Problems with urinary catheter pain after placement. History of present illness: This is a [AGE] year old very pleasant gentleman who has [MEDICAL CONDITION] and is in a nursing home. He is non-ambulatory apparently has a suprapubic catheter and this was replaced today at the nursing home, then he had problems with pain eventually calling EMS to send him to the emergency room . On arrival there, EMS noted that there was no drainage from the catheter, he was brought to the ER and evaluation revealed a suprapubic catheter was actually placed in the suprapubic opening and then went into the penile urethra. This was repositioned. A CT scan was performed that showed this, and he was noted to have a (kidney stone). There was a significant amount of bleeding associated with the repositioning of the catheter, as the balloon was blown up partially in the penile urethra. The patient was noted to have a significant amount of pyuria and bacteriuria, which you would expect from a chronic indwelling catheter, but he also had a 20,000 white count. He has not had any fever, chills or associated symptoms. (Sic). Impression/Plan: 1. UTI present on admission. The patient has a chronic suprapubic catheter, but has a 20,000 white count that seems like the only source of his urine .He also has a UTI with [MEDICATION NAME]. 2. Malpositioned suprapubic catheter: This has been repositioned. If problems with drainage, it may need to be flushed. 3. Staghorn calculus in the left kidney. (Sic). Record Review of the ER Nurses' Notes, dated 11/5/17, revealed: 8:19 p.m.: Patient to ER 35 via EMS stretcher. 8:35 p.m.: To CT via stretcher. 10:00 p.m.: Catheter balloon emptied and catheter pulled back slightly to remove from urethra. Per Dr. orders. Catheter flushed and blood with clots came out of penis. Catheter flushed 2 more times with 20 ml of sterile water until blood and clots removed from Foley tubing. Balloon reinflated with removed fluid from deflation. Record Review of CT Cystogram Pelvis Report, dated 11/6/17, revealed: Findings: CT images demonstrate the presence of a suprapubic catheter. The catheter extends through the lumen of the urinary bladder and into the base of the penis. The Foley balloon tipped has been inflated at the base of the penis and repositioning is recommended. Conclusion: 1. Distal tip of the suprapubic catheter extends into the base of the penis. The balloon is insufflated (inflated). Recommend deflation and withdrawal of the catheter by approximately 16.5 cm. Record Review of Physician Consultation Report, dated 11/6/17, revealed: History of present illness: [AGE] year old male who was admitted for UTI. He was noted to have a non-draining suprapubic tube. It previously had been replaced yesterday at the nursing home. It never drained well. A CT scan showed the suprapubic tube had tracked down the penile urethra. The balloon was deflated, repositioned and it is draining now. He states his pain has resolved. Record Review of the Physician Discharge Summary, dated 11/9/17, revealed: Admitting Diagnoses: [REDACTED].>1. Urinary tract infection present on admission, complicated. 2. Malpositioned suprapubic catheter. 3. Left Kidney Stone. Hospital Course: The patient was admitted to the floor on broad-spectrum antibiotics therapy .Final cultures revealed Pseudomonas aeruginosa, Proteus mirabilis and [MEDICATION NAME] feacalis (Note: bacteria typically found in fecal material) .(Resident's Urologist) was consulted regarding the kidney stone and a suprapubic catheter malplacement. A CT scan ordered to evaluate suprapubic catheter did demonstrate malpositioning and high density material in the bladder, likely blood products. After repositioning he does have a left kidney (stone) but will need an outpatient [MEDICAL CONDITION] preoperative clearance prior to considering nephrolithotripsy. During an interview on 2/22/18 at 9:32 a.m., WCD denied knowledge that Resident #49's catheter had been inserted improperly. He stated he had heard something about the catheter being pulled down into the urethra, but (he didn't) remember much about it. He confirmed the nursing documentation regarding the catheter change was lacking because it failed to clearly document the time of the change, whether there was resistance during the insertion, or urine return upon insertion. When asked how far a suprapubic catheter should be inserted, he stated, 2-4 inches. When asked if bleeding, severe pain, and no urine output are signs of an improperly placed catheter, he stated, yes. When shown the CT Scan Report requesting the catheter be retracted 16.5cm (almost 6.5 inches) and asked whether the catheter was incorrectly placed, he stated, yeah, I guess it would be .substantially too far. It's safe to say. It's common sense. When asked in his nursing judgment if there was any way the catheter balloon being inflated in the penis could happen other than improper placement, he denied knowledge of any other causes. He confirmed he had not seen the hospital medical records. During an interview on 2/22/18 at 10:24 a.m., DON confirmed she was unaware of any complications with catheters in the facility. She confirmed nursing documentation should include whether there was resistance during the insertion, or urine return upon insertion. When asked how far a suprapubic catheter should be inserted, she stated, look for some urine, you don't need to go in very far. It's right there .3-4 inches in. When asked what are the complications of an improperly placed catheter, she stated, pain, a lot of pain, and no urine. When asked what a prudent nurse should do if presented with pain, bleeding, and no urine output, she stated, stop what you are doing, and call and get help .the nurse practitioner, doctor, another nurse, somebody. When shown the CT Scan Report recommended retracting the suprapubic catheter 16.5 cm and asked if that indicated the catheter was inserted way too far, she stated, yes. When asked what complications can result from inflation of the catheter bulb in the penis, she stated, pain, inability to urinate, a lot of distention, risk of infection and necrosis (death of the urethra and penile tissue). She confirmed he had not seen the hospital medical records. During an interview on 2/22/18 at 2:38 p.m., MD denied being informed by administration about ER findings when Resident # 49 was sent to the hospital. He stated he found out that the suprapubic catheter had been placed incorrectly by a floor nurse several days after Resident #49 arrived back at the facility. He confirmed at a minimum he should have been informed by administration that Resident #49 required admission to the hospital and treatment for [REDACTED]. During an interview on 2/23/18 at 9:16 a.m., LVN G confirmed the facility provided no formal training on suprapubic catheter care, maintenance or insertion. She denied a skills check off during orientation, and she denied caring for a resident with a suprapubic catheter during her orientation. She stated she was not familiar with the term suprapubic catheter and does not know the difference between suprapubic and indwelling catheter. During an interview on 2/23/18 at 9:18 a.m., WCD confirmed the facility provided no additional training for suprapubic catheters, except during the 3 day orientation that nurses receive. He confirmed no check-off training had occurred because nurses are taught in school. He stated the facility was aware Resident #49 had went to the hospital on [DATE] because hospitalization s are covered in the morning administrative meeting. He stated he found out in the morning meeting way after he went to the hospital they thought the catheter put in and blown up in the penis. He stated, he dismissed the idea because it would have to be improperly inserted to have been so far in that the bulb was inflated in his penis. He stated had he known he would have done an in-service immediately. As far as he knew, Resident #49 was fine when he got back. He confirmed he had no idea how far the catheter was inserted into Resident #49, the bulb was inflated in his penis, or that he had a kidney stone until the Survey Team presented the hospital CT Scan Report on 2/22/18. During an interview on 2/23/18 at 9:55 a.m., LVN H denied any formal facility-provided training regarding suprapubic catheters. She stated the only training provided was three days of orientation, and she stated she did not care for a resident with a suprapubic catheter. During an interview on 2/26/18 at 10:36 a.m., LVN B stated she was the night nurse that relieved LVN A. She stated LVN A had reported that she had changed Resident #49's suprapubic catheter, and subsequent to the catheter change, he had pain, bleeding, and decreased urine output. She stated, as soon as I got report, his wife came and got me. He was having significant pain, and I contacted the provider and transferred him quickly. She denied knowledge of the ultimate disposition of Resident #49 because he was admitted . When informed that the catheter had been threaded into and inflated in his penis. LVN B gasped, and stated, oh my. When asked if pain, bleeding, and decreased urine output were symptoms of an improperly inserted catheter, she stated, Yes, they are. When asked if the only way the catheter bulb could be inflated in the penis was that it was the catheter was improperly inserted, she stated, definitely. When asked if retracting the catheter 16.5 cm shows that the catheter was inserted improperly, she stated further, I have changed his suprapubic several times, you only have to insert it 2-3 inches. Record Review of the facility's policy for Supra-Pubic Catheter Care, dated 9/24/11, stated: Policy: To cleanse and maintain hygiene of suprapubic catheter stoma. To remove mucous from around supra-pubic catheter to prevent excoriation, inflammation and discomfort. Record review of the facility's policy for Supra-Pubic Catheter Reinsertion, dated 9/24/11, stated: Policy: Supra-pubic catheter will be reinserted into the bladder to resume continuous urinary drainage in accordance with a physician order. Procedure: 12. Insert lubricated tip of catheter approximately 1 ½ inches into the opening. Do not force if there is resistance. Notify MD if resistance is identified. 13. When urine has ceased flowing, insert amount of sterile water needed to inflate the balloon. Note: -This procedure should not be painful. If the resident experiences pain, stop the procedure until the source of pain is discovered. -The Supra-pubic catheter and drainage bag is a closed sterile system. This system must remain closed as much as possible. The facility DON was notified on 2/23/18 at 11:40 a.m. that an Immediate Jeopardy situation had been identified due to the above failures. During an interview on 2/27/18 at 10:35 a.m., DON was asked How do you think this incident (Immediate Jeopardy) related to catheter care came about? She stated, I have never had an IJ. I don't think it happened. I don't think it happened. I have known this nurse for years. She said she didn't insert it in that far. I believe her. DON was asked What resources are available for the staff and facility to ensure proper suprapubic catheter care? She stated, To be truthful, we never thought about it being an issue. All this time it wasn't an issue; it only became an issue when he was discharged . There was never a grievance filed. They (Resident #49 and his ex-wife) never complained when he returned from the hospital. Maybe we should have done some training, but they learn that in school. The facility submitted their Plan of Removal on 2/23/18 at 5:16 p.m. and it was accepted on 2/26/18 at 10:00 a.m. The Plan of Removal documented the following: Plumcreek Residence Amarillo, name changed to Landmark of Amarillo No Suprapubic catheters will be changed in this facility. If catheter needs to be changed resident will be taken to urologist for procedure. All nurses are currently being inserviced on new procedure/policy and will complete competency evaluations for catheter care within 24 hours beginning at 1300 (1:00 pm) on Friday, February 23rd. Failure to complete this requirement will result in removal from schedule until above stated requirements are met. The specific resident affected, and the single resident who had a suprapubic catheter is no longer in the facility. The incident occurred in November with no complain or concerns voiced by resident or family at that time. There are 8 residents currently in the facility who have foley catheters. ADON's are assessing them related to their catheters and the catheter care at this time. The assessments will be completed by 1400 (2:00 pm), Friday February 23rd. The Policy concerning catheter care is currently being revised to address that this facility will no longer change suprapubic catheters and will transport to urologist or ER for this care. Orientation of new hire nurses will include specific instructions about not changing suprapubic catheters and instructions and competency checkoffs for other urinary catheters before being released to work on the floors and within 3 days of floor orientation. Affirmation that all current nursing staff have completed the competency checkoff and have been inserviced about not changing suprapubic catheters will be confirmed by the signature of every nurse on said forms which will be reviewed by the DON or designed by 1500 (3:00 pm) Saturday February 23rd. Affirmation that all new hire nurses have been inserviced on the policy and checked off on the competency form will also be confirmed by each signature. This will be monitored by the DON or designee. Anytime a nurse perceives that there may be an issue or event concerning a catheter, he/she will notify the ADON or ADON on call. The ADON will instruct the nurse on how to proceed or contact the DON or designee for directions. All nursing staff will be trained to assess for potential negative reactions to improperly inserted catheters, malfunction of catheter, displacement of cathter or other anomalies related to catheter and care including urinary tract infections, [MEDICATION NAME], urethral injury, blood infection, bacteriuria, blood in the urine, injury to the urethra, kidney damage, and or [MEDICAL CONDITION]. This training will be completed by March 1st, 2018. Any time an unusual event occurs or a nurse does not feel comfortable or does not feel that she/he has adequate training for the task needing to be completed, that nurse should contact the ADON for that unit or after hours the ADON on call before proceeding. The ADON will then immediately contact the DON or designee. The survey Team confirmed that the facility's plan of removal was implemented on 2/26/18 as evidenced by: 1) Interviews with 5 licensed nurses and registered nurses to confirm the additional training regarding catheters had been performed. 2) Interviews with 2 administrative staff to confirm the LVN A had been trained regarding catheter care, changes, positioning and new policy implementation. 3) Interviews with 5 licensed nurses and registered nurses to confirm they had been educated on the implementation of the new policy to send residents to the emergency room for catheter changes. During an interview on 2/26/18 at 10:30 a.m., DON was informed the IJ was removed. However, the facility remained out of compliance at a severity actual harm with a scope identified as pattern. The facility was continuing to monitor to ensure assessments for side rails were accurate for all residents. The facility was continuing to monitor to ensure catheter care in accordance with professional standards for all residents. Review of the facility provided CMS form 802 Roster/Sample Matrix, dated 2/20/18, documented 9 residents with catheters (WCD interview).

Based on interview and record review it was determined the facility failed to ensure sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and [DIAGNOSES REDACTED].#49). LVN A incorrectly inserted a suprapubic catheter (a catheter to drain urine that inserts a few inches through a stoma on the abdomen into the bladder) and threaded the catheter 16.5cm (almost 6.5 inches) too far and inflated the catheter bulb in Resident #49's penis. Resident #49 required transfer to the local emergency room for treatment and admission on 11/5/18 through 11/8/18. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 2/23/18 that occurred on 11/5/17. While the IJ was removed on 2/26/18, the facility remained out of compliance at a severity of actual harm with a scope identified as pattern. The facility was continuing to monitor to ensure catheter care in accordance with professional standards for all residents. The facility's failure to ensure sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and [DIAGNOSES REDACTED]. Findings include: Record Review of Resident #49's clinical record revealed: Resident #49 is a [AGE] year old male with an admission date of [DATE], a readmission date of [DATE], and was transferred to another nursing facility on 2/22/18. He had [DIAGNOSES REDACTED]. Record Review of the care plan for Resident #49, dated 1/22/18, stated: Resident #49 has limited mobility, requires a Hoyer lift for transfers, has an ADL deficit requiring at least 2 person assist, has pain, depression, requires adaptive equipment to assist with eating, has a suprapubic catheter, is at risk for injuries related to diabetes and hypertension, and is at risk for weight loss and pressure sores. Record Review of Resident #49's MDS, dated [DATE], stated: Resident #49 has BIMS-15, indicating no cognitive impairment; Depression-8; no behaviors; requires total 2 person assist for all bed mobility, transfers, dressing, toileting, ADLs, and bathing; requires extensive 1 person assist for hygiene; requires a wheelchair of mobility; has bilateral upper and lower extremity impairment; has an indwelling catheter; is always continent of bowel; has occasional complaints of pain requiring medication; and is at risk pressure sores. During an interview on 2/20/18 at 3:27 p.m., Resident #49 was asked about any care issues during his stay at the facility. He stated he had some problems and stated, one of the nurses came in on the weekend (11/5/17), and she changed (the suprapubic catheter) around lunch time, but she didn't do it right. I had to go to the hospital, and I was there for 4 days for bleeding and an infection in my bladder. During an interview on 2/23/18 at 11:20 a.m., LVN A stated she wasn't comfortable changing that (suprapubic) catheter because Resident #49 was having bladder spasms. She confirmed there was a standing order to change the catheter as needed. She stated she contacted the on call provider and received an order for [REDACTED].#49 had severe pelvic pain and blood in his urine. She stated the facility had not provided any additional training on inserting, changing or care of suprapubic catheters. When asked if she had changed suprapubic catheters before, she stated, I'm not new to this. When asked how far the suprapubic catheter tubing should be inserted, she stated, 1.5 to 2 inches is the normal length. LVN A was informed the catheter had been inserted and the CT Scan showed the catheter bulb was inflated in his penis, and the catheter required retracting 16.5 cm. She stated, Wow, I didn't know that. It wasn't that way when he went out. LVN A confirmed she was not the nurse that transferred Resident #49 to the ER. She stated, This is a 'Safe Harbor' issue because of the types of residents we deal with here. You have to have a psychiatric illness, dementia or behavior [DIAGNOSES REDACTED]. Nurses should be demanding adequate staffing because of the high acuity care here. She stated further staffing is lacking, not just here, but in all long term care in general. When asked if she had filed Safe Harbor related to the incident on 11/5/17, she replied, No and confirmed she had never filed any Safe Harbor paperwork related to any issues. Review of Facility Nurses' Notes revealed: 11/5/2017 at 6:38 p.m.: Nursing Progress Note: 2:24 p.m. Contacted NP due to patient complaining of severe bladder spasms, pain scale 10/10, yelling for help and called wife crying. NP gave orders to give [MEDICATION NAME] 10mg one by mouth every 12 hours. Resident given Tylenol #3 at 3:00 p.m., was effective with pain management, pain scale 4/10 after 30 minutes of administration. No further complaints of pain at this time. 6:48 p.m. Patient did receive catheter change per their (Resident and his ex-wife) demand. Patient thought it would stop bladder spasms, they continue with leakage of urine tinged pink blood. At 5:41 p.m., NP notified of bladder spasms continue with urine tinged pink blood approximately size of 8-9 sock on sheet noted. (This is how the nurse described the size of the blood.) NP advised to continue to monitor, bleeding should stop on its own in a couple of days, if becomes red staff to contact provider. (Resident #49's daughter) notified of bladder spasms continue with leakage of urine with tinged pink blood and NP notified. (Sic)- LVN A 11/5/2017 at 9:58 p.m.: Nursing Progress Note: Resident called this nurse into his room at 7:15 p.m. this evening complaining of severe bladder spasm's pain scale 8/10 resident is crying and asking for help this nurse called nurse practitioner on call and received orders to send resident out to emergency room (ER) wife at bedside agreed that she does want resident to go to ER. This nurse called non emergent (EMS) at 7:30 p.m. they arrived on unit at 7:46 p.m. and left facility at 8:00 p.m. will continue to monitor closely. (Sic) - LVN B Review of Resident #49's Hospital Medical Record revealed: Record Review of the Physician History and Physical, dated 11/5/17, revealed: Chief Complaint: Problems with urinary catheter pain after placement. History of present illness: This is a [AGE] year old very pleasant gentleman who has [MEDICAL CONDITION] and is in a nursing home. He is non-ambulatory apparently has a suprapubic catheter and this was replaced today at the nursing home, then he had problems with pain eventually calling EMS to send him to the emergency room . On arrival there, EMS noted that there was no drainage from the catheter, he was brought to the ER and evaluation revealed a suprapubic catheter was actually placed in the suprapubic opening and then went into the penile urethra. This was repositioned. A CT scan was performed that showed this, and he was noted to have a (kidney stone). There was a significant amount of bleeding associated with the repositioning of the catheter, as the balloon was blown up partially in the penile urethra. The patient was noted to have a significant amount of pyuria and bacteriuria, which you would expect from a chronic indwelling catheter, but he also had a 20,000 white count. He has not had any fever, chills or associated symptoms. (Sic). Impression/Plan: 1. UTI present on admission. The patient has a chronic suprapubic catheter, but has a 20,000 white count that seems like the only source of his urine .He also has a UTI with [MEDICATION NAME]. 2. Malpositioned suprapubic catheter: This has been repositioned. If problems with drainage, it may need to be flushed. 3. Staghorn calculus in the left kidney. (Sic). Record Review of the ER Nurses' Notes, dated 11/5/17, revealed: 8:19 p.m.: Patient to ER 35 via EMS stretcher. 8:35 p.m.: To CT via stretcher. 10:00 p.m.: Catheter balloon emptied and catheter pulled back slightly to remove from urethra. Per Dr. orders. Catheter flushed and blood with clots came out of penis. Catheter flushed 2 more times with 20 ml of sterile water until blood and clots removed from Foley tubing. Balloon reinflated with removed fluid from deflation. Record Review of CT Cystogram Pelvis Report, dated 11/6/17, revealed: Findings: CT images demonstrate the presence of a suprapubic catheter. The catheter extends through the lumen of the urinary bladder and into the base of the penis. The Foley balloon tipped has been inflated at the base of the penis and repositioning is recommended. Conclusion: 1. Distal tip of the suprapubic catheter extends into the base of the penis. The balloon is insufflated (inflated). Recommend deflation and withdrawal of the catheter by approximately 16.5 cm (almost 6.5 inches). Record Review of Physician Consultation Report, dated 11/6/17, revealed: History of present illness: [AGE] year old male who was admitted for UTI. He was noted to have a non-draining suprapubic tube. It previously had been replaced yesterday at the nursing home. It never drained well. A CT scan showed the suprapubic tube had tracked down the penile urethra. The balloon was deflated, repositioned and it is draining now. He states his pain has resolved. Record Review of the Physician Discharge Summary, dated 11/9/17, revealed: Admitting Diagnoses: [REDACTED].>1. Urinary tract infection present on admission, complicated. 2. Malpositioned suprapubic catheter. 3. Left Kidney Stone. Hospital Course: The patient was admitted to the floor on broad-spectrum antibiotics therapy .Final cultures revealed Pseudomonas aeruginosa, Proteus mirabilis and [MEDICATION NAME] feacalis (Note: bacteria typically found in fecal material) .(Resident's Urologist) was consulted regarding the kidney stone and a suprapubic catheter malplacement. A CT scan ordered to evaluate suprapubic catheter did demonstrate malpositioning and high density material in the bladder, likely blood products. After repositioning he does have a left kidney (stone) but will need an outpatient [MEDICAL CONDITION] preoperative clearance prior to considering nephrolithotripsy. During an interview on 2/22/18 at 9:32 a.m., WCD denied knowledge that Resident #49's catheter had been inserted improperly. He stated he had heard something about the catheter being pulled down into the urethra, but (he didn't) remember much about it. He confirmed the nursing documentation regarding the catheter change was lacking because it failed to clearly document the time of the change, whether there was resistance during the insertion, or urine return upon insertion. When asked how far a suprapubic catheter should be inserted, he stated, 2-4 inches. When asked if bleeding, severe pain, and no urine output are signs of an improperly placed catheter, he stated, yes. When shown the CT Scan Report requesting the catheter be retracted 16.5cm (almost 6.5 inches) and asked whether the catheter was incorrectly placed, he stated, yeah, I guess it would be .substantially too far. It's safe to say. It's common sense. When asked in his nursing judgment if there was any way the catheter balloon being inflated in the penis could happen other than improper placement, he denied knowledge of any other causes. He confirmed he had not seen the hospital medical records. During an interview on 2/22/18 at 10:24 a.m., DON confirmed she was unaware of any complications with catheters in the facility. She confirmed nursing documentation should include whether there was resistance during the insertion, or urine return upon insertion. When asked how far a suprapubic catheter should be inserted, she stated, look for some urine, you don't need to go in very far. It's right there .3-4 inches in. When asked what are the complications of an improperly placed catheter, she stated, pain, a lot of pain, and no urine. When asked what a prudent nurse should do if presented with pain, bleeding, and no urine output, she stated, stop what you are doing, and call and get help .the nurse practitioner, doctor, another nurse, somebody. When shown the CT Scan Report recommended retracting the suprapubic catheter 16.5 cm and asked if that indicated the catheter was inserted way too far, she stated, yes. When asked what complications can result from inflation of the catheter bulb in the penis, she stated, pain, inability to urinate, a lot of distention, risk of infection and necrosis (death of the urethra and penile tissue). She confirmed he had not seen the hospital medical records. During an interview on 2/22/18 at 2:38 p.m., MD denied being informed by administration about ER findings when Resident # 49 was sent to the hospital. He stated he found out that the suprapubic catheter had been placed incorrectly by a floor nurse several days after Resident # 49 arrived back at the facility. He confirmed at a minimum he should have been informed by administration that Resident #49 required admission to the hospital and treatment for [REDACTED]. During an interview on 2/23/18 at 9:16 a.m., LVN G confirmed the facility provided no formal training on suprapubic catheter care, maintenance or insertion. She denied a skills check off during orientation, and she denied caring for a resident with a suprapubic catheter during her orientation. She stated she was not familiar with the term suprapubic catheter and does not know the difference between suprapubic and indwelling catheter. During an interview on 2/23/18 at 9:18 a.m., WCD confirmed the facility provided no additional training for suprapubic catheters, except during the 3 day orientation that nurses receive. He confirmed no check-off training had occurred because nurses are taught in school. He stated the facility was aware Resident #49 had went to the hospital on [DATE] because hospitalization s are covered in the morning administrative meeting. He stated he found out in the morning meeting way after he went to the hospital they thought the catheter put in and blown up in the penis. He stated, he dismissed the idea because it would have to be improperly inserted to have been so far in that the bulb was inflated in his penis. He stated had he known he would have done an in-service immediately. As far as he knew, Resident #49 was fine when he got back. He confirmed he had no idea how far the catheter was inserted into Resident #49, the bulb was inflated in his penis, or that he had a kidney stone until the Survey Team presented the hospital CT Scan Report on 2/22/18. During an interview on 2/23/18 at 9:55 a.m., LVN H denied any formal facility-provided training regarding suprapubic catheters. She stated the only training provided was three days of orientation, and she stated she did not care for a resident with a suprapubic catheter. During an interview on 2/26/18 at 10:36 a.m., LVN B stated she was the night nurse that relieved LVN A. She stated LVN A had reported that she had changed Resident # 49's suprapubic catheter, and subsequent to the catheter change, he had pain, bleeding, and decreased urine output. She stated, as soon as I got report, his wife came and got me. He was having significant pain, and I contacted the provider and transferred him quickly. She denied knowledge of the ultimate disposition of Resident #49 because he was admitted . When informed that the catheter had been threaded into and inflated in his penis. LVN B gasped, and stated, oh my. When asked if pain, bleeding, and decreased urine output were symptoms of an improperly inserted catheter, she stated, Yes, they are. When asked if the only way the catheter bulb could be inflated in the penis was that it was the catheter was improperly inserted, she stated, definitely. When asked if retracting the catheter 16.5 cm shows that the catheter was inserted improperly, she stated further, I have changed his suprapubic several times, you only have to insert it 2-3 inches. Record Review of the facility's policy for Supra-Pubic Catheter Care, dated 9/24/11, stated: Policy: To cleanse and maintain hygiene of suprapubic catheter stoma. To remove mucous from around supra-pubic catheter to prevent excoriation, inflammation and discomfort. Record review of the facility's policy for Supra-Pubic Catheter Reinsertion, dated 9/24/11, stated: Policy: Supra-pubic catheter will be reinserted into the bladder to resume continuous urinary drainage in accordance with a physician order. Procedure: 12. Insert lubricated tip of catheter approximately 1 ½ inches into the opening. Do not force if there is resistance. Notify MD if resistance is identified. 13. When urine has ceased flowing, insert amount of sterile water needed to inflate the balloon. Note: -This procedure should not be painful. If the resident experiences pain, stop the procedure until the source of pain is discovered. -The Supra-pubic catheter and drainage bag is a closed sterile system. This system must remain closed as much as possible. The facility DON was notified on 2/23/18 at 11:40 a.m. that an Immediate Jeopardy situation had been identified due to the above failures. During an interview on 2/27/18 at 10:35 a.m., DON was asked How do you think this incident (Immediate Jeopardy) related to catheter care came about? She stated, I have never had an IJ. I don't think it happened. I don't think it happened. I have known this nurse for years. She said she didn't insert it in that far. I believe her. DON was asked What resources are available for the staff and facility to ensure proper suprapubic catheter care? She stated, To be truthful, we never thought about it being an issue. All this time it wasn't an issue; it only became an issue when he was discharged . There was never a grievance filed. They (Resident #49 and his ex-wife) never complained when he returned from the hospital. Maybe we should have done some training, but they learn that in school. The facility submitted their Plan of Removal on 2/23/18 at 5:16 p.m. and it was accepted on 2/26/18 at 10:00 a.m. The Plan of Removal documented the following: Plumcreek Residence Amarillo, name changed to Landmark of Amarillo No Suprapubic catheters will be changed in this facility. If catheter needs to be changed resident will be taken to urologist for procedure. All nurses are currently being inserviced on new procedure/policy and will complete competency evaluations for catheter care within 24 hours beginning at 1300 (1:00 pm) on Friday, February 23rd. Failure to complete this requirement will result in removal from schedule until above stated requirements are met. The specific resident affected, and the single resident who had a suprapubic catheter is no longer in the facility. The incident occurred in November with no complain or concerns voiced by resident or family at that time. There are 8 residents currently in the facility who have foley catheters. ADON's are assessing them related to their catheters and the catheter care at this time. The assessments will be completed by 1400 (2:00 pm), Friday February 23rd. The Policy concerning catheter care is currently being revised to address that this facility will no longer change suprapubic catheters and will transport to urologist or ER for this care. Orientation of new hire nurses will include specific instructions about not changing suprapubic catheters and instructions and competency checkoffs for other urinary catheters before being released to work on the floors and within 3 days of floor orientation. Affirmation that all current nursing staff have completed the competency checkoff and have been inserviced about not changing suprapubic catheters will be confirmed by the signature of every nurse on said forms which will be reviewed by the DON or designed by 1500 (3:00 pm) Saturday February 23rd. Affirmation that all new hire nurses have been inserviced on the policy and checked off on the competency form will also be confirmed by each signature. This will be monitored by the DON or designee. Anytime a nurse perceives that there may be an issue or event concerning a catheter, he/she will notify the ADON or ADON on call. The ADON will instruct the nurse on how to proceed or contact the DON or designee for directions. All nursing staff will be trained to assess for potential negative reactions to improperly inserted catheters, malfunction of catheter, displacement of cathter or other anomalies related to catheter and care including urinary tract infections, [MEDICATION NAME], urethral injury, blood infection, bacteriuria, blood in the urine, injury to the urethra, kidney damage, and or [MEDICAL CONDITION]. This training will be completed by March 1st, 2018. Any time an unusual event occurs or a nurse does not feel comfortable or does not feel that she/he has adequate training for the task needing to be completed, that nurse should contact the ADON for that unit or after hours the ADON on call before proceeding. The ADON will then immediately contact the DON or designee. The survey Team confirmed that the facility's plan of removal was implemented on 2/26/18 as evidenced by: 1) Interviews with 5 licensed nurses and registered nurses to confirm the additional training regarding catheters had been performed. 2) Interviews with 2 administrative staff to confirm the LVN A had been trained regarding catheter care, changes, positioning and new policy implementation. 3) Interviews with 5 licensed nurses and registered nurses to confirm they had been educated on the implementation of the new policy to send residents to the emergency room for catheter changes. During an interview on 2/26/18 at 10:30 a.m., DON was informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm with a scope identified as pattern. The facility was continuing to monitor to ensure assessments for side rails were accurate for all residents. The facility was continuing to monitor to ensure catheter care in accordance with professional standards for all residents. Review of the facility provided CMS form 802 Roster/Sample Matrix, dated 2/20/18, documented 9 residents with catheters (WCD interview).

Based on interview and record review; it was determined the Administrator and the DON failed to ensure the facility was administered in a manner which enabled it to use its resources effectively and efficiently to maintain the highest practicable physical well-being for 1 of 23 residents (Resident #49) reviewed for catheter care and neglect. The Administrator failed to ensure the facility's policies and procedures were implemented for the prohibition of neglect when LVN A incorrectly inserted a suprapubic catheter (a catheter to drain urine that inserts a few inches through a stoma on the abdomen into the bladder) and threaded the catheter 16.5cm (almost 6.5 inches) too far and inflated the catheter bulb in Resident #49's penis causing pain, bleeding, and decreased urine output. Resident #49 required transfer to the local emergency room for treatment and admission to the hospital on [DATE] through 11/8/18. The Administrator and the DON failed to supervise the ADON to ensure incidents involving Residents being sent to the hospital were thoroughly investigated. The Administrator and the DON failed to identify there was an issue with catheter care and training on catheter care. The DON failed to effectively train and monitor staff to ensure catheter care was done appropriately. The Administrator and the DON failed to adequately staff the facility with competent nursing staff. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 2/23/18 that occurred on 11/5/17. While the IJ was removed on 2/26/18, the facility remained out of compliance at a severity of actual harm with a scope identified as pattern. The facility was continuing to monitor to ensure catheter care in accordance with professional standards for all residents. The facility's failures could place 9 residents requiring catheter care at risk for pain, [MEDICAL CONDITION], genital-urinary trauma, [MEDICAL CONDITION], blood loss, shock, and death. Findings include: The Administrator who was employed at the time of the incident was no longer the Administrator of the facility at the time of the survey. Record Review of Resident #49's clinical record revealed: Resident #49 is a [AGE] year old male with an admission date of [DATE], a readmission date of [DATE], and was transferred to another nursing facility on 2/22/18. He had [DIAGNOSES REDACTED]. Record Review of the care plan for Resident #49, dated 1/22/18, stated: Resident #49 has limited mobility, requires a Hoyer lift for transfers, has an ADL deficit requiring at least 2 person assist, has pain, depression, requires adaptive equipment to assist with eating, has a suprapubic catheter, is at risk for injuries related to diabetes and hypertension, and is at risk for weight loss and pressure sores. Record Review of Resident #49's MDS, dated [DATE], stated: Resident #49 has BIMS-15, indicating no cognitive impairment; Depression-8; no behaviors; requires total 2 person assist for all bed mobility, transfers, dressing, toileting, ADLs, and bathing; requires extensive 1 person assist for hygiene; requires a wheelchair of mobility; has bilateral upper and lower extremity impairment; has an indwelling catheter; is always continent of bowel; has occasional complaints of pain requiring medication; and is at risk pressure sores. During an interview on 2/20/18 at 3:27 p.m., Resident #49 was asked about any care issues during his stay at the facility. He stated he had some problems and stated, one of the nurses came in on the weekend (11/5/17), and she changed (the suprapubic catheter) around lunch time, but she didn't do it right. I had to go to the hospital, and I was there for 4 days for bleeding and an infection in my bladder. During an interview on 2/23/18 at 11:20 a.m., LVN A stated she wasn't comfortable changing that (suprapubic) catheter because Resident #49 was having bladder spasms. She confirmed there was a standing order to change the catheter as needed. She stated she contacted the on call provider and received an order for [REDACTED].#49 had severe pelvic pain and blood in his urine. She stated the facility had not provided any additional training on inserting, changing or care of suprapubic catheters. When asked if she had changed suprapubic catheters before, she stated, I'm not new to this. When asked how far the suprapubic catheter tubing should be inserted, she stated, 1.5 to 2 inches is the normal length. LVN A was informed the catheter had been inserted and the CT Scan showed the catheter bulb was inflated in his penis, and the catheter required retracting 16.5 cm. She stated, Wow, I didn't know that. It wasn't that way when he went out. LVN A confirmed she was not the nurse who transferred Resident #49 to the ER. Review of Facility Nurses' Notes revealed: 11/5/2017 at 6:38 p.m.: Nursing Progress Note: 2:24 p.m. Contacted NP due to patient complaining of severe bladder spasms, pain scale 10/10, yelling for help and called wife crying. NP gave orders to give [MEDICATION NAME] 10mg one by mouth every 12 hours. Resident given Tylenol #3 at 3:00 p.m., was effective with pain management, pain scale 4/10 after 30 minutes of administration. No further complaints of pain at this time. 6:48 p.m. Patient did receive catheter change per their (Resident and his ex-wife) demand. Patient thought it would stop bladder spasms, they continue with leakage of urine tinged pink blood. At 5:41 p.m., NP notified of bladder spasms continue with urine tinged pink blood approximately size of 8-9 sock on sheet noted. (This is how the nurse described the size of the blood.) NP advised to continue to monitor, bleeding should stop on its own in a couple of days, if becomes red staff to contact provider. (Resident #49's daughter) notified of bladder spasms continue with leakage of urine with tinged pink blood and NP notified. (Sic)- LVN A 11/5/2017 at 9:58 p.m.: Nursing Progress Note: Resident called this nurse into his room at 7:15 p.m. this evening complaining of severe bladder spasm's pain scale 8/10 resident is crying and asking for help this nurse called nurse practitioner on call and received orders to send resident out to emergency room (ER) wife at bedside agreed that she does want resident to go to ER. This nurse called non emergent (EMS) at 7:30 p.m. they arrived on unit at 7:46 p.m. and left facility at 8:00 p.m. will continue to monitor closely. (Sic) - LVN B Review of Resident #49's Hospital Medical Record revealed: Record Review of the Physician History and Physical, dated 11/5/17, revealed: Chief Complaint: Problems with urinary catheter pain after placement. History of present illness: This is a [AGE] year old very pleasant gentleman who has [MEDICAL CONDITION] and is in a nursing home. He is non-ambulatory apparently has a suprapubic catheter and this was replaced today at the nursing home, then he had problems with pain eventually calling EMS to send him to the emergency room . On arrival there, EMS noted that there was no drainage from the catheter, he was brought to the ER and evaluation revealed a suprapubic catheter was actually placed in the suprapubic opening and then went into the penile urethra. This was repositioned. A CT scan was performed that showed this, and he was noted to have a (kidney stone). There was a significant amount of bleeding associated with the repositioning of the catheter, as the balloon was blown up partially in the penile urethra. The patient was noted to have a significant amount of pyuria and bacteriuria, which you would expect from a chronic indwelling catheter, but he also had a 20,000 white count. He has not had any fever, chills or associated symptoms. (Sic). Impression/Plan: 1. UTI present on admission. The patient has a chronic suprapubic catheter, but has a 20,000 white count that seems like the only source of his urine .He also has a UTI with [MEDICATION NAME]. 2. Malpositioned suprapubic catheter: This has been repositioned. If problems with drainage, it may need to be flushed. 3. Staghorn calculus in the left kidney. (Sic). Record Review of the ER Nurses' Notes, dated 11/5/17, revealed: 8:19 p.m.: Patient to ER 35 via EMS stretcher. 8:35 p.m.: To CT via stretcher. 10:00 p.m.: Catheter balloon emptied and catheter pulled back slightly to remove from urethra. Per Dr. orders. Catheter flushed and blood with clots came out of penis. Catheter flushed 2 more times with 20 ml of sterile water until blood and clots removed from Foley tubing. Balloon reinflated with removed fluid from deflation. Record Review of CT Cystogram Pelvis Report, dated 11/6/17, revealed: Findings: CT images demonstrate the presence of a suprapubic catheter. The catheter extends through the lumen of the urinary bladder and into the base of the penis. The Foley balloon tipped has been inflated at the base of the penis and repositioning is recommended. Conclusion: 1. Distal tip of the suprapubic catheter extends into the base of the penis. The balloon is insufflated (inflated). Recommend deflation and withdrawal of the catheter by approximately 16.5 cm. Record Review of Physician Consultation Report, dated 11/6/17, revealed: History of present illness: [AGE] year old male who was admitted for UTI. He was noted to have a non-draining suprapubic tube. It previously had been replaced yesterday at the nursing home. It never drained well. A CT scan showed the suprapubic tube had tracked down the penile urethra. The balloon was deflated, repositioned and it is draining now. He states his pain has resolved. Record Review of the Physician Discharge Summary, dated 11/9/17, revealed: Admitting Diagnoses: [REDACTED].>1. Urinary tract infection present on admission, complicated. 2. Malpositioned suprapubic catheter. 3. Left Kidney Stone. Hospital Course: The patient was admitted to the floor on broad-spectrum antibiotics therapy .Final cultures revealed Pseudomonas aeruginosa, Proteus mirabilis and [MEDICATION NAME] feacalis (Note: bacteria typically found in fecal material) .(Resident's Urologist) was consulted regarding the kidney stone and a suprapubic catheter malplacement. A CT scan ordered to evaluate suprapubic catheter did demonstrate malpositioning and high density material in the bladder, likely blood products. After repositioning he does have a left kidney (stone) but will need an outpatient [MEDICAL CONDITION] preoperative clearance prior to considering nephrolithotripsy. During an interview on 2/22/18 at 9:32 a.m., WCD denied knowledge that Resident #49's catheter had been inserted improperly. He stated he had heard something about the catheter being pulled down into the urethra, but (he didn't) remember much about it. He confirmed the nursing documentation regarding the catheter change was lacking because it failed to clearly document the time of the change, whether there was resistance during the insertion, or urine return upon insertion. When asked how far a suprapubic catheter should be inserted, he stated, 2-4 inches. When asked if bleeding, severe pain, and no urine output are signs of an improperly placed catheter, he stated, yes. When shown the CT Scan Report requesting the catheter be retracted 16.5cm (almost 6.5 inches) and asked whether the catheter was incorrectly placed, he stated, yeah, I guess it would be .substantially too far. It's safe to say. It's common sense. When asked in his nursing judgment if there was any way the catheter balloon being inflated in the penis could happen other than improper placement, he denied knowledge of any other causes. He confirmed he had not seen the hospital medical records. He confirmed the facility had not investigated the incident. He confirmed he investigates nursing issues related to care and neglect. During an interview on 2/22/18 at 10:24 a.m., DON confirmed she was unaware of any complications with catheters in the facility. She confirmed nursing documentation should include whether there was resistance during the insertion, or urine return upon insertion. When asked how far a suprapubic catheter should be inserted, she stated, look for some urine, you don't need to go in very far. It's right there .3-4 inches in. When asked what are the complications of an improperly placed catheter, she stated, pain, a lot of pain, and no urine. When asked what a prudent nurse should do if presented with pain, bleeding, and no urine output, she stated, stop what you are doing, and call and get help .the nurse practitioner, doctor, another nurse, somebody. When shown the CT Scan Report recommended retracting the suprapubic catheter 16.5 cm and asked if that indicated the catheter was inserted way too far, she stated, yes. When asked what complications can result from inflation of the catheter bulb in the penis, she stated, pain, inability to urinate, a lot of distention, risk of infection and necrosis (death of the urethra and penile tissue). She confirmed he had not seen the hospital medical records. She confirmed the facility had not investigated the incident. During an interview on 2/22/18 at 2:38 p.m., MD denied being informed by administration about ER findings when Resident # 49 was sent to the hospital. He stated he found out that the suprapubic catheter had been placed incorrectly by a floor nurse several days after Resident #49 arrived back at the facility. He confirmed at a minimum he should have been informed by administration that Resident #49 required admission to the hospital and treatment for [REDACTED]. During an interview on 2/23/18 at 9:16 a.m., LVN G confirmed the facility provided no formal training on suprapubic catheter care, maintenance or insertion. She denied a skills check off during orientation, and she denied caring for a resident with a suprapubic catheter during her orientation. She stated she was not familiar with the term suprapubic catheter and does not know the difference between suprapubic and indwelling catheter. During an interview on 2/23/18 at 9:18 a.m., WCD confirmed the facility provided no additional training for suprapubic catheters, except during the 3 day orientation that nurses receive. He confirmed no check-off training had occurred because nurses are taught in school. He stated the facility was aware Resident #49 had went to the hospital on [DATE] because hospitalization s are covered in the morning administrative meeting. He stated he found out in the morning meeting way after he went to the hospital they thought the catheter put in and blown up in the penis. He stated, he dismissed the idea because it would have to be improperly inserted to have been so far in that the bulb was inflated in his penis. He stated had he known he would have done an in-service immediately. As far as he knew, Resident #49 was fine when he got back. He confirmed he had no idea how far the catheter was inserted into Resident #49, the bulb was inflated in his penis, or that he had a kidney stone until the Survey Team presented the hospital CT Scan Report on 2/22/18. During an interview on 2/23/18 at 9:55 a.m., LVN H denied any formal facility-provided training regarding suprapubic catheters. She stated the only training provided was three days of orientation, and she stated she did not care for a resident with a suprapubic catheter. During an interview on 2/26/18 at 10:36 a.m., LVN B stated she was the night nurse that relieved LVN A. She stated LVN A had reported that she had changed Resident #49's suprapubic catheter, and subsequent to the catheter change, he had pain, bleeding, and decreased urine output. She stated, as soon as I got report, his wife came and got me. He was having significant pain, and I contacted the provider and transferred him quickly. She denied knowledge of the ultimate disposition of Resident #49 because he was admitted . When informed that the catheter had been threaded into and inflated in his penis. LVN B gasped, and stated, oh my. When asked if pain, bleeding, and decreased urine output were symptoms of an improperly inserted catheter, she stated, Yes, they are. When asked if the only way the catheter bulb could be inflated in the penis was that it was the catheter was improperly inserted, she stated, definitely. When asked if retracting the catheter 16.5 cm shows that the catheter was inserted improperly, she stated further, I have changed his suprapubic several times, you only have to insert it 2-3 inches. Record Review of the facility's policy for Supra-Pubic Catheter Care, dated 9/24/11, stated: Policy: To cleanse and maintain hygiene of suprapubic catheter stoma. To remove mucous from around supra-pubic catheter to prevent excoriation, inflammation and discomfort. Record review of the facility's policy for Supra-Pubic Catheter Reinsertion, dated 9/24/11, stated: Policy: Supra-pubic catheter will be reinserted into the bladder to resume continuous urinary drainage in accordance with a physician order. Procedure: 12. Insert lubricated tip of catheter approximately 1 ½ inches into the opening. Do not force if there is resistance. Notify MD if resistance is identified. 13. When urine has ceased flowing, insert amount of sterile water needed to inflate the balloon. Note: -This procedure should not be painful. If the resident experiences pain, stop the procedure until the source of pain is discovered. -The Supra-pubic catheter and drainage bag is a closed sterile system. This system must remain closed as much as possible. Record Review of the facility's policy for Reporting Abuse to Facility Management, dated 12/2013, stated: It is the responsibility of our employees .to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source .to facility management. Policy Interpretation and Implementation 2f. Neglect is defined as failure to provide goods or services necessary to avoid physical harm, mental anguish, or mental illness. Record Review of the facility's policy for Abuse Investigations, dated 4/2014, stated: All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. Policy Interpretation and Implementation 1. Should an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident. 3. The individual conducting the investigation will, as a minimum: b. Review the resident's medical record to determine events leading up to the incident; c. Interview the person(s) reporting the incident; d. Interview any witnesses to the incident; e. Interview the resident; f. Interview the resident's Attending Medical Physician as needed to determine the resident's current level of cognitive function and medical condition; g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; h. Interview the resident's roommate, family members, and visitors; j. Review all events leading up to the incident. 5. Witness reports will be obtained in writing. The facility DON was notified on 2/23/18 at 11:40 a.m. that an Immediate Jeopardy situation had been identified due to the above failures. During an interview on 2/27/18 at 10:35 a.m., DON was asked How do you think this incident (Immediate Jeopardy) related to catheter care came about? She stated, I have never had an IJ. I don't think it happened. I don't think it happened. I have known this nurse for years. She said she didn't insert it in that far. I believe her. DON was asked What resources are available for the staff and facility to ensure proper suprapubic catheter care? She stated, To be truthful, we never thought about it being an issue. All this time it wasn't an issue; it only became an issue when he was discharged . There was never a grievance filed. They (Resident #49 and his ex-wife) never complained when he returned from the hospital. Maybe we should have done some training, but they learn that in school. The facility submitted their Plan of Removal on 2/23/18 at 5:16 p.m. and it was accepted on 2/26/18 at 10:00 a.m. The Plan of Removal documented the following: Plumcreek Residence Amarillo, name changed to Landmark of Amarillo No Suprapubic catheters will be changed in this facility. If catheter needs to be changed resident will be taken to urologist for procedure. All nurses are currently being inserviced on new procedure/policy and will complete competency evaluations for catheter care within 24 hours beginning at 1300 (1:00 pm) on Friday, February 23rd. Failure to complete this requirement will result in removal from schedule until above stated requirements are met. The specific resident affected, and the single resident who had a suprapubic catheter is no longer in the facility. The incident occurred in November with no complain or concerns voiced by resident or family at that time. There are 8 residents currently in the facility who have foley catheters. ADON's are assessing them related to their catheters and the catheter care at this time. The assessments will be completed by 1400 (2:00 pm), Friday February 23rd. The Policy concerning catheter care is currently being revised to address that this facility will no longer change suprapubic catheters and will transport to urologist or ER for this care. Orientation of new hire nurses will include specific instructions about not changing suprapubic catheters and instructions and competency checkoffs for other urinary catheters before being released to work on the floors and within 3 days of floor orientation. Affirmation that all current nursing staff have completed the competency checkoff and have been inserviced about not changing suprapubic catheters will be confirmed by the signature of every nurse on said forms which will be reviewed by the DON or designed by 1500 (3:00 pm) Saturday February 23rd. Affirmation that all new hire nurses have been inserviced on the policy and checked off on the competency form will also be confirmed by each signature. This will be monitored by the DON or designee. Anytime a nurse perceives that there may be an issue or event concerning a catheter, he/she will notify the ADON or ADON on call. The ADON will instruct the nurse on how to proceed or contact the DON or designee for directions. All nursing staff will be trained to assess for potential negative reactions to improperly inserted catheters, malfunction of catheter, displacement of cathter or other anomalies related to catheter and care including urinary tract infections, [MEDICATION NAME], urethral injury, blood infection, bacteriuria, blood in the urine, injury to the urethra, kidney damage, and or [MEDICAL CONDITION]. This training will be completed by March 1st, 2018. Any time an unusual event occurs or a nurse does not feel comfortable or does not feel that she/he has adequate training for the task needing to be completed, that nurse should contact the ADON for that unit or after hours the ADON on call before proceeding. The ADON will then immediately contact the DON or designee. The survey Team confirmed that the facility's plan of removal was implemented on 2/26/18 as evidenced by: 1) Interviews with 5 licensed nurses and registered nurses to confirm the additional training regarding catheters had been performed. 2) Interviews with 2 administrative staff to confirm the LVN A had been trained regarding catheter care, changes, positioning and new policy implementation. 3) Interviews with 5 nurses and registered nurses to confirm they had been educated on the implementation of the new policy to send residents to the emergency room for catheter changes. During an interview on 2/26/18 at 10:30 a.m., DON was informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm with a scope identified as pattern. The facility was continuing to monitor to ensure assessments for side rails were accurate for all residents. The facility was continuing to monitor to ensure catheter care in accordance with professional standards for all residents. Review of the facility provided CMS form 802 Roster/Sample Matrix, dated 2/20/18, documented 9 residents with catheters (WCD interview).

Based on observation, interview and record review; it was determined the facility failed to ensure each resident received the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for 2 of 5 residents reviewed for Quality of Care (Resident #1 and Resident #2). Resident #1 was transferred to her Geri-chair. The Facility failed to place the chair alarm as care planned, and Resident #1 subsequently fell while getting out of the Geri-chair causing fractures to her pelvis, left femur and lumbosacral spine. The Facility failed to initiate authorization and administer Resident #2's [MEDICATION NAME] (a muscle relaxant used to treat muscle spasms and pain) for 12-16 hours after he arrived back in the facility from the emergency room . The facility's failure to ensure each resident received the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being could place 6 residents requiring bed/chair alarms due to fall risks and 19 residents requiring muscle relaxants at risk for falls, pain, bruising, cuts, lacerations, blood loss, broken bones, head injuries, coma and death. Findings include: Record review revealed: Resident #1 is an [AGE] year old female with an admission date of [DATE] with readmission date of [DATE]. She has [DIAGNOSES REDACTED]. While reviewing Resident #1's MDS, dated [DATE], it stated: Resident #1 has vision impairment; a Brief Interview for Mental Status (BIMS) of 3, indicating severe cognitive impairment; requires extensive 1 person assist for all transfers and toileting, dressing, bathing and other activities of daily living (ADL's); uses a wheelchair for mobility; has unilateral lower extremity impairment; is frequently incontinent of bowel and occasionally incontinent of bladder; has pain issues; has had falls; and is at risk for pressure sores. While reviewing the care plan for Resident #1, dated 7/3/17, it states: Resident #1 is care planned for impaired cognition, resisting care, anxiety, pain, impaired mobility, depression, ADL deficit and need for assistance by 1 person, multiple falls, high risk for weight loss and pressure sores. Resident #1 was care planned for a fall mat and bed/chair alarms to prevent falls. While reviewing the nursing notes for Resident #1, it stated: 8/6/2017 at 5:28 p.m.: This nurse was getting ready to pass meds when I glanced over(,) patient was falling to the floor. Patient hit her head on the left side, and also hit her left hip on the tile floor .Patient off unit via ambulance in route to (hospital). House supervisor notified administration. 8/6/2017 at 6:27 p.m.: This nurse called (hospital) to check status of patient and to give report to emergency room nurse. Was informed by Registered Nurse in emergency room (ER) patient sustained a left [MEDICAL CONDITION] from fall, and they are currently awaiting the results from other testing that was done at the emergency room . This nurse notified house supervisor whom notified administration. During an interview on 8/22/17 at 10:13 a.m., CNA A confirmed she assisted family with transferring Resident #1 to her Geri-chair. She confirmed the chair alarm was not placed. She stated, I know I should have checked .But I don't think it would have helped. She confirmed she was busy answering call lights and LVN B was giving meds. She confirmed Resident attempted to stand from Geri-chair and fell . During an interview on 8/22/17 at 10:30 a.m., ADON stated Resident #1 was assisted to her Geri-chair by family, and they didn't put the chair alarm on. She confirmed on 8/6/17 about 5:30 p.m., LVN B was passing medications, and CNA A was answering call lights. She confirmed Resident #1 attempted to get out of the Geri-chair and fell . She stated, LVN B turned in time to see Resident fall. LVN B examined Resident #1. Resident #1 was transferred by EMS to the local hospital. She confirmed 6:27 p.m., LVN B called hospital for update and discovered Resident #1 sustained a fractured left hip. ADON confirmed the Facility is responsible for ensuring chair alarm was in place, not the family. LVN B had recently moved to Florida, and an interview with LVN B was not be possible. Record review revealed: Resident #2 is a [AGE] year old male with an admission date of [DATE] with readmission 4/25/17. He has [DIAGNOSES REDACTED]. While reviewing Resident #2's MDS, dated [DATE], it stated: Resident #2 has a BIMS of 13, indicating mild cognitive deficit; requires limited 1 person assist for all ambulation and bathing, transfers, dressing, toileting and other ADLs; uses both a wheelchair and walker; is always continent of bowel and bladder; has pain issues; has had 2 falls with no injury; and is at risk for pressure sores. While reviewing the care plan for Resident #2, dated 8/11/17, it stated: Resident #2 is care planned for impaired cognition, pain, an ADL deficit requiring at least 1 person assist, walker use, transfer assist by 1 person, refusal of care frequently, depression, impaired mobility, vision impairment, bowel and bladder incontinence, multiple falls, and at risk for pressure sores and wandering. While reviewing the nurses' notes for Resident #2, it stated: Resident #2 sustained a fall on 8/16/17 about 4:30 p.m., while ambulating in his room and struck his chest on an armrest of a wooden chair. He denied any injuries on exam, except pain. Resident #2 continued to complain of pain and was transferred to the ER about 8 p.m. The ER physician diagnosed Resident #2 with bruised ribs and prescribed [MEDICATION NAME] and Tylenol #3 order for pain. No nurses' notes were documented for the night shift of 8/16/17. There was no documentation of Resident #2's return from the ER, notification of the physician or family, or interventions. During a confidential interview on 8/21/17 at 11:30 a.m., Confidential Individual confirmed Resident #2 returned from the ER and arrived back at the facility at approximately 1:30 a.m. During an observation on initial tour on 8/22/2017 at 5:05 a.m., Resident #2 was sitting in his wheelchair in the doorway to his room. Resident #2 had a large purple bruise (approximately the size of a grapefruit) to his left chest and a larger purple bruise (approximately the size of an orange) to his right chest. During an interview on 8/22/2017 at 7:11 a.m., Resident #2 confirmed he fell .a little while back. I fell into a wood chair and really bruised myself up. Resident confirmed he requires pain medication and muscle relaxants to control the pain. He was unable to recall if he had to wait for his mediation, but confirmed he had been in pain since he fell . During an interview on 8/22/2017 at 8:34 a.m., NP confirmed she authorized Resident #2's medication from Hospital #1 when she had received a call from facility upon his return to the facility during the night. She was unable to recall what time she received the call. She stated, I talked with the daughter, and she told me he went some ungodly amount of time without his medication. I don't know if the delay was with the facility or the pharmacy, but I authorized the medication. During an interview on 8/22/2017 at 10:30 a.m., ADON confirmed Resident #2 has advancing dementia and will forget to call for assistance before transferring or ambulating. She confirmed he ambulates with a walker or wheelchair, depending on his preference. She confirmed he had fallen 2 times without injury prior to fall. She confirmed on 8/16/17 about 4:30 p.m., Resident fell in his room while ambulating and struck his chest on an armrest of a wooden chair. He denied any injuries on exam, except pain. Resident continued to complain of pain and was transferred to the ER about 8 p.m. The ER physician diagnosed Resident #2 with bruised ribs and prescribed [MEDICATION NAME] and Tylenol #3 order for pain. ADON was uncertain what time he returned from the ER. During an interview 8/22/2017 at 2:45 p.m., ADON confirmed Resident #2's [MEDICATION NAME] was not administered until 5 p.m. on 8/17/17. She stated she was informed that the medication had not been started because they were waiting on the physician to call back and authorize the medication. She confirmed she discovered the medication had not been ordered after morning meeting (about 10 a.m.) on 8/17/17. She did not know why there was a delay. She confirmed as soon as medication is ordered an authorization should be obtained from the physician. Once the medication is authorized, it should be ordered from the pharmacy and given. During an interview on 8/22/2017 at 2:54 p.m., ADM confirmed he discovered the delay in initiating and administering the [MEDICATION NAME] shortly after morning meeting (about 10 a.m. on 8/17/17) when LVN D informed him. He confirmed he had been told the [MEDICATION NAME] had not been started because staff couldn't get the physician to return the calls. He confirmed he contacted the pharmacy and expedited the medication being delivered. After being informed of the NP's statement that she had authorized the medications shortly after Resident's return to facility from the ER between 1-4 a.m., he was uncertain if the delay was due to the physician failing to return calls, the nurse failing to initiate the orders, or pharmacy failing to deliver the medication. He was unable to determine why the [MEDICATION NAME] was not given until 5 p.m., and he confirmed 12-16 hours is excessive wait for this type of medication. During an interview on 8/22/2017 at 3:15 p.m., LVN C confirmed he was the nurse on duty when Resident #2 arrived back to facility from the ER. He was unable to recall when Resident #2 returned from the ER, but confirmed it was before 4:30 a.m. He confirmed he did not notify the provider on call of the Resident's return or order the medications. He confirmed Resident #2 was on Tylenol #3 already, but needed the [MEDICATION NAME] authorized and ordered. He stated, Since I was agency I didn't know how to work their computer system, so I couldn't order or chart. I told the nurse coming on that I didn't know how to order it, and she said she 'would take care of it'. During an interview on 8/22/2017 at 3:26 p.m., LVN D confirmed she relieved LVN C. She denied receiving any type of report from LVN C. She denied telling him she would handle calling the physician. She stated, I didn't even know he went to the hospital; I found out from his daughter. She confirmed she found the hospital paperwork and prescriptions about 10:00 a.m. and reported it to the administrator. She confirmed she notified the physician at that time. She was uncertain when she received the orders for the [MEDICATION NAME], but she confirmed the medication was not given until 5 p.m. She said delay was due to awaiting authorization from the physician. While reviewing the facility's policy for Verbal Orders, dated February 2014, it stated: Policy Interpretation and Implementation 2. A telephone order is a verbal order given over the telephone. While reviewing the facility's policy for Medication and Treatment Orders, dated April 2014, it stated: Policy Interpretation and Implementation 8. Verbal orders must be recorded immediately in the resident's chart by the person receiving the order . No policies regarding bed/chair alarms or fall prevention were provided. Review of the Resident Census, dated 8/22/2017, documented a census of 75 resident with 6 residents requiring bed/chair alarms and 19 residents requiring muscle relaxant medication (ADON interview).

Based on interviews and record review, it was determined the facility failed to ensure 1 of 2 residents (Resident #18), who had a catheter and a penile implant, and was unable to provide his own catheter care, was provided necessary services. Resident #18 was his penile implant protruding approximately 2 inches out from his penis with drainage coming from his scrotum area. As a result, Resident #18 had surgery 2 days later to remove the penile implant and to repair his penis. Failure to ensure catheter care was provided placed the one additional resident with a catheter and penile implant at risk of lack of care with resulting failure to identify issues with the penile implant. In addition, failure to provide routinely catheter care placed all 20 residents with catheters, at risk for lack of care with resulting discomfort, skin breakdown and infection. The evidence is as follows: 1. Review of Resident #18's clinical record revealed the following: - The face sheet documented an admission date of [DATE], was [AGE] years of age, with the following Diagnoses: [REDACTED]. - An annual MDS, dated [DATE], documented the following: resident had a catheter at time of assessment, continent of bowel. - Nurses' notes documented the following: 5/17/12 at 12:10 p.m. - LVN-B noted CNA observed resident attempting to transfer self and he was unable to complete transfer, staff intervened and resident was assisted back to the side of his bed, resident reports his left leg doesn't work as well as it used to and that it has become harder and harder for him to transfer himself. Resident reports that is why he has been staying in his room more and refusing his showers because he is embarrassed that he is requiring more assistance. Resident had a large incontinent BM and was assisted into the shower. 5/17/12 at 9:48 p.m. - LVN-H noted Foley cath intact/patent draining via gravity amber urine with mild odor. 5/18/12 at 1:13 p.m. - RN-D made the only nursing entry for that day, but made no notation regarding his Foley catheter. 5/19/12 at 2:40 p.m. - LVN-B noted Foley cath is patent and draining light amber urine, denies any pain or discomfort. 5/20/12 at 11:51 p.m. - LVN-I made the only nurses' note entry and noted his oxygen saturation level was at 96% 5/21/12 at 1:05 p.m. - LVN-B noted CNA called this nurse into the shower room where resident was noted to have a clear foreign object protruding approximately 2 inches out from the meatus (head) of his penis with serous (thin and red) drainage coming from his scrotum area, dry gauze was applied to scrotum area. The rapid response team was called and an assessment was completed. Resident reports that he had a penile implant done several years ago and has had no complications that he was aware of, resident shower was completed and resident was assisted back into bed via sit to stand lift with 2 staff members. 5/21/12 at 7:41 p.m. - LVN-H noted that at 3:50 p.m. he left by means of ambulance. It noted that prior to leaving he denies pain/discomfort, states, "I didn't even realize it was out" pointing to penile implant serosanquineous draining from left scrotum, towel placed around area, transported to a local hospital. 2. Review of Resident #18's local hospital's clinical record revealed the following: -The face sheet documented the resident was admitted on [DATE] with the following Diagnoses: [REDACTED]. -A physician progress notes [REDACTED]. -A physician progress notes [REDACTED]. 3. During an interview on 6/1/12 at 5:10 p.m., Resident #18's urologist, stated for Resident #18 to have erosion like that on the end of his penis, it was going on for a "long time." He stated the penile implant was sticking out the meatus or head of Resident #18's penis and that would not occur over night. He stated if staff were taking care of Resident #18 on a regular basis, someone should have noticed his red, swollen and inflamed penis and scrotum. He stated, "You are going to see a lot of things going on, for a good length of time, before something protrudes out the end of a person's penis. I feel strongly that this man was neglected." 4. Review of Resident #18's Hygiene Roster, dated 4/1/2012 through 5/31/12, documented the following: 5/19/12 at 10:06 a.m. and 4:26 p.m. - CNA-A noted peri care was provided. There was no documentation of care prior to 10:06 a.m. or after 4:26 p.m. 5/20/12 at 8:34 a.m. and 3:45 p.m. - CNA-A noted peri care was provided. There was no documentation of care prior to 8:34 a.m. or afte 3:45 p.m. 5/21/12 at 1:52 p.m. - CNA-A noted peri care was provided. There was no documentation of care prior to 1:52 p.m. 5. Review of the staffing schedule for May 2012 documented the nurse aides worked 8 hour shifts. The above documented peri care was only noted for CNA-A not the nurse aides from the other two shifts. 6. During an interview on 6/7/12 at 12:19 p.m., CNA-A stated she had taken care of Resident #18 on Saturday, Sunday and Monday (5/19, 5/20 and 5/21). She stated when she would change Resident #18's brief, she would provide catheter care. She stated she did not see any skin issues with Resident #18 on 5/19 or 5/20. She said it was not until he was in the shower on 5/21/12 (at 1:52 p.m.). She stated when Resident #18 was in the shower, she stood him up and sat him in the shower chair and noticed something was wrong with his penis. She stated Resident #18 had what looked like a big white [MEDICATION NAME] sticking out of his penis. She stated she reported the problem to LVN-B. She stated she tried to wash Resident #18's scrotum but his scrotum started bleeding and oozing pus. 7. Attempts were made to interview the nurse aides who had worked with Resident #18 on the other two shifts for the days preceding 5/21/12 when Resident #18's penile implant was found protruding from his penis. The nurse aides failed to return the investigator's calls. 8. During an interview on 6/8/12 at 9:46 a.m., LVN-B stated she had taken care of Resident #18 for two days before the penile implant was found sticking out of his penis. She stated she had checked the catheter several times and there was no swelling or redness to Resident #18's penis or scrotum. 9. Review of Resident #18's clinical record (to include nurses' notes, treatment sheet) noted LVN-B provided evidence she had checked his catheter on 5/19/12 at 2:40 p.m. There was no additional documentation by LVN-B until two days later on 5/21/12 at 2:21 p.m., when she noted a nurse aide called her to the shower room. 10. During an interview on 6/7/12 at 9:39 a.m., the DON stated staff should of seen something wrong with Resident #18's penis if care was being provided. 10. Review of the Resident Census and Condition of Residents (CMS Form 672), dated 6/4/12, documented 20 residents with an indwelling catheter. 11. During an interview on 6/4/12 at 4:25 p.m., the Administrator stated she was aware of 2 residents in the facility with a penile implant.

Based on interviews and record reviews, it was determined the facility failed to implement their policies and procedures to prohibit neglect, when two of two nurses (LVN A and LVN D) failed to ensure one of five sampled resident's (Resident #1's) physician was immediately consulted and the family immediately notified of Resident #1's change of condition. Resident #1, a resident who received blood thinning medications, experienced severe bleeding which included expelling blood clots. Resident #1 received four medications which increased her risk of bleeding and had experienced a fall on 12/5/11. On 12/6/11 at 1:00 a.m., Resident #1 was found with her disposable brief saturated with blood. Seven hours after LVN A and LVN D became aware of Resident #1's change of condition, LVN B consulted Resident #1's physician's FNP and called 911. When the Emergency Medical Technicians assessed Resident #1 to be unresponsive and to have no blood pressure. Within 30 minutes of arriving at the local hospital's emergency room Resident #1 was started on one unit of blood. Resident #1 remained in the hospital four days and received a total of four units of blood. Resident #1 did not return to the nursing facility. Failure to immediately consult Resident #1's physician and failure to immediately notify Resident #1's family of her significant change of condition resulted in Resident #1 not receiving timely care and services and placed her at risk of death. As of 12/21/11, the facility had taken no action to prevent further incidents from occurring; thus, all 8 residents on blood thinners and 1 resident with a change of condition were placed at risk of their attending physician not being immediately consulted and their family not being immediately notified in the event the resident experienced a significant change of condition. This placed all 20 residents on the Skilled Nursing Unit at risk of not receiving timely evaluation and treatment with an outcome of potential death. This failure led to the identification of Immediate Jeopardy (IJ) on 12/22/11. While the IJ was removed on 12/23/11, the facility remained out of compliance at a level of actual harm with a scope identified isolated. The facility continued to in-service the nursing staff regarding immediate consult with physicians (i.e., physician's FNP or PA) should a resident experience a change of condition. The evidence is as follows: 1. Review of Resident #1's clinical record revealed the following: - The face sheet documented an admission date of [DATE] to the Skilled Nursing Unit, with the following Diagnoses: [REDACTED]. It documented Resident #1's current age was 82. - Review of Resident #1's admission MDS, dated [DATE], documented the resident had no long/short term memory or decision making impairment. The resident required the minimal assist of 1 for transferring, dressing, personal hygiene, and bathing. The resident was wheelchair dependent and could propel self in a wheelchair. The resident was continent of bowel and bladder. - Review of Resident's #1 Care Plan, dated 11/23/11. documented the following: Risk for Falls: Monitor labs and report abnormals to MD. History of [MEDICAL CONDITION]: Give meds per order, monitor labs and report abnormals to the MD. Keep MD and responsible party informed of resident's progress. There was no Care Plan for Potential for Bleeding. - Review of the Admission physician's orders [REDACTED]. by mouth every day. [MEDICATION NAME] (blood thinner) 50 mg. by mouth twice a day, - physician's orders [REDACTED]. sq (subcutaneous) every day. [MEDICATION NAME] 500 mg. (anti-[MEDICAL CONDITION]) 500 mg. by mouth every six hours for 48 hours, then every 6 hours as needed. - A Physician's Progress Note, dated 12/5/11, documented the resident admitted with primary [DIAGNOSES REDACTED]. It further noted her [DIAGNOSES REDACTED]. - The November and December 2011 Medication Administration Records documented Resident #1 received four medications which increased the risk of bleeding: 40 mEq of [MEDICATION NAME] subcutaneous every day (a blood thinner), 50 mg of [MEDICATION NAME] twice a day (a platelet-aggregation inhibitor), two tablets of 220 mg [MEDICATION NAME] every day (a non-steroid anti-[MEDICAL CONDITION] pain medication), and 81 mg of aspirin once a day (a pain medication also used to thin blood and prevent blood clots). The [MEDICATION NAME] was first administered on 11/23/11. Reference: The National Library of Health's on-line resource - Medline Plus: www.nlm.nih.gov/medlineplus/druginfor/meds. 2. Review of an Accident/Incident Report, dated 12/5/11, documented on 12/5/11 at 5:45 a.m., a nurse aide found Resident #1 sitting on her bedroom floor soaked in urine. It documented Resident #1 stated she was going to the bathroom when she fell . It documented she was assessed to have no injuries and she complained of no pain. It documented hip x-rays were negative for a fracture. 3. Review of Resident #1's Departmental (Nurses') Notes revealed the following: - From 12/5/11 at 8:24 p.m. until 12/6/11 at 1:00 a.m., the notes provided no evidence to indicate Resident #1 experienced a significant change in her condition (i.e., pain, bleeding). - On 12/6/11 1:00 a.m., Charge nurse, LVN A, documented Resident #1 called for assistance to move to her bedside commode. It noted when the nurse pulled down the resident's pull-ups, she observed the brief was "saturated" and "full of bloody urine, (the brief) was also very heavy". The nurse also noted there was blood tinged urine in the commode. It noted the resident stated she was very weak. It then noted there were a "couple small clots in the bucket also". - On 12/6/11 at 2:00 a.m. (one hour later), LVN A noted she found a blood clot, the size of a marble, in Resident #1's brief and "minimal blood". She noted the resident "urinated bright red blood" and she called the physician's FNP and left a message. 4. Review of Resident #1's laboratory reports, documented the following: - Blood draw obtained on 12/5/11 at 6:40 a.m. revealed her Hemoglobin (reflects the number of red blood cells in blood) was at 10.5 (normal value 12-16) and her Hematocrit (% of the total blood volume) was at 30.5 (normal value 37-47). - Blood draw obtained on 12/6/11 at 7:10 a.m. (one day later) revealed her Hemoglobin was at 7.6 and her Hematocrit was at 22.4, which revealed the levels had decreased from the prior day and were indicators of blood loss. 5. During a phone interview on 12/22/11 at 3:45 p.m. with LVN A, she said she was Resident #1's charge nurse on the night of 12-5/6-11. She said on 12/6/11 at 1:00 a.m., Resident#1's brief was "completely saturated" with blood. She said the amount of blood alarmed her at first. She said on 12/6/11, she ordered a Chem 7 (gives Potassium, Sodium, etc levels). She said she meant to order a CBC (complete blood count). When asked if she had a physician's orders [REDACTED]. 6. Further review of Resident #1's Departmental (Nurses') Notes revealed the following: - On 12/6/11 (no time), Charge nurse LVN B documented she went to Resident #1's room to assist her off the bedpan. She noted there was "copious amounts of bright red blood". She noted the resident's vital signs were blood pressure: 70/40, pulse: 80, respirations: 22. - On 12/6/11 at 7:50 a.m., LVN B documented she called the physician's FNP and received an order to send the resident to the hospital. She noted that at 8:05 a.m., the ambulance arrived, and (they) were unable to get blood pressure. - A late entry, completed by LVN A on 12/13/11 3:16 a.m., for the remainder of the shift on 12/6/11, documented Resident #1 had no additional episodes of bleeding during the time frame of 2:00 a..m. to 6:45 a.m. 7. Review of the Resident/Patient Transfer form for Resident #1, dated 12/6/11, documented the reason for transfer as "copious amounts of blood from anus/vagina". 8. Review of the Ambulance record, dated 12/6/11, documented the following: - Received call at 8:00 a.m., - Ambulance arrived at the facility at 8:13 a.m. - Primary Impression: Hemorrhage (loss of a large amount of blood) - Medical Necessity: Emergency - Vital signs at 8:28 a.m.: B/P 70/36, pulse 102, respirations 18, - Vital signs at 8:32 a.m.: B/P 84/46, pulse 120, respirations 18 - Treatment: Oxygen per nasal cannula at 3 liters per minute. IV of Normal Saline started, [MEDICATION NAME] (for nausea) given at 8:32 a.m. 9. Review of Resident #1's closed hospital record revealed the following: - The Emergency Department Nursing Record, dated 12/6/11, documented she arrived at 9:05 a.m. and was assessed to have shallow, labored breathing and hematuria (blood) in her urine. It documented at 9:35 a.m. (30 minutes later), they initiated an IV (intravenous) infusion of one unit of blood. - A Radiology Report, dated 12/6/11, documented there was high density material within the bladder suggestive of hemorrhage. It also documented she had an acute left superior pubic and inferior pubic fractures. - Laboratory results, dated 12/6/11 9:00 a.m., documented Resident's Hemoglobin was 8.9 and her Hematocrit 26.4. A laboratory result, dated 12/6/11 12:30 a.m., documented her Hemoglobin was down to 8.1 and her Hematocrit was down to 23.8. - A Diagnostic Imaging titled, Cystogram, dated 12/6/11 at 12:09 p.m., documented "Filling defects (Bladder does not fill properly) within the bladder consistent with clot". - The History and Physical, dated 12/6/11, documented Resident #1 had experienced a fall at the facility on 12/5/11 had the x-ray had apparently revealed no fracture. It documented an indwelling catheter was placed while in the emergency room and they received more than one liter of gross hematuria (bloody urine). It documented Resident #1 received one unit of blood and one liter of fluid while in the emergency room . It documented that despite receiving one unit of blood, her hemoglobin was 8.1. It documented her overall condition was "guarded". - The Discharge Summary, dated 12/10/11, documented Resident #1's discharge [DIAGNOSES REDACTED]. It documented that at the time of arrival to the emergency room , Resident #1 was on [MEDICATION NAME], (blood thinner), [MEDICATION NAME], (anti [MEDICAL CONDITION]) and aspirin (blood thinner), which were all stopped. It documented she received a total of 4 units of blood while in the hospital. 10. During a confidential phone interview on 12/21/11 at 12:45 p.m., C-1 (a family member of Resident #1) said Resident #1 called on the morning of 12/6/11 and when she answered the phone Resident #1 "sounded bad". C-1 said Resident #1 handed the phone to LVN B and LVN B said Resident #1 was "bleeding so bad, it's unreal." C-1 said no call had been received from facility staff prior to calling to visit with Resident #1. C-1 said Resident #1 had said she was not sure she was going to make it out of the hospital alive. 11. During a confidential interview on 12/21/11 at 1:10 p.m., C-2 (another family member of Resident #1) said she received a phone call from Resident #1 asking her to call Resident #1's brother. The family member was told Resident #1 was on her way to the hospital and didn't think she would survive due to bleeding so much. C-2 said when she arrived at the resident's room, she noticed the toilet, bedpan, and bed were full of blood. C-2 asked the nurse what was wrong with Resident #1, and was told she (LVN B) did not know. 12. During an interview on 12/22/11 at 9:35 a.m., with Resident #1 (at the nursing facility she currently resided at), she said she had bleeding through the night, and did not remember having any bleeding before she fell . Resident #1 does not remember going to the hospital by ambulance. 13. Review of the facility submitted form titled, Time Detail, revealed two nurses worked the on the unit Resident #1 resided on at the time of the incident: - LVN A worked from 12/5/11 at 10:45 p.m., to 12/6/11 at 7:16 a.m. during the night Resident #1 experienced the change of condition. - LVN D worked the night shift on 12/5/11 at 10:43 p.m., to 12/6/11 at 7:08 a.m. 14. During a phone interview on 12/22/11 at 3:45 p.m. with charge nurse LVN A, she said on 12/6/11 at 1:00 a.m., she had helped Resident #1 to the bathroom. She said when she pulled down Resident#1's brief, the brief was "completely saturated" with blood. She said the amount of blood alarmed her at first. She said Resident #1 told her she only bled heavy when she stood up. She said she left a message for the on-call provider, but she could not remember what time. She said, "I don't think Resident #1 got the best care." LVN A said prior to 12/6/11 at 1:00 a.m., Resident #1 had some blood tinged urine and was being treated for [REDACTED]. LVN A admitted the brief "completely saturated" with blood was a change in the resident's condition. 15. During a phone interview on 12/22/11 at 3:45 p.m. with LVN A, she said she had helped Resident #1 to the bathroom. When she pulled down Resident#1's brief, the brief was "completely saturated" with blood. She said the amount of blood alarmed her at first. She said Resident #1 told her she only bled heavy when she stood up. She said she ordered a Chem 7 (gives Potassium, Sodium, etc levels), she said she meant to order a CBC (complete blood count). When asked if she had a physician's orders [REDACTED]. She said she left a message for the on-call provider, but she could not remember what time. She said, "I don't think Resident #1 got the best care." LVN A said the resident had some blood tinged urine and was being treated for [REDACTED]. LVN A admitted the brief "completely saturated" with blood was a change in the resident's condition. 16. During a phone interview on 112/22/11 at 5:00 p.m., with LVN D, who worked the same unit with LVN A on 12/6/11, she said LVN A had asked her to look at the amount of Resident #1's blood. LVN D said she told LVN A, to wait to call the physician until the resident was checked again and to compare the amount of blood to the first time. 17. During an interview on 12/22/11 at 4:35 p.m. with RN C, she said she had entered Resident #1's room on the morning of 12/6/11 and found her lying in bed with blood on the drawsheet under her. She said she removed the bedpan from under Resident #1, which had approximately 200 ml of blood, but she did not measure the amount of blood. 18. During an interview on 12/22/11 at 4:45 p.m., with LVN B, she said she worked the day shift on 12/6/11 and came on duty at or about 7:00 a.m. She said LVN A had told her in report that Resident #1 had a small amount of blood in her urine, but LVN A had not made her aware Resident #1 had a saturated her disposable brief. She said when she entered Resident #1's room to take her off the bedpan, she discovered the bedpan was full of blood. LVN B said the sheets were saturated with blood down to the mattress. LVN B said, "I've never seen that much blood." 19. Review of the nursing 24 hour report, documented the following: - On 12/6/11 - night shift noted for Resident #1: vaginal bleeding. There was no documentation on how much bleeding, for how long, or any complaints of pain. 20. During an interview on 12/21/11 at 2:50 p.m., with Resident #1's physician's FNP, he said he did not know about Resident #1's bleeding until 12/6/11 when LVN B called him. He said there was a message left in the early morning. He said when an individual calls their telephone number, they get the message tone, then there is a prompt to push "6" if there is an emergency and the phone rings directly to the on call person. The FNP said he should have been advised by the nurse about the situation at 1:00 a.m. He said he brought his concern to the DON. 21. During an interview on 12/21/11 at 10:15 a.m., with the DON, she said she focused on the fall as the cause of the bleeding and did in-services on fall management. She said she was aware the resident had a urinary tract infection, and had some blood tinged urine. She said she was aware there had been bleeding on 12/6/11, and thought the physician had been called, and labs ordered. She was not aware there had been no contact made by LVN A until she was contacted by the physician's FNP. She said the facility had done training several times on the Rapid Response Team which would respond from the attached hospital to the nursing home in any emergency situation. She said she did not know why LVN A didn't talk call the team. When asked about investigation into the nurse not contacting the physician, she said she was focused on the fall, and did all the in-services on fall prevention. She said she spoke to LVN A, and asked why she didn't speak to the on call person, and LVN A told her she had just left a message. The DON said she had no idea what LVN A was thinking when she left a message only. The DON admitted she did not do an investigation regarding the delay of notification to the physician and responsible party. She said she was focused on the fall as the cause of the bleeding. 22. During an interview on 12/22/11 at 11:30 a.m., with Resident #1's physician (MD), he said he felt the nurse should have talked to the on-call person. He said he had no knowledge Resident #1 was having any bleeding. The MD said he was not comfortable with nurse's ordering lab tests, especially during an emergency. The MD was able to pull up the message on his computer. The screen display documented the time of the call made by LVN A was at 6:23 a.m., (5 hours and 23 minutes later after the nurse first observed the blood saturated brief). The message left was, LVN A came on duty at 11:00 p.m., and when she assisted Resident #1 to the bathroom, Resident #1's pull-up was "soaked with blood", and the next time LVN A checked Resident #1 there were marble sized clots in her brief. LVN A went on to say she ordered a Chem 7. The MD said he would have considered this an emergency situation, and LVN A should have spoken directly to the on-call provider. 23. Review of the facility submitted Policy and Procedure titled, Patient Change in Condition, dated 5/1/11, documented the following: - The facility clinicians will notify the resident's physician and family or legal representative immediately, if there is a crucial/significant change in the resident's condition. Notify the Physician, family, or legal representative immediately if there is a significant change in condition, regardless of time. 24. Review of the facility's Policy and Procedure titled, Abuse Prevention, dated 5/1/11, documented the following: - The facility prohibits the mistreatment, neglect and abuse of residents. - Identification: Identify events, such as suspicious bruising or resident, occurrences, patterns and trends that my constitute abuse or neglect. - The Administrator and Director of Nursing are responsible for investigation - Investigation: Initiate the Incidents Entry report, Investigation, Follow-up process. Collect data on the incident report. Initiate the investigative Action Plan worksheet to guide you through the investigative process. The investigation must be thorough with witness statements from staff, residents, family members who may be interviewable and have information regarding the allegation. Document results of the investigation. 25. On 12/22/11 at 5:23 p.m., the Administrator, DON, QM, and two ADON's were notified of the Immediate Jeopardy. 26. On 12/23/11, the facility's Action Plan for removal of the Immediate Jeopardy was accepted. The plan documented the following: - All nurses (registered and licensed) and nurse aides will be educated on the principles of the change of condition and the corresponding assessments, documentation, and treatments as ordered by the physician and facility protocols prior to return to work assignments and for all new hires on December 23, 2011. - The nurse involved in the incident (LVN A) was suspended pending investigation and termination will take place today. The DON will be reporting her license to the Nursing Board by months end. - All nursing staff will utilize the attached tools of acute change of condition (ACOC) and complete the ACOC determination too. These tools will be attached to the daily 24 hour report and monitored by the DON or designee on a daily basis. - CHECK - (1) Nursing Administrative staff and Administrative designees will complete rounds and will receive a verbal report from the nurse on duty. (2) Facility protocols have been established on contacting physicians, ADON and DON and additionally the appointment of facility house supervisor who will facilitate and act as a point of contact regarding change of conditions and the initiation of the facility rapid response team prior to return to work and for all new hires on December 23, 2011. (3) All nurses will be educated and re-educated on the Professional Standards of Nurses as outlined in the Texas Nurse Practice Act prior to their return to work and for all new hires on December 23, 2011. (4) The Administrator will in-service nursing management on the aspects of a thorough investigation. All future self reports will utilize the agenda "Self Report Identification Checklist" prior to submission. All future reports will be a group decision of the facility leadership team and for all new hires on December 23, 2011. (5) Educate and reeducate facility staff on the facility abuse and neglect policy prior staff returning to work and for all new hires on December 23, 2011. 27. On 12/23/11 at 4:10 p.m., the Administrator was notified the Immediate Jeopardy was removed. The decision to remove the IJ was based on review of the action plan, review of the in-service training records for each shift of nurses and nurse aides, and interviews with nurses and nurse aides from each shift, which verified their knowledge of procedures to follow in the event of a resident's change of condition. Although, the IJ was removed, the facility remained out of compliance at a level of actual harm and a scope identified as a pattern. The facility remained out of compliance due to not all staff had been in-serviced on notification of the physician when a resident experienced a change of condition. 28. Review of the facility submitted form, untitled, undated, documented eight residents were on blood thinners, and one resident had a change in condition on the Skilled Nursing Unit.

Based on interviews and record reviews, it was determined the facility failed to implement their written policy and procedures for abuse/neglect prevention when they - 1) Failed to thoroughly investigate one of one incident of neglect involving Resident #1 who experienced a significant change of condition and the the physician was not immediately consulted and the family was not immediately notified of the significant change of condition (Resident #1). 2) Failed to ensure staff implemented their policies and procedures related to resident change of condition for for one of five sampled residents, who had experienced a change of condition. The physician was not immediately consulted and the family was not immediately notified of the significant change of condition (Resident #1). Resident #1 received four medications which increased her risk of bleeding and had experienced a fall on 12/5/11. On 12/6/11 at 1:00 a.m., Resident #1 was found with her disposable brief saturated with blood. Seven hours after LVN A and LVN D became aware of Resident #1's change of condition, LVN B consulted Resident #1's physician's FNP and called 922. When the Emergency Medical Technicians assessed Resident #1 to be unresponsive and to have no blood pressure. Within 30 minutes of arriving at the local hospital's emergency room Resident #1 was started on one unit of blood. Resident #1 remained in the hospital four days and received a total of four units of blood. Resident #1 did not return to the nursing facility. The facility investigated the circumstances of the fall, but failed to recognize the delay in consulting Resident #1's physician's FNP and delay in notifying the family of the significant change of condition when Resident #1 was found to have a saturated brief. This placed Resident #1 at risk of death. As of 12/21/11 (15 days after Resident #1's significant change of condition), the facility had taken no action to prevent further incidents of failure to immediately consult a resident's physician and notify a resident's family when a resident experiencing a significant change of condition. This placed all 84 residents at risk of not receiving timely evaluation and treatment with a potential outcome of death. This failure led to the identification of Immediate Jeopardy (IJ) on 12/22/11. While the IJ was removed on 12/23/11, the facility remained out of compliance at a level of actual harm with a scope identified isolated. The facility continued to in-service the nursing staff regarding reporting incidents of neglect, conducting thorough investigations and ensuring immediate consult with physicians (i.e., physician's FNP or PA) should a resident experience a change of condition. The evidence is as follows: 1. Review of the facility's Policy and Procedure titled, Abuse Prevention, dated 5/1/11, documented the following: - The facility prohibits the mistreatment, neglect and abuse of residents. - Identification: Identify events, such as suspicious bruising or resident, occurrences, patterns and trends that my constitute abuse or neglect. - The Administrator and Director of Nursing are responsible for investigation - Investigation: Initiate the Incidents Entry report, Investigation, Follow-up process. Collect data on the incident report. Initiate the investigative Action Plan worksheet to guide you through the investigative process. The investigation must be thorough with witness statements from staff, residents, family members who may be interviewable and have information regarding the allegation. Document results of the investigation. 2. Review of Resident #1's clinical record revealed the following: - The face sheet documented a re-admission date of [DATE] with the following Diagnoses: [REDACTED]. It documented Resident #1's current age was 82. - A Physician's Progress Note, dated 12/5/11, documented the resident admitted with primary [DIAGNOSES REDACTED]. It further noted her [DIAGNOSES REDACTED]. - The November and December 2011 Medication Administration Records documented Resident #1 received four medications which increased the risk of bleeding: 40 mEq of [MEDICATION NAME] subcutaneous every day (a blood thinner), 50 mg of [MEDICATION NAME] twice a day (a platelet-aggregation inhibitor), two tablets of 220 mg [MEDICATION NAME] every day (a non-steroid anti-[MEDICAL CONDITION] pain medication), and 81 mg of aspirin once a day (a pain medication also used to thin blood and prevent blood clots). The [MEDICATION NAME] was first administered on 11/23/11. Reference: The National Library of Health's on-line resource - Medline Plus: www.nlm.nih.gov/medlineplus/druginfor/meds. 3. Review of an Accident/Incident Report, dated 12/5/11, documented on 12/5/11 at 5:45 a.m., a nurse aide found Resident #1 sitting on her bedroom floor soaked in urine. It documented Resident #1 stated she was going to the bathroom when she fell . It documented she was assessed to have no injuries and she complained of no pain. It documented hip x-rays were negative for a fracture. 4. Review of Resident #1's Departmental (Nurses') Notes revealed the following: - From 12/5/11 at 8:24 p.m. until 12/6/11 at 1:00 a.m., the notes provided no evidence to indicate Resident #1 experienced a significant change in her condition (i.e., pain, bleeding). - On 12/6/11 1:00 a.m., LVN A documented Resident #1 called for assistance at her bedside commode. It noted that when the nurse pulled down the resident's pull-ups, she observed the brief was "saturated" and "full of bloody urine, (the brief) was also very heavy". The nurse also noted there was blood tinged urine in the commode. It noted the resident stated she was very weak. It then noted there were a "couple small clots in the bucket also". - On 12/6/11 at 2:00 a.m. (one hour later), LVN A noted she found a blood clot, the size of a marble, in Resident #1's brief and "minimal blood". She then noted the resident "urinated bright red blood" and that she called the physician's FNP and left a message. 5. Review of Resident #1's laboratory reports, documented the following: - Blood draw obtained on 12/5/11 at 6:40 a.m. revealed her Hemoglobin (reflects the number of red blood cells in blood) was at 10.5 (normal value 12-16) and her Hematocrit (% of the total blood volume) was at 30.5 (normal value 37-47). - Blood draw obtained on 12/6/11 at 7:10 a.m. (one day later) revealed her Hemoglobin was at 7.6 and her Hematocrit was at 22.4, which revealed the levels had decreased from the prior day and were indicators of blood loss. 6. During a phone interview on 12/22/11 at 3:45 p.m. with LVN A, she said she was Resident #1's charge nurse on the night of 12-5/6-11. She said on 12/6/11 at 1:00 a.m., Resident#1's brief was "completely saturated" with blood. She said the amount of blood alarmed her at first. She said on 12/6/11, she ordered a Chem 7 (gives Potassium, Sodium, etc levels). She said she meant to order a CBC (complete blood count). When asked if she had a physician's orders [REDACTED]. 7. Further review of Resident #1's Departmental (Nurses') Notes revealed the following: - On 12/6/11 (no time), LVN B documented she went to Resident #1's room to assist her off the bedpan. She noted there was "copious amounts of bright red blood". She noted the resident's vital signs were blood pressure: 70/40, pulse: 80, respirations: 22. - On 12/6/11 at 7:50 a.m., LVN B documented she called the physician's FNP and received an order to send the resident to the hospital. She noted that at 8:05 a.m., the ambulance arrived, and (they) were unable to get blood pressure. - A late entry, completed by LVN A on 12/13/11 3:16 a.m., for the remainder of the shift on 12/6/11, documented Resident #1 had no additional episodes of bleeding during the timeframe of 2:00 a..m. to 6:45 a.m. 8. Review of the Resident/Patient Transfer form for Resident #1, dated 12/6/11, documented the reason for transfer as "copious amounts of blood from anus/vagina". 9. Review of the Ambulance record, dated 12/6/11, documented the following: - Received call at 8:00 a.m., - Ambulance arrived at the facility at 8:13 a.m. - Primary Impression: Hemorrhage (loss of a large amount of blood) - Medical Necessity: Emergency - Vital signs at 8:28 a.m.: B/P 70/36, pulse 102, respirations 18, - Vital signs at 8:32 a.m.: B/P 84/46, pulse 120, respirations 18 - Treatment: Oxygen per nasal cannula at 3 liters per minute. IV of Normal Saline started, [MEDICATION NAME] (for nausea) given at 8:32 a.m. 10. Review of Resident #1's closed hospital record revealed the following: - The Emergency Department Nursing Record, dated 12/6/11, documented she arrived at 9:05 a.m. and was assessed to have shallow, labored breathing and hematuria (blood) in her urine. It documented at 9:35 a.m. (30 minutes later), they initiated an IV (intravenous) infusion of one unit of blood. - A Radiology Report, dated 12/6/11, documented there was high density material within the bladder suggestive of hemorrhage. It also documented she had an acute left superior pubic and inferior pubic fractures. - Laboratory results, dated 12/6/11 9:00 a.m., documented Resident's Hemoglobin was 8.9 and her Hematocrit 26.4. A laboratory result, dated 12/6/11 12:30 a.m., documented her Hemoglobin was down to 8.1 and her Hematocrit was down to 23.8. - A Diagnostic Imaging titled, Cystogram, dated 12/6/11 at 12:09 p.m., documented "Filling defects (Bladder does not fill properly) within the bladder consistent with clot". - The History and Physical, dated 12/6/11, documented Resident #1 had experienced a fall at the facility on 12/5/11 had the x-ray had apparently revealed no fracture. It documented an indwelling catheter was placed while in the emergency room and they received more than one liter of gross hematuria (bloody urine). It documented Resident #1 received one unit of blood and one liter of fluid while in the emergency room . it documented they would discontinue [MEDICATION NAME], Aspirin, and NSAIDS. It documented the impression was acute blood loss/[MEDICAL CONDITION] and an acute left superior and inferior pubic fracture. It documented that despite receiving one unit of blood, her hemoglobin was 8.1. It documented her overall condition was "guarded". - The Discharge Summary, dated 12/10/11, documented Resident #1's discharge [DIAGNOSES REDACTED]. It documented that at the time of arrival to the emergency room , Resident #1 was on [MEDICATION NAME], (blood thinner), [MEDICATION NAME], (anti [MEDICAL CONDITION]) and aspirin (blood thinner), which were all stopped. It documented she received a total of four units of blood while in the hospital. 11. During a confidential phone interview on 12/21/11 at 12:45 p.m., C-1 (a family member of Resident #1) said Resident #1 called on the morning of 12/6/11 and when she answered the phone Resident #1 "sounded bad". C-1 said Resident #1 handed the phone to LVN B and LVN B said Resident #1 was "bleeding so bad, it's unreal." C-1 said no call had been received from facility staff prior to calling to visit with Resident #1. C-1 said Resident #1 had said she was not sure she was going to make it out of the hospital alive. 12. During a confidential interview on 12/21/11 at 1:10 p.m., C-2 (another family member of Resident #1) said she received a phone call from Resident #1 asking her to call Resident #1's brother. The family member was told Resident #1 was on her way to the hospital and didn't think she would survive due to bleeding so much. C-2 said when she arrived at the resident's room, she noticed the toilet, bedpan, and bed were full of blood. C-2 asked the nurse what was wrong with Resident #1, and was told she (LVN B) did not know. 13. During an interview on 12/22/11 at 9:35 a.m., with Resident #1 (at the nursing facility she currently resided at), she said she had bleeding through the night, and did not remember having any bleeding before she fell . Resident #1 does not remember going to the hospital by ambulance. 14. Review of the facility submitted form titled, Time Detail, revealed two nurses worked the on the unit Resident #1 resided on at the time of the incident: - LVN A worked from 12/5/11 at 10:45 p.m., to 12/6/11 at 7:16 a.m. during the night Resident #1 experienced the change of condition. - LVN D worked the night shift on 12/5/11 at 10:43 p.m., to 12/6/11 at 7:08 a.m. 15. During a phone interview on 12/22/11 at 3:45 p.m. with charge nurse LVN A, she said on 12/6/11 at 1:00 a.m., she had helped Resident #1 to the bathroom. She said when she pulled down Resident#1's brief, the brief was "completely saturated" with blood. She said the amount of blood alarmed her at first. She said Resident #1 told her she only bled heavy when she stood up. She said she left a message for the on-call provider, but she could not remember what time. She said, "I don't think Resident #1 got the best care." LVN A said prior to 12/6/11 at 1:00 a.m., Resident #1 had some blood tinged urine and was being treated for [REDACTED]. LVN A admitted the brief "completely saturated" with blood was a change in the resident's condition. 16. During a phone interview on 112/22/11 at 5:00 p.m., with LVN D, who worked the same unit with LVN A on 12/6/11, she said LVN A had asked her to look at the amount of Resident #1's blood. LVN D said she told LVN A, to wait to call the physician until the resident was checked again and to compare the amount of blood to the first time. 17. During an interview on 12/22/11 at 4:35 p.m. with RN C, she said she had entered Resident #1's room on the morning of 12/6/11 and found her lying in bed with blood on the drawsheet under her. She said she removed the bedpan from under Resident #1, which had approximately 200 ml of blood, but she did not measure the amount of blood. 18. During an interview on 12/22/11 at 4:45 p.m., with LVN B, she said she worked the day shift on 12/6/11 and came on duty at or about 7:00 a.m. She said LVN A had told her in report that Resident #1 had a small amount of blood in her urine, but LVN A had not made her aware Resident #1 had a saturated her disposable brief. She said when she entered Resident #1's room to take her off the bedpan, she discovered the bedpan was full of blood. LVN B said the sheets were saturated with blood down to the mattress. LVN B said, "I've never seen that much blood." 19. Review of the nursing 24 hour report, documented the following: - On 12/6/11 - night shift noted for Resident #1: vaginal bleeding. There was no documentation on how much bleeding, for how long, or any complaints of pain. 20. During an interview on 12/21/11 at 2:50 p.m., with Resident #1's physician's FNP, he said he did not know about Resident #1's bleeding until 12/6/11 when LVN B called him. He said there was a message left in the early morning. He said when an individual calls their telephone number, they get the message tone, then there is a prompt to push "6" if there is an emergency and the phone rings directly to the on call person. The FNP said he should have been advised by the nurse about the situation at 1:00 a.m. He said he brought his concern to the DON. 21. During an interview on 12/21/11 at 10:15 a.m., with the DON, she said she focused on the fall as the cause of the bleeding and did in-services on fall management. She said she was aware the resident had a urinary tract infection, and had some blood tinged urine. She said she was aware there had been bleeding on 12/6/11, and thought the physician had been called, and labs ordered. She was not aware there had been no contact made by LVN A until she was contacted by the physician's FNP. She said the facility had done training several times on the Rapid Response Team which would respond from the attached hospital to the nursing home in any emergency situation. She said she did not know why LVN A didn't talk call the team. When asked about investigation into the nurse not contacting the physician, she said she was focused on the fall, and did all the in-services on fall prevention. She said she spoke to LVN A, and asked why she didn't speak to the on call person, and LVN A told her she had just left a message. The DON said she had no idea what LVN A was thinking when she left a message only. The DON admitted she did not do an investigation regarding the delay of notification to the physician and responsible party. She said she was focused on the fall as the cause of the bleeding. 22. During an interview on 12/22/11 at 11:30 a.m., with Resident #1's physician (MD), he said he felt the nurse should have talked to the on-call person. He said he had no knowledge Resident #1 was having any bleeding. The MD said he was not comfortable with nurse's ordering lab tests, especially during an emergency. The MD was able to pull up the message on his computer. The screen display documented the time of the call made by LVN A was at 6:23 a.m., (5 hours and 23 minutes later). The message left was LVN A came on duty at 11:00 p.m., and when she assisted Resident #1 to the bathroom, Resident #1's pull-up was "soaked with blood", and the next time LVN A checked Resident #1 there were marble sized clots in her brief. LVN A went on to say she ordered a Chem 7. The MD said he would have considered this an emergency situation, and LVN A should have spoken directly to the on-call provider. 23. Review of the facility submitted Policy and Procedure titled, Patient Change in Condition, dated 5/1/11, documented the following: - The facility clinicians will notify the resident's physician and family or legal representative immediately, if there is a crucial/significant change in the resident's condition. Notify the Physician, family, or legal representative immediately if there is a significant change in condition, regardless of time. 24. Review of the facility's Policy and Procedure titled, Abuse Prevention, dated 5/1/11, documented the following: - The facility prohibits the mistreatment, neglect and abuse of residents. - Identification: Identify events, such as suspicious bruising or resident, occurrences, patterns and trends that my constitute abuse or neglect. - The Administrator and Director of Nursing are responsible for investigation - Investigation: Initiate the Incidents Entry report, Investigation, Follow-up process. Collect data on the incident report. Initiate the investigative Action Plan worksheet to guide you through the investigative process. The investigation must be thorough with witness statements from staff, residents, family members who may be interviewable and have information regarding the allegation. Document results of the investigation. 25. On 12/22/11 at 5:23 p.m., the Administrator, DON, QM, and two ADON's were notified of the Immediate Jeopardy. 26. On 12/23/11, the facility's Action Plan for removal of the Immediate Jeopardy was accepted. The plan documented the following: - All nurses (registered and licensed) and nurse aides will be educated on the principles of the change of condition and the corresponding assessments, documentation, and treatments as ordered by the physician and facility protocols prior to return to work assignments and for all new hires on December 23, 2011. - The nurse involved in the incident (LVN A) was suspended pending investigation and termination will take place today. The DON will be reporting her license to the Nursing Board by months end. - All nursing staff will utilize the attached tools of acute change of condition (ACOC) and complete the ACOC determination too. These tools will be attached to the daily 24 hour report and monitored by the DON or designee on a daily basis. - CHECK - (1) Nursing Administrative staff and Administrative designees will complete rounds and will receive a verbal report from the nurse on duty. (2) Facility protocols have been established on contacting physicians, ADON and DON and additionally the appointment of facility house supervisor who will facilitate and act as a point of contact regarding change of conditions and the initiation of the facility rapid response team prior to return to work and for all new hires on December 23, 2011. (3) All nurses will be educated and re-educated on the Professional Standards of Nurses as outlined in the Texas Nurse Practice Act prior to their return to work and for all new hires on December 23, 2011. (4) The Administrator will in-service nursing management on the aspects of a thorough investigation. All future self reports will utilize the agenda "Self Report Identification Checklist" prior to submission. All future reports will be a group decision of the facility leadership team and for all new hires on December 23, 2011. (5) Educate and reeducate facility staff on the facility abuse and neglect policy prior staff returning to work and for all new hires on December 23, 2011. 27. On 12/23/11 at 4:10 p.m., the Administrator was notified the Immediate Jeopardy was removed. The decision to remove the IJ was based on review of the action plan, review of the in-service training records for each shift of nurses and nurse aides, and interviews with nurses and nurse aides from each shift, which verified their knowledge of procedures to follow in the event of a resident's change of condition. Although, the IJ was removed, the facility remained out of compliance at a level of actual harm and a scope identified as a pattern. The facility remained out of compliance due to not all staff had been in-serviced on notification of the physician when a resident experienced a change of condition. 28. Review of the facility submitted form, untitled, undated, documented eight residents were on blood thinners, and one resident had a change in condition on the Skilled Nursing Unit.

Based on interviews and record reviews, it was determined the facility failed to ensure two of two nurses (LVN A and LVN D) exhibited professional standards in their response to an incident of Resident #1 experiencing a significant change of condition. On 12/6/11, Resident #1 was found with her disposable brief saturated with blood. Resident #1 had experienced a fall the prior day, plus, she received four medications which increased her risk of bleeding. One hour later, the resident had marble sized blood clots in her brief. Five hours and 23 minutes later, LVN A left a voice message for the physician's FNP instead of calling the telephone number, which would have provided immediate contact with the physician's FNP. Approximately six and one-half hours later, the on-coming nurse (LVN B) found Resident #1 lying in a bed saturated with blood with a bedpan under her, which contained a large amount of blood. Seven hours after the initial observations of blood, the physician's FNP was consulted and 911 was notified. The family was not notified, but instead called the facility at or about seven hours after the initial observations of blood and became aware of the significant change of condition. When the emergency medical technician's arrived, they assessed Resident #1 to be unresponsive and to have no blood pressure. Upon arrival at the local hospital's emergency room , Resident #1 was started on one unit of blood. Resident #1 remained in the hospital four days and received a total of four units of blood. Failure to immediately consult Resident #1's physician and failure to immediately notify Resident #1's family of her significant change of condition resulted in Resident #1 not receiving timely care and services and placed her at risk of death. As of 12/21/11, the facility had taken no action to prevent further incidents from occurring; thus, all 84 residents were placed at risk of their attending physician not being immediately consulted and their family not being immediately notified in the event of the resident experiencing a significant change of condition. This placed all 84 residents at risk of not receiving timely evaluation and treatment with an outcome of potential death. This failure led to the identification of Immediate Jeopardy (IJ) on 12/22/11. While the IJ was removed on 12/23/11, the facility remained out of compliance at a level of actual harm with a scope identified isolated. The facility continued to in-service the nursing staff regarding immediate consult with physicians (i.e., physician's FNP or PA) should a resident experience a change of condition. The evidence is as follows: 1. Excerpt from the Board of Nursing's Rules and Regulations - 217.11. Standards of Nursing Practice (1) Standards Applicable to All Nurses, All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (D) Accurately and completely report and document: (i) the clients status including signs and symptoms (vi) contacts with other health care team members concerning significant events regarding clients status. - 217.12 Unprofessional Conduct (6) (C) Causing or permitting . . . neglect to the client. 2. Review of Resident #1's clinical record revealed the following: - The face sheet documented a re-admission date of [DATE] with the following Diagnoses: [REDACTED]. It documented Resident #1's current age was 82. - A Physician's Progress Note, dated 12/5/11, documented the resident admitted with primary [DIAGNOSES REDACTED]. It further noted her [DIAGNOSES REDACTED]. - The November and December 2011 Medication Administration Records documented Resident #1 received four medications which increased the risk of bleeding: 40 mEq of [MEDICATION NAME] subcutaneous every day (a blood thinner), 50 mg of [MEDICATION NAME] twice a day (a platelet-aggregation inhibitor), two tablets of 220 mg [MEDICATION NAME] every day (a non-steroid anti-[MEDICAL CONDITION] pain medication), and 81 mg of aspirin once a day (a pain medication also used to thin blood and prevent blood clots). The [MEDICATION NAME] was first administered on 11/23/11. Reference: The National Library of Health's on-line resource - Medline Plus: www.nlm.nih.gov/medlineplus/druginfor/meds. 3. Review of an Accident/Incident Report, dated 12/5/11, documented on 12/5/11 at 5:45 a.m., a nurse aide found Resident #1 sitting on her bedroom floor soaked in urine. It documented Resident #1 stated she was going to the bathroom when she fell . It documented she was assessed to have no injuries and she complained of no pain. It documented hip x-rays were negative for a fracture. 4. Review of Resident #1's Departmental (Nurses') Notes revealed the following: - From 12/5/11 at 8:24 p.m. until 12/6/11 at 1:00 a.m., the notes provided no evidence to indicate Resident #1 experienced a significant change in her condition (i.e., pain, bleeding). - On 12/6/11 1:00 a.m., LVN A documented Resident #1 called for assistance at her bedside commode. It noted that when the nurse pulled down the resident's pull-ups, she observed the brief was "saturated" and "full of bloody urine, (the brief) was also very heavy". The nurse also noted there was blood tinged urine in the commode. It noted the resident stated she was very weak. It then noted there were a "couple small clots in the bucket also". - On 12/6/11 at 2:00 a.m. (one hour later), LVN A noted she found a blood clot, the size of a marble, in Resident #1's brief and "minimal blood". She then noted the resident "urinated bright red blood" and that she called the physician's FNP and left a message. 5. Review of Resident #1's laboratory reports, documented the following: - Blood draw obtained on 12/5/11 at 6:40 a.m. revealed her Hemoglobin (reflects the number of red blood cells in blood) was at 10.5 (normal value 12-16) and her Hematocrit (% of the total blood volume) was at 30.5 (normal value 37-47). - Blood draw obtained on 12/6/11 at 7:10 a.m. (one day later) revealed her Hemoglobin was at 7.6 and her Hematocrit was at 22.4, which revealed the levels had decreased from the prior day and were indicators of blood loss. 6. During a phone interview on 12/22/11 at 3:45 p.m. with LVN A, she said she had helped Resident #1 to the bathroom. When she pulled down Resident#1's brief, the brief was "completely saturated" with blood. She said the amount of blood alarmed her at first. She said Resident #1 told her she only bled heavy when she stood up. She said she ordered a Chem 7 (gives Potassium, Sodium, etc levels), she said she meant to order a CBC (complete blood count). When asked if she had a physician's orders [REDACTED]. 7. Further review of Resident #1's Departmental (Nurses') Notes revealed the following: - On 12/6/11 (no time), LVN B documented she went to Resident #1's room to assist her off the bedpan. She noted there was "copious amounts of bright red blood". She noted the resident's vital signs were blood pressure: 70/40, pulse: 80, respirations: 22. - On 12/6/11 at 7:50 a.m., LVN B documented she called the physician's FNP and received an order to send the resident to the hospital. She noted that at 8:05 a.m., the ambulance arrived, and (they) were unable to get blood pressure. - A late entry, completed by LVN A on 12/13/11 3:16 a.m., for the remainder of the shift on 12/6/11, documented Resident #1 had no additional episodes of bleeding during the timeframe of 2:00 a..m. to 6:45 a.m. 8. Review of the Resident/Patient Transfer form for Resident #1, dated 12/6/11, documented the reason for transfer as "copious amounts of blood from anus/vagina". 9. Review of the Ambulance record, dated 12/6/11, documented the following: - Received call at 8:00 a.m., - Ambulance arrived at the facility at 8:13 a.m. - Primary Impression: Hemorrhage (loss of a large amount of blood) - Medical Necessity: Emergency - Vital signs at 8:28 a.m.: B/P 70/36, pulse 102, respirations 18, - Vital signs at 8:32 a.m.: B/P 84/46, pulse 120, respirations 18 - Treatment: Oxygen per nasal cannula at 3 liters per minute. IV of Normal Saline started, [MEDICATION NAME] (for nausea) given at 8:32 a.m. 10. Review of Resident #1's closed hospital record revealed the following: - The Emergency Department Nursing Record, dated 12/6/11, documented she arrived at 9:05 a.m. and was assessed to have shallow, labored breathing and hematuria (blood) in her urine. It documented at 9:35 a.m. (30 minutes later), they initiated an IV (intravenous) infusion of one unit of blood. - A Radiology Report, dated 12/6/11, documented there was high density material within the bladder suggestive of hemorrhage. It also documented she had an acute left superior pubic and inferior pubic fractures. - Laboratory results, dated 12/6/11 9:00 a.m., documented Resident's Hemoglobin was 8.9 and her Hematocrit 26.4. A laboratory result, dated 12/6/11 12:30 a.m., documented her Hemoglobin was down to 8.1 and her Hematocrit was down to 23.8. - A Diagnostic Imaging titled, Cystogram, dated 12/6/11 at 12:09 p.m., documented "Filling defects (Bladder does not fill properly) within the bladder consistent with clot". - The History and Physical, dated 12/6/11, documented Resident #1 had experienced a fall at the facility on 12/5/11 had the x-ray had apparently revealed no fracture. It documented an indwelling catheter was placed while in the emergency room and they received more than one liter of gross hematuria (bloody urine). It documented Resident #1 received one unit of blood and one liter of fluid while in the emergency room . it documented they would discontinue [MEDICATION NAME], Aspirin, and NSAIDS. It documented the impression was acute blood loss/[MEDICAL CONDITION] and an acute left superior and inferior pubic fracture. It documented that despite receiving one unit of blood, her hemoglobin was 8.1. It documented her overall condition was "guarded". - The Discharge Summary, dated 12/10/11, documented Resident #1's discharge [DIAGNOSES REDACTED]. It documented that at the time of arrival to the emergency room , Resident #1 was on [MEDICATION NAME], (blood thinner), [MEDICATION NAME], (anti [MEDICAL CONDITION]) and aspirin (blood thinner), which were all stopped. It documented she received a total of 4 units of blood while in the hospital. 11. During a confidential phone interview on 12/21/11 at 12:45 p.m., C-1 (a family member of Resident #1) said Resident #1 called on the morning of 12/6/11 and when she answered the phone Resident #1 "sounded bad". C-1 said Resident #1 handed the phone to LVN B and LVN B said Resident #1 was "bleeding so bad, it's unreal." C-1 said no call had been received from facility staff prior to calling to visit with Resident #1. C-1 said Resident #1 had said she was not sure she was going to make it out of the hospital alive. 12. During a confidential interview on 12/21/11 at 1:10 p.m., C-2 (another family member of Resident #1) said she received a phone call from Resident #1 asking her to call Resident #1's brother. The family member was told Resident #1 was on her way to the hospital and didn't think she would survive due to bleeding so much. C-2 said when she arrived at the resident's room, she noticed the toilet, bedpan, and bed were full of blood. C-2 asked the nurse what was wrong with Resident #1, and was told she (LVN B) did not know. 13. During an interview on 12/22/11 at 9:35 a.m., with Resident #1 (at the nursing facility she currently resided at), she said she had bleeding through the night, and did not remember having any bleeding before she fell . Resident #1 does not remember going to the hospital by ambulance. 14. Review of the facility submitted form titled, Time Detail, revealed two nurses worked the on the unit Resident #1 resided on at the time of the incident: - LVN A worked from 12/5/11 at 10:45 p.m., to 12/6/11 at 7:16 a.m. during the night Resident #1 experienced the change of condition. - LVN D worked the night shift on 12/5/11 at 10:43 p.m., to 12/6/11 at 7:08 a.m. 15. During a phone interview on 12/22/11 at 3:45 p.m. with charge nurse LVN A, she said on 12/6/11 at 1:00 a.m., she had helped Resident #1 to the bathroom. She said when she pulled down Resident#1's brief, the brief was "completely saturated" with blood. She said the amount of blood alarmed her at first. She said Resident #1 told her she only bled heavy when she stood up. She said she left a message for the on-call provider, but she could not remember what time. She said, "I don't think Resident #1 got the best care." LVN A said prior to 12/6/11 at 1:00 a.m., Resident #1 had some blood tinged urine and was being treated for [REDACTED]. LVN A admitted the brief "completely saturated" with blood was a change in the resident's condition. 16. During a phone interview on 112/22/11 at 5:00 p.m., with LVN D, who worked the same unit with LVN A on 12/6/11, she said LVN A had asked her to look at the amount of Resident #1's blood. LVN D said she told LVN A, to wait to call the physician until the resident was checked again and to compare the amount of blood to the first time. 17. During an interview on 12/22/11 at 4:35 p.m. with RN C, she said she had entered Resident #1's room on the morning of 12/6/11 and found her lying in bed with blood on the drawsheet under her. She said she removed the bedpan from under Resident #1, which had approximately 200 ml of blood, but she did not measure the amount of blood. 18. During an interview on 12/22/11 at 4:45 p.m., with LVN B, she said she worked the day shift on 12/6/11 and came on duty at or about 7:00 a.m. She said LVN A had told her in report Resident #1 had a small amount of blood in her urine, but LVN A had not made her aware Resident #1 had a saturated her disposable brief. She said when she entered Resident #1's room to take her off the bedpan, she discovered the bedpan was full of blood. LVN B said the sheets were saturated with blood down to the mattress. LVN B said, "I've never seen that much blood." 19. Review of the nursing 24 hour report, documented the following: - On 12/6/11 - night shift noted for Resident #1: vaginal bleeding. There was no documentation on how much bleeding, for how long, or any complaints of pain. 20. During an interview on 12/21/11 at 2:50 p.m., with Resident #1's physician's FNP, he said he did not know about Resident #1's bleeding until 12/6/11 when LVN B called him. He said there was a message left in the early morning. He said when an individual calls their telephone number, they get the message tone, then there is a prompt to push "6" if there is an emergency and the phone rings directly to the on call person. The FNP said he should have been advised by the nurse about the situation at 1:00 a.m. He said he brought his concern to the DON. 21. During an interview on 12/22/11 at 11:30 a.m., with Resident #1's physician (MD), he said he felt the nurse should have talked to the on-call person. He said he had no knowledge Resident #1 was having any bleeding. The MD said he was not comfortable with nurse's ordering lab tests, especially during an emergency. The MD was able to pull up the message on his computer. The computer screen display documented the time of the call was made by LVN A was at 6:23 a.m., (5 hours and 23 minutes after Resident #1 was discovered with her disposable brief saturated with blood). The message left was, LVN A came on duty at 11:00 p.m., and when she assisted Resident #1 to the bathroom, Resident #1's pull-up was "soaked with blood", and the next time LVN A checked Resident #1 there were marble sized clots in her brief. LVN A went on to say she ordered a Chem 7. The MD said he would have considered this an emergency situation, and LVN A should have spoken directly to the on-call provider. 22. Review of the facility submitted Policy and Procedure titled, Patient Change in Condition, dated 5/1/11, documented the following: - The facility clinicians will notify the resident's physician and family or legal representative immediately, if there is a crucial/significant change in the resident's condition. Notify the Physician, family, or legal representative immediately if there is a significant change in condition, regardless of time. 23. Review of the Provider Investigation Report, signed by the DON on 12/12/11, documented the following: - Description of Allegation: Resident fell when attempting to go the bathroom. - Description of Injury: Resident had a fall on the early morning of 12/5/11 at 5:45 a.m. X-rays were obtained to bilateral hips and the results showed no fracture. On 12/6/11 at 1:00 a.m., the nurse was noted the resident was experiencing bleeding. At 2:00 a.m., more blood was noted in the urine. The physician was notified and a Chem 7 (blood test) was ordered and pain medication administered. At 7:50 a.m., the resident was losing a large amount of blood vaginally and the resident was sent to the hospital via ambulance. At 5 p.m., the family informed the facility the resident had a fractured pelvis and that ruptured the bladder. - Description of Assessment: The resident was found to have large amounts of bright red blood in brief. Vital signs Blood pressure 70/40, pulse 80, respirations 22, oxygen saturation 92%. Pain was controlled with pain medication that was offered and she did not desire any medication. - Investigation summary: Resident had an unwitnessed fall that resulted in internal bleeding. Initial X ray did not diagnose any fracture. - Provider response: Notified family and physician of fall, ordered X-rays. ordered labs, updated care plan, assessed plan, with held physical therapy pending results of X rays. - Educate and re educate staff on falling star program. Educate ADON's on pharmacy review of medications post fall. 24. The Providers Investigation Report failed to note Resident #1 received four medications which placed her at high risk of bleeding. The investigation report failed to note LVN A did not immediately consult with Resident #1's physician or immediately notify Resident #1's family of the change of condition, or the nurse waited five hours and 23 minutes to leave a voice message for the physician. Due to failure to conduct a through investigation, as of 12/21/11 (15 days after Resident #1's change of condition), the facility had not implemented measures to reduce the risk of further incidents of failure to ensure a resident received timely care and services in the event of a change of condition. 25. Review of the facility's Policy and Procedure titled, Abuse Prevention, dated 5/1/11, documented the following: - The facility prohibits the mistreatment, neglect and abuse of residents. - Identification: Identify events, such as suspicious bruising or resident, occurrences, patterns and trends that my constitute abuse or neglect. - The Administrator and Director of Nursing are responsible for investigation - Investigation: Initiate the Incidents Entry report, Investigation, Follow-up process. Collect data on the incident report. Initiate the investigative Action Plan worksheet to guide you through the investigative process. The investigation must be thorough with witness statements from staff, residents, family members who may be interviewable and have information regarding the allegation. Document results of the investigation. 26. During an interview on 12/21/11 at 10:15 a.m., with the DON, she said she focused on the fall as the cause of the bleeding and did in-services on fall management. She said she was aware the resident had a urinary tract infection, and had some blood tinged urine. She said she was aware there had been bleeding on 12/6/11, and thought the physician had been called, and labs ordered. She was not aware there had been no contact made by LVN A until she was contacted by the physician's FNP. She said the facility had done training several times on the Rapid Response Team which would respond from the attached hospital to the nursing home in any emergency situation. She said she did not know why LVN A didn't talk call the team. When asked about investigation into the nurse not contacting the physician, she said she was focused on the fall, and did all the in-services on fall prevention. She said she spoke to LVN A, and asked why she didn't speak to the on call person, and LVN A told her she had just left a message. The DON said she had no idea what LVN A was thinking when she left a message only. The DON admitted she did not do an investigation regarding the delay of notification to the physician and responsible party. She said she was focused on the fall as the cause of the bleeding. 27. On 12/22/11 at 5:23 p.m., the Administrator, DON, QM, and two ADON's were notified of the Immediate Jeopardy. 28. On 12/23/11, the facility's Action Plan for removal of the Immediate Jeopardy was accepted. The plan documented the following: - All nurses (registered and licensed) and nurse aides will be educated on the principles of the change of condition and the corresponding assessments, documentation, and treatments as ordered by the physician and facility protocols prior to return to work assignments and for all new hires on December 23, 2011. - The nurse involved in the incident (LVN A) was suspended pending investigation and termination will take place today. The DON will be reporting her license to the Nursing Board by months end. - All nursing staff will utilize the attached tools of acute change of condition (ACOC) and complete the ACOC determination too. These tools will be attached to the daily 24 hour report and monitored by the DON or designee on a daily basis. - CHECK - (1) Nursing Administrative staff and Administrative designees will complete rounds and will receive a verbal report from the nurse on duty. (2) Facility protocols have been established on contacting physicians, ADON and DON and additionally the appointment of facility house supervisor who will facilitate and act as a point of contact regarding change of conditions and the initiation of the facility rapid response team prior to return to work and for all new hires on December 23, 2011. (3) All nurses will be educated and re-educated on the Professional Standards of Nurses as outlined in the Texas Nurse Practice Act prior to their return to work and for all new hires on December 23, 2011. (4) The Administrator will in-service nursing management on the aspects of a thorough investigation. All future self reports will utilize the agenda "Self Report Identification Checklist" prior to submission. All future reports will be a group decision of the facility leadership team and for all new hires on December 23, 2011. (5) Educate and reeducate facility staff on the facility abuse and neglect policy prior staff returning to work and for all new hires on December 23, 2011. 29. On 12/23/11 at 4:10 p.m., the Administrator was notified the Immediate Jeopardy was removed. The decision to remove the IJ was based on review of the action plan, review of the in-service training records for each shift of nurses and nurse aides, and interviews with nurses and nurse aides from each shift, which verified their knowledge of procedures to follow in the event of a resident's change of condition. Although, the IJ was removed, the facility remained out of compliance at a level of actual harm and a scope identified as a pattern. The facility remained out of compliance due to not all staff had been in-serviced on notification of the physician when a resident experienced a change of condition. 30. Review of the facility submitted form, untitled, undated, documented eight residents were on blood thinners, and one resident had a change in condition on the Skilled Nursing Unit.

Based on interviews and record reviews, it was determined two of two nurses failed to ensure one of five sampled residents received the assessed and care planned level of care and services when they failed to immediately consult Resident #1's physician and immediately notify her family when Resident #1, a resident who received blood thinning medications, experienced severe bleeding which included expelling blood clots. Resident #1 received four medications which increased her risk of bleeding and had experienced a fall on 12/5/11. On 12/6/11 at 1:00 a.m., Resident #1 was found with her disposable brief saturated with blood. Seven hours after LVN A and LVN D became aware of Resident #1's change of condition, LVN B consulted Resident #1's physician's FNP and called 922. When the Emergency Medical Technicians assessed Resident #1 to be unresponsive and to have no blood pressure. Within 30 minutes of arriving at the local hospital's emergency room Resident #1 was started on one unit of blood. Resident #1 remained in the hospital four days and received a total of four units of blood. Resident #1 did not return to the nursing facility. Failure to immediately consult Resident #1's physician and failure to immediately notify Resident #1's family of her significant change of condition resulted in Resident #1 not receiving timely care and services and placed her at risk of death. As of 12/21/11, the facility had taken no action to prevent further incidents from occurring; thus, all 8 residents on blood thinners and 1 resident with a change of condition were placed at risk of their attending physician not being immediately consulted and their family not being immediately notified in the event the resident experienced a significant change of condition. This placed all 20 residents on the Skilled Nursing Unit at risk of not receiving timely evaluation and treatment with an outcome of potential death. This failure led to the identification of Immediate Jeopardy (IJ) on 12/22/11. While the IJ was removed on 12/23/11, the facility remained out of compliance at a level of actual harm with a scope identified isolated. The facility continued to in-service the nursing staff regarding immediate consult with physicians (i.e., physician's FNP or PA) should a resident experience a change of condition. The evidence is as follows: 1. Review of Resident #1's clinical record revealed the following: - The face sheet documented an admission date of [DATE] to the Skilled Nursing Unit, with the following Diagnoses: [REDACTED]. It documented Resident #1's current age was 82. - Review of Resident #1's admission MDS, dated [DATE], documented the resident had no long/short term memory or decision making impairment. The resident required the minimal assist of 1 for transferring, dressing, personal hygiene, and bathing. The resident was wheelchair dependent and could propel self in a wheelchair. The resident was continent of bowel and bladder. - Review of Resident's #1 Care Plan, dated 11/23/11. documented the following: Risk for Falls: Monitor labs and report abnormals to MD. History of [MEDICAL CONDITION]: Give meds per order, monitor labs and report abnormals to the MD. Keep MD and responsible party informed of resident's progress. There was no Care Plan for Potential for Bleeding. - Review of the Admission physician's orders [REDACTED]. by mouth every day. [MEDICATION NAME] (a platelet-aggregation inhibitor), 50 mg. by mouth twice a day, [MEDICATION NAME] (anti-[MEDICAL CONDITION]) 220 mg. 2 by mouth every day. - physician's orders [REDACTED]. sq (subcutaneous) every day, and [MEDICATION NAME] 500 mg. (anti-[MEDICAL CONDITION]/muscle relaxer) 500 mg by mouth every six hours for 48 hours, then every 6 hours as needed. - A Physician's Progress Note, dated 12/5/11, documented the resident admitted with primary [DIAGNOSES REDACTED]. It further noted her [DIAGNOSES REDACTED]. - The November and December 2011 Medication Administration Records documented Resident #1 received four medications which increased the risk of bleeding: 40 mEq of [MEDICATION NAME] subcutaneous every day (a blood thinner), 50 mg of [MEDICATION NAME] twice a day (a platelet-aggregation inhibitor), two tablets of 220 mg [MEDICATION NAME] every day (a non-steroid anti-[MEDICAL CONDITION] pain medication), and 81 mg of aspirin once a day (a pain medication also used to thin blood and prevent blood clots). The [MEDICATION NAME] was first administered on 11/23/11. Reference: The National Library of Health's on-line resource - Medline Plus: www.nlm.nih.gov/medlineplus/druginfor/meds. 2. Review of an Accident/Incident Report, dated 12/5/11, documented on 12/5/11 at 5:45 a.m., a nurse aide found Resident #1 sitting on her bedroom floor soaked in urine. It documented Resident #1 stated she was going to the bathroom when she fell . It documented she was assessed to have no injuries and she complained of no pain. It documented hip x-rays were negative for a fracture. 3. Review of Resident #1's Departmental (Nurses') Notes revealed the following: - From 12/5/11 at 8:24 p.m. until 12/6/11 at 1:00 a.m., the notes provided no evidence to indicate Resident #1 experienced a significant change in her condition (i.e., pain, bleeding). - On 12/6/11 1:00 a.m., Charge nurse, LVN A, documented Resident #1 called for assistance to move to her bedside commode. It noted when the nurse pulled down the resident's pull-ups, she observed the brief was "saturated" and "full of bloody urine, (the brief) was also very heavy". The nurse also noted there was blood tinged urine in the commode. It noted the resident stated she was very weak. It then noted there were a "couple small clots in the bucket also". - On 12/6/11 at 2:00 a.m. (one hour later), LVN A noted she found a blood clot, the size of a marble, in Resident #1's brief and "minimal blood". She noted the resident "urinated bright red blood" and she called the physician's FNP and left a message. 4. Review of Resident #1's laboratory reports, documented the following: - Blood draw obtained on 12/5/11 at 6:40 a.m. revealed her Hemoglobin (reflects the number of red blood cells in blood) was at 10.5 (normal value 12-16) and her Hematocrit (% of the total blood volume) was at 30.5 (normal value 37-47). - Blood draw obtained on 12/6/11 at 7:10 a.m. (one day later) revealed her Hemoglobin was at 7.6 and her Hematocrit was at 22.4, which revealed the levels had decreased from the prior day and were indicators of blood loss. 5. During a phone interview on 12/22/11 at 3:45 p.m. with LVN A, she said she was Resident #1's charge nurse on the night of 12-5/6-11. She said on 12/6/11 at 1:00 a.m., Resident#1's brief was "completely saturated" with blood. She said the amount of blood alarmed her at first. She said on 12/6/11, she ordered a Chem 7 (gives Potassium, Sodium, etc levels). She said she meant to order a CBC (complete blood count). When asked if she had a physician's orders [REDACTED]. 6. Further review of Resident #1's Departmental (Nurses') Notes revealed the following: - On 12/6/11 (no time), Charge nurse LVN B documented she went to Resident #1's room to assist her off the bedpan. She noted there was "copious amounts of bright red blood". She noted the resident's vital signs were blood pressure: 70/40, pulse: 80, respirations: 22. - On 12/6/11 at 7:50 a.m., LVN B documented she called the physician's FNP and received an order to send the resident to the hospital. She noted that at 8:05 a.m., the ambulance arrived, and (they) were unable to get blood pressure. - A late entry, completed by LVN A on 12/13/11 3:16 a.m., for the remainder of the shift on 12/6/11, documented Resident #1 had no additional episodes of bleeding during the time frame of 2:00 a..m. to 6:45 a.m. 7. Review of the Resident/Patient Transfer form for Resident #1, dated 12/6/11, documented the reason for transfer as "copious amounts of blood from anus/vagina". 8. Review of the Ambulance record, dated 12/6/11, documented the following: - Received call at 8:00 a.m., - Ambulance arrived at the facility at 8:13 a.m. - Primary Impression: Hemorrhage (loss of a large amount of blood) - Medical Necessity: Emergency - Vital signs at 8:28 a.m.: B/P 70/36, pulse 102, respirations 18, - Vital signs at 8:32 a.m.: B/P 84/46, pulse 120, respirations 18 - Treatment: Oxygen per nasal cannula at 3 liters per minute. IV of Normal Saline started, [MEDICATION NAME] (for nausea) given at 8:32 a.m. 9. Review of Resident #1's closed hospital record revealed the following: - The Emergency Department Nursing Record, dated 12/6/11, documented she arrived at 9:05 a.m. and was assessed to have shallow, labored breathing and hematuria (blood) in her urine. It documented at 9:35 a.m. (30 minutes later), they initiated an IV (intravenous) infusion of one unit of blood. - A Radiology Report, dated 12/6/11, documented there was high density material within the bladder suggestive of hemorrhage. It also documented she had an acute left superior pubic and inferior pubic fractures. - Laboratory results, dated 12/6/11 9:00 a.m., documented Resident's Hemoglobin was 8.9 and her Hematocrit 26.4. A laboratory result, dated 12/6/11 12:30 a.m., documented her Hemoglobin was down to 8.1 and her Hematocrit was down to 23.8. - A Diagnostic Imaging titled, Cystogram, dated 12/6/11 at 12:09 p.m., documented "Filling defects (Bladder does not fill properly) within the bladder consistent with clot". - The History and Physical, dated 12/6/11, documented Resident #1 had experienced a fall at the facility on 12/5/11 had the x-ray had apparently revealed no fracture. It documented an indwelling catheter was placed while in the emergency room and they received more than one liter of gross hematuria (bloody urine). It documented Resident #1 received one unit of blood and one liter of fluid while in the emergency room . It documented that despite receiving one unit of blood, her hemoglobin was 8.1. It documented her overall condition was "guarded". - The Discharge Summary, dated 12/10/11, documented Resident #1's discharge [DIAGNOSES REDACTED]. It documented that at the time of arrival to the emergency room , Resident #1 was on [MEDICATION NAME], (blood thinner), [MEDICATION NAME], (anti [MEDICAL CONDITION]) and aspirin (blood thinner), which were all stopped. It documented she received a total of 4 units of blood while in the hospital. 10. During a confidential phone interview on 12/21/11 at 12:45 p.m., C-1 (a family member of Resident #1) said Resident #1 called on the morning of 12/6/11 and when she answered the phone Resident #1 "sounded bad". C-1 said Resident #1 handed the phone to LVN B and LVN B said Resident #1 was "bleeding so bad, it's unreal." C-1 said no call had been received from facility staff prior to calling to visit with Resident #1. C-1 said Resident #1 had said she was not sure she was going to make it out of the hospital alive. 11. During a confidential interview on 12/21/11 at 1:10 p.m., C-2 (another family member of Resident #1) said she received a phone call from Resident #1 asking her to call Resident #1's brother. The family member was told Resident #1 was on her way to the hospital and didn't think she would survive due to bleeding so much. C-2 said when she arrived at the resident's room, she noticed the toilet, bedpan, and bed were full of blood. C-2 asked the nurse what was wrong with Resident #1, and was told she (LVN B) did not know. 12. During an interview on 12/22/11 at 9:35 a.m., with Resident #1 (at the nursing facility she currently resided at), she said she had bleeding through the night, and did not remember having any bleeding before she fell . Resident #1 does not remember going to the hospital by ambulance. 13. Review of the facility submitted form titled, Time Detail, revealed two nurses worked the on the unit Resident #1 resided on at the time of the incident: - LVN A worked from 12/5/11 at 10:45 p.m., to 12/6/11 at 7:16 a.m. during the night Resident #1 experienced the change of condition. - LVN D worked the night shift on 12/5/11 at 10:43 p.m., to 12/6/11 at 7:08 a.m. 14. During a phone interview on 12/22/11 at 3:45 p.m. with charge nurse LVN A, she said on 12/6/11 at 1:00 a.m., she had helped Resident #1 to the bathroom. She said when she pulled down Resident#1's brief, the brief was "completely saturated" with blood. She said the amount of blood alarmed her at first. She said Resident #1 told her she only bled heavy when she stood up. She said she left a message for the on-call provider, but she could not remember what time. She said, "I don't think Resident #1 got the best care." LVN A said prior to 12/6/11 at 1:00 a.m., Resident #1 had some blood tinged urine and was being treated for [REDACTED]. LVN A admitted the brief "completely saturated" with blood was a change in the resident's condition. 15. During a phone interview on 112/22/11 at 5:00 p.m., with LVN D, who worked the same unit with LVN A on 12/6/11, she said LVN A had asked her to look at the amount of Resident #1's blood. LVN D said she told LVN A, to wait to call the physician until the resident was checked again and to compare the amount of blood to the first time. 16. During an interview on 12/22/11 at 4:35 p.m. with RN C, she said she had entered Resident #1's room on the morning of 12/6/11 and found her lying in bed with blood on the drawsheet under her. She said she removed the bedpan from under Resident #1, which had approximately 200 ml of blood, but she did not measure the amount of blood. 17. During an interview on 12/22/11 at 4:45 p.m., with LVN B, she said she worked the day shift on 12/6/11 and came on duty at or about 7:00 a.m. She said LVN A had told her in report that Resident #1 had a small amount of blood in her urine, but LVN A had not made her aware Resident #1 had a saturated her disposable brief. She said when she entered Resident #1's room to take her off the bedpan, she discovered the bedpan was full of blood. LVN B said the sheets were saturated with blood down to the mattress. LVN B said, "I've never seen that much blood." 18. Review of the nursing 24 hour report, documented the following: - On 12/6/11 - night shift noted for Resident #1: vaginal bleeding. There was no documentation on how much bleeding, for how long, or any complaints of pain. 19. During an interview on 12/21/11 at 2:50 p.m., with Resident #1's physician's FNP, he said he did not know about Resident #1's bleeding until 12/6/11 when LVN B called him. He said there was a message left in the early morning. He said when an individual calls their telephone number, they get the message tone, then there is a prompt to push "6" if there is an emergency and the phone rings directly to the on call person. The FNP said he should have been advised by the nurse about the situation at 1:00 a.m. He said he brought his concern to the DON. 20. During an interview on 12/21/11 at 10:15 a.m., with the DON, she said she focused on the fall as the cause of the bleeding and did in-services on fall management. She said she was aware the resident had a urinary tract infection, and had some blood tinged urine. She said she was aware there had been bleeding on 12/6/11, and thought the physician had been called, and labs ordered. She was not aware there had been no contact made by LVN A until she was contacted by the physician's FNP. She said the facility had done training several times on the Rapid Response Team which would respond from the attached hospital to the nursing home in any emergency situation. She said she did not know why LVN A didn't talk call the team. When asked about investigation into the nurse not contacting the physician, she said she was focused on the fall, and did all the in-services on fall prevention. She said she spoke to LVN A, and asked why she didn't speak to the on call person, and LVN A told her she had just left a message. The DON said she had no idea what LVN A was thinking when she left a message only. The DON admitted she did not do an investigation regarding the delay of notification to the physician and responsible party. She said she was focused on the fall as the cause of the bleeding. 21. During an interview on 12/22/11 at 11:30 a.m., with Resident #1's physician (MD), he said he felt the nurse should have talked to the on-call person. He said he had no knowledge Resident #1 was having any bleeding. The MD said he was not comfortable with nurse's ordering lab tests, especially during an emergency. The MD was able to pull up the message on his computer. The screen display documented the time of the call made by LVN A was at 6:23 a.m., (5 hours and 23 minutes later after the nurse first observed the blood saturated brief). The message left was, LVN A came on duty at 11:00 p.m., and when she assisted Resident #1 to the bathroom, Resident #1's pull-up was "soaked with blood", and the next time LVN A checked Resident #1 there were marble sized clots in her brief. LVN A went on to say she ordered a Chem 7. The MD said he would have considered this an emergency situation, and LVN A should have spoken directly to the on-call provider. 22. Review of the facility submitted Policy and Procedure titled, Patient Change in Condition, dated 5/1/11, documented the following: - The facility clinicians will notify the resident's physician and family or legal representative immediately, if there is a crucial/significant change in the resident's condition. Notify the Physician, family, or legal representative immediately if there is a significant change in condition, regardless of time. 23. Review of the facility's Policy and Procedure titled, Abuse Prevention, dated 5/1/11, documented the following: - The facility prohibits the mistreatment, neglect and abuse of residents. - Identification: Identify events, such as suspicious bruising or resident, occurrences, patterns and trends that my constitute abuse or neglect. - The Administrator and Director of Nursing are responsible for investigation - Investigation: Initiate the Incidents Entry report, Investigation, Follow-up process. Collect data on the incident report. Initiate the investigative Action Plan worksheet to guide you through the investigative process. The investigation must be thorough with witness statements from staff, residents, family members who may be interviewable and have information regarding the allegation. Document results of the investigation. 24. On 12/22/11 at 5:23 p.m., the Administrator, DON, QM, and two ADON's were notified of the Immediate Jeopardy. 25. On 12/23/11, the facility's Action Plan for removal of the Immediate Jeopardy was accepted. The plan documented the following: - All nurses (registered and licensed) and nurse aides will be educated on the principles of the change of condition and the corresponding assessments, documentation, and treatments as ordered by the physician and facility protocols prior to return to work assignments and for all new hires on December 23, 2011. - The nurse involved in the incident (LVN A) was suspended pending investigation and termination will take place today. The DON will be reporting her license to the Nursing Board by months end. - All nursing staff will utilize the attached tools of acute change of condition (ACOC) and complete the ACOC determination too. These tools will be attached to the daily 24 hour report and monitored by the DON or designee on a daily basis. - CHECK - (1) Nursing Administrative staff and Administrative designees will complete rounds and will receive a verbal report from the nurse on duty. (2) Facility protocols have been established on contacting physicians, ADON and DON and additionally the appointment of facility house supervisor who will facilitate and act as a point of contact regarding change of conditions and the initiation of the facility rapid response team prior to return to work and for all new hires on December 23, 2011. (3) All nurses will be educated and re-educated on the Professional Standards of Nurses as outlined in the Texas Nurse Practice Act prior to their return to work and for all new hires on December 23, 2011. (4) The Administrator will in-service nursing management on the aspects of a thorough investigation. All future self reports will utilize the agenda "Self Report Identification Checklist" prior to submission. All future reports will be a group decision of the facility leadership team and for all new hires on December 23, 2011. (5) Educate and reeducate facility staff on the facility abuse and neglect policy prior staff returning to work and for all new hires on December 23, 2011. 26. On 12/23/11 at 4:10 p.m., the Administrator was notified the Immediate Jeopardy was removed. The decision to remove the IJ was based on review of the action plan, review of the in-service training records for each shift of nurses and nurse aides, and interviews with nurses and nurse aides from each shift, which verified their knowledge of procedures to follow in the event of a resident's change of condition. Although, the IJ was removed, the facility remained out of compliance at a level of actual harm and a scope identified as a pattern. The facility remained out of compliance due to not all staff had been in-serviced on notification of the physician when a resident experienced a change of condition. 27. Review of the facility submitted form, untitled, undated, documented eight residents were on blood thinners, and one resident had a change in condition on the Skilled Nursing Unit.

Based on interviews and record reviews, it was determined two of two nurses (LVN A and LVN D) failed to ensure one of five sampled resident's physician was immediately consulted and the family immediately notified when Resident #1, who received blood thinning medications, experienced a significant change of condition, when she experienced severe bleeding which included expelling blood clots. Resident #1 received four medications which increased her risk of bleeding and had experienced a fall on 12/5/11. On 12/6/11 at 1:00 a.m., Resident #1 was found with her disposable brief saturated with blood. Seven hours after LVN A and LVN D became aware of Resident #1's change of condition, LVN B consulted Resident #1's physician's FNP and called 922. When the Emergency Medical Technicians assessed Resident #1 to be unresponsive and to have no blood pressure. Within 30 minutes of arriving at the local hospital's emergency room Resident #1 was started on one unit of blood. Resident #1 remained in the hospital four days and received a total of four units of blood. Resident #1 did not return to the nursing facility. Failure to immediately consult Resident #1's physician and failure to immediately notify Resident #1's family of her significant change of condition resulted in Resident #1 not receiving timely care and services and placed her at risk of death. As of 12/21/11, the facility had taken no action to prevent further incidents from occurring; thus, all 8 residents on blood thinners, and 1 resident who had a change in condition on the Skilled Nursing Unit were placed at risk of their attending physician not being immediately consulted and their family not being immediately notified in the event the resident experienced a significant change of condition. This placed all 20 residents on the Skilled Nursing Unit at risk of not receiving timely evaluation and treatment with an outcome of potential death. This failure led to the identification of Immediate Jeopardy (IJ) on 12/22/11. While the IJ was removed on 12/23/11, the facility remained out of compliance at a level of actual harm with a scope identified isolated. The facility continued to in-service the nursing staff regarding immediate consult with physicians (i.e., physician's FNP or PA) should a resident experience a change of condition. The evidence is as follows: 1. Review of Resident #1's closed clinical record revealed the following: - The face sheet documented an admission date of [DATE], to the Skilled Nursing Unit with the following Diagnoses: [REDACTED]. It documented Resident #1's current age was 82. - Review of the Admission physician's orders [REDACTED]. by mouth every day. [MEDICATION NAME] (blood thinner) 50 mg. by mouth twice a day, - physician's orders [REDACTED]. sq (subcutaneous) every day. [MEDICATION NAME] 500 mg. (anti-[MEDICAL CONDITION]) 500 mg. by mouth every six hours for 48 hours, then every 6 hours as needed. - A Physician's Progress Note, dated 12/5/11, documented the resident admitted with primary [DIAGNOSES REDACTED]. It further noted her [DIAGNOSES REDACTED]. - The November and December 2011 Medication Administration Records documented Resident #1 received four medications which increased the risk of bleeding: 40 mEq of [MEDICATION NAME] subcutaneous every day (a blood thinner), 50 mg of [MEDICATION NAME] twice a day (a platelet-aggregation inhibitor), two tablets of 220 mg [MEDICATION NAME] every day (a non-steroid anti-[MEDICAL CONDITION] pain medication), and 81 mg of aspirin once a day (a pain medication also used to thin blood and prevent blood clots). The [MEDICATION NAME] was first administered on 11/23/11. Reference: The National Library of Health's on-line resource - Medline Plus: www.nlm.nih.gov/medlineplus/druginfor/meds. 2. Review of an Accident/Incident Report, dated 12/5/11, documented on 12/5/11 at 5:45 a.m., a nurse aide found Resident #1 sitting on her bedroom floor soaked in urine. It documented Resident #1 stated she was going to the bathroom when she fell . It documented she was assessed to have no injuries and she complained of no pain. It documented hip x-rays were negative for a fracture. 3. Further review of Resident #1's closed clinical record revealed the Departmental (Nurses') Notes documented the following: - From 12/5/11 at 8:24 p.m. until 12/6/11 at 1:00 a.m., the notes provided no evidence to indicate Resident #1 experienced a significant change in her condition (i.e., pain, bleeding). - On 12/6/11 1:00 a.m., LVN A noted Resident #1 called for assistance at her bedside commode. It noted that when the nurse pulled down the resident's pull-ups, she observed the brief was "saturated" and "full of bloody urine, (the brief) was also very heavy". The nurse also noted there was blood tinged urine in the commode. It noted the resident stated she was very weak. It then noted there were a "couple small clots in the bucket also". - On 12/6/11 at 2:00 a.m. (one hour later), LVN A noted she found a blood clot, the size of a marble, in Resident #1's brief and "minimal blood". She then noted the resident "urinated bright red blood" and that she called the physician's FNP and left a message. Neither entry by LVN A provided any evidence the nurse consulted with Resident #1's physician or notified Resident #1's family. 4. Review of Resident #1's laboratory reports, documented the following: - Blood draw obtained on 12/5/11 at 6:40 a.m. revealed her Hemoglobin (reflects the number of red blood cells in blood) was at 10.5 (normal value 12-16) and her Hematocrit (% of the total blood volume) was at 30.5 (normal value 37-47). - Blood draw obtained on 12/6/11 at 7:10 a.m. (one day later) revealed her Hemoglobin was at 7.6 and her Hematocrit was at 22.4, which revealed the levels had decreased from the prior day and were indicators of blood loss. 5. During a phone interview on 12/22/11 at 3:45 p.m. with LVN A, she said she was Resident #1's charge nurse on the night of 12-5/6-11. She said on 12/6/11 at 1:00 a.m., Resident#1's brief was "completely saturated" with blood. She said the amount of blood alarmed her at first. She said on 12/6/11, she ordered a Chem 7 (gives Potassium, Sodium, etc levels). She said she meant to order a CBC (complete blood count). When asked if she had a physician's orders [REDACTED]. 6. Additional review of Resident #1's closed clinical record revealed the Departmental (Nurses') Notes documented the following: - On 12/6/11 (no time), LVN B documented she went to Resident #1's room to assist her off the bedpan. She noted there was "copious amounts of bright red blood". She noted the resident's vital signs were blood pressure: 70/40, pulse: 80, respirations: 22. - On 12/6/11 at 7:50 a.m., LVN B documented she called the physician's FNP and received an order to send the resident to the hospital. She noted that at 8:05 a.m., the ambulance arrived, and (they) were unable to get blood pressure. - A late entry, completed by LVN A on 12/13/11 3:16 a.m., for the remainder of the shift on 12/6/11, documented Resident #1 had no additional episodes of bleeding during the timeframe of 2:00 a..M. to 6:45 a.m. 7. Review of the Resident/Patient Transfer form for Resident #1, dated 12/6/11, documented the reason for transfer as "copious amounts of blood from anus/vagina". 8. Review of Resident #1's Ambulance record, dated 12/6/11, documented the following: - Received call at 8:00 a.m., - Ambulance arrived at the facility at 8:13 a.m. - Primary Impression: Hemorrhage (loss of a large amount of blood) - Medical Necessity: Emergency - Vital signs at 8:28 a.m.: B/P 70/36, pulse 102, respirations 18, - Vital signs at 8:32 a.m.: B/P 84/46, pulse 120, respirations 18 - Treatment: Oxygen per nasal cannula at 3 liters per minute. IV of Normal Saline started, [MEDICATION NAME] (for nausea) given at 8:32 a.m. 9. Review of Resident #1's closed hospital record revealed the following: - The Emergency Department Nursing Record, dated 12/6/11, documented she arrived at 9:05 a.m. and was assessed to have shallow, labored breathing and hematuria (blood) in her urine. It documented at 9:35 a.m. (30 minutes later), they initiated an IV (intravenous) infusion of one unit of blood. - A Radiology Report, dated 12/6/11, documented there was high density material within the bladder suggestive of hemorrhage. It also documented she had an acute left superior pubic and inferior pubic fractures. - Laboratory results, dated 12/6/11 9:00 a.m., documented Resident's Hemoglobin was 8.9 and her Hematocrit 26.4. A laboratory result, dated 12/6/11 12:30 a.m., documented her Hemoglobin was down to 8.1 and her Hematocrit was down to 23.8. - A Diagnostic Imaging titled, Cystogram, dated 12/6/11 at 12:09 p.m., documented "Filling defects (the bladder was not filling properly) within the bladder consistent with clot". - The History and Physical, dated 12/6/11, documented Resident #1 had experienced a fall at the facility on 12/5/11 had the x-ray had apparently revealed no fracture. It documented an indwelling catheter was placed while in the emergency room and they received more than one liter of gross hematuria (bloody urine). It documented that despite receiving one unit of blood, her hemoglobin was 8.1. It documented her overall condition was "guarded". - The Discharge Summary, dated 12/10/11, documented Resident #1's discharge [DIAGNOSES REDACTED]. It documented that at the time of arrival to the emergency room , Resident #1 was on [MEDICATION NAME], (blood thinner), [MEDICATION NAME], (anti [MEDICAL CONDITION]) and aspirin (blood thinner), which were all stopped. It documented she received a total of 4 units of blood while in the hospital. 10. During a confidential phone interview on 12/21/11 at 12:45 p.m., C-1 (a family member of Resident #1) said Resident #1 called on the morning of 12/6/11 and when she answered the phone Resident #1 "sounded bad". C-1 said Resident #1 handed the phone to LVN B and LVN B said Resident #1 was "bleeding so bad, it's unreal." C-1 said no call had been received from facility staff prior to calling to visit with Resident #1. C-1 said Resident #1 had said she was not sure she was going to make it out of the hospital alive. 11. During a confidential interview on 12/21/11 at 1:10 p.m., C-2 (another family member of Resident #1) said she received a phone call from Resident #1 asking her to call Resident #1's brother. The family member was told Resident #1 was on her way to the hospital and didn't think she would survive due to bleeding so much. C-2 said when she arrived at the resident's room, she noticed the toilet, bedpan, and bed were full of blood. C-2 asked the nurse what was wrong with Resident #1, and was told she (LVN B) did not know. 12. During an interview on 12/22/11 at 9:35 a.m., with Resident #1 (at the nursing facility she currently resided at), she said she had bleeding through the night, and did not remember having any bleeding before she fell . Resident #1 does not remember going to the hospital by ambulance. 13. Review of the facility submitted form titled, Time Detail, revealed two nurses worked the on the unit Resident #1 resided on at the time of the incident: - LVN A worked from 12/5/11 at 10:45 p.m., to 12/6/11 at 7:16 a.m. during the night Resident #1 experienced the change of condition. - LVN D worked the night shift on 12/5/11 at 10:43 p.m., to 12/6/11 at 7:08 a.m. 14. During a phone interview on 12/22/11 at 3:45 p.m. with charge nurse LVN A, she said on 12/6/11 at 1:00 a.m., she had helped Resident #1 to the bathroom. She said when she pulled down Resident#1's brief, the brief was "completely saturated" with blood. She said the amount of blood alarmed her at first. She said Resident #1 told her she only bled heavy when she stood up. She said she left a message for the on-call provider, but she could not remember what time. She said, "I don't think Resident #1 got the best care." LVN A said prior to 12/6/11 at 1:00 a.m., Resident #1 had some blood tinged urine and was being treated for [REDACTED]. LVN A admitted the brief "completely saturated" with blood was a change in the resident's condition. 15. During a phone interview on 11/22/11 at 5:00 p.m., with charge nurse LVN D, who worked the same unit with LVN A on 12/6/11, she said LVN A had asked her to look at the amount of Resident #1's blood. LVN D said she told LVN A, to wait to call the physician until the resident was checked again and to compare the amount of blood to the first time. 16. During an interview on 12/22/11 at 4:35 p.m. with day shift charge nurse RN C, she said she had entered Resident #1's room on the morning of 12/6/11 and found her lying in bed with blood on the drawsheet under her. She said she removed the bedpan from under Resident #1, which had approximately 200 ml of blood, but she did not measure the amount of blood. She said LVN B arrived, who was Resident #1's charge nurse, and she (RN C) left. 17. During an interview on 12/22/11 at 4:45 p.m., with day shift charge nurse LVN B, she said she worked the day shift on 12/6/11 and came on duty at or about 7:00 a.m. She said she was Resident #1's charge nurse. She said LVN A had told her in report that Resident #1 had a small amount of blood in her urine, but LVN A had not made her aware Resident #1 had a saturated her disposable brief. She said when she entered Resident #1's room to take her off the bedpan, she discovered the bedpan was full of blood. LVN B said the sheets were saturated with blood down to the mattress. LVN B said, "I've never seen that much blood." She said she then went and immediately consulted Resident #1's physician's FNP and received ordered to call 911 and transfer the resident to a local hospital. 18. Review of the nursing 24 hour report, documented the following: - On 12/6/11 - night shift noted for Resident #1: vaginal bleeding. There was no documentation on how much bleeding, for how long, or any complaints of pain. 19. During an interview on 12/21/11 at 2:50 p.m., with Resident #1's physician's FNP, he said he did not know about Resident #1's bleeding until 12/6/11 when LVN B called him. He said there was a message left in the early morning. He said when an individual calls their telephone number, they get the message tone, then there is a prompt to push "6" if there is an emergency and the phone rings directly to the on call person. The FNP said he should have been advised by the nurse about the situation at 1:00 a.m. He said he brought his concern to the DON. 20. During an interview on 12/21/11 at 10:15 a.m., with the DON, she said she focused on the fall as the cause of the bleeding and did in-services on fall management. She said she was aware the resident had a urinary tract infection, and had some blood tinged urine. She said she was aware there had been bleeding on 12/6/11, and thought the physician had been called, and labs ordered. She was not aware there had been no contact made by LVN A until she was contacted by the physician's FNP. She said the facility had done training several times on the Rapid Response Team which would respond from the attached hospital to the nursing home in any emergency situation. She said she did not know why LVN A didn't talk call the team. When asked about investigation into the nurse not contacting the physician, she said she was focused on the fall, and did all the in-services on fall prevention. She said she spoke to LVN A, and asked why she didn't speak to the on call person, and LVN A told her she had just left a message. The DON said she had no idea what LVN A was thinking when she left a message only. The DON admitted she did not do an investigation regarding the delay of notification to the physician and responsible party. She said she was focused on the fall as the cause of the bleeding. 21. During an interview on 12/22/11 at 11:30 a.m., with Resident #1's physician (MD), he said he felt the nurse should have talked to the on-call person. He said he had no knowledge Resident #1 was having any bleeding. The MD said he was not comfortable with nurse's ordering lab tests, especially during an emergency. The MD was able to pull up the message on his computer. The screen display on the MD's computer documented the time of the call made by LVN A was at 6:23 a.m., (5 hours and 23 minutes after Resident #1 was discovered with her disposable brief saturated with blood.). The message left documented LVN A came on duty at 11:00 p.m., and when she assisted Resident #1 to the bathroom at 1:00 a.m., Resident #1's pull-up was "soaked with blood", and the next time LVN A checked Resident #1 there were marble sized clots in her brief. LVN A went on to say she ordered a Chem 7. The MD said he would have considered this an emergency situation, and LVN A should have spoken directly to the on-call provider. 22. Review of the facility submitted Policy and Procedure titled, Patient Change in Condition, dated 5/1/11, documented the following: - The facility clinicians will notify the resident's physician and family or legal representative immediately, if there is a crucial/significant change in the resident's condition. Notify the Physician, family, or legal representative immediately if there is a significant change in condition, regardless of time. 23. On 12/22/11 at 5:23 p.m., the Administrator, DON, QM, and two ADON's were notified of the Immediate Jeopardy. 24. On 12/23/11, the facility's Action Plan for removal of the Immediate Jeopardy was accepted. The plan documented the following: - All nurses (registered and licensed) and nurse aides will be educated on the principles of the change of condition and the corresponding assessments, documentation, and treatments as ordered by the physician and facility protocols prior to return to work assignments and for all new hires on December 23, 2011. - The nurse involved in the incident (LVN A) was suspended pending investigation and termination will take place today. The DON will be reporting her license to the Nursing Board by months end. - All nursing staff will utilize the attached tools of acute change of condition (ACOC) and complete the ACOC determination too. These tools will be attached to the daily 24 hour report and monitored by the DON or designee on a daily basis. - CHECK - (1) Nursing Administrative staff and Administrative designees will complete rounds and will receive a verbal report from the nurse on duty. (2) Facility protocols have been established on contacting physicians, ADON and DON and additionally the appointment of facility house supervisor who will facilitate and act as a point of contact regarding change of conditions and the initiation of the facility rapid response team prior to return to work and for all new hires on December 23, 2011. (3) All nurses will be educated and re-educated on the Professional Standards of Nurses as outlined in the Texas Nurse Practice Act prior to their return to work and for all new hires on December 23, 2011. (4) The Administrator will in-service nursing management on the aspects of a thorough investigation. All future self reports will utilize the agenda "Self Report Identification Checklist" prior to submission. All future reports will be a group decision of the facility leadership team and for all new hires on December 23, 2011. (5) Educate and reeducate facility staff on the facility abuse and neglect policy prior staff returning to work and for all new hires on December 23, 2011. 25. On 12/23/11 at 4:10 p.m., the Administrator was notified the Immediate Jeopardy was removed. The decision to remove the IJ was based on review of the action plan, review of the in-service training records for each shift of nurses and nurse aides, and interviews with nurses and nurse aides from each shift, which verified their knowledge of procedures to follow in the event of a resident's change of condition. Although, the IJ was removed, the facility remained out of compliance at a level of actual harm and a scope identified as a pattern. The facility remained out of compliance due to not all staff had been in-serviced on notification of the physician when a resident experienced a change of condition. 26. Review of the facility submitted form, untitled, undated, documented eight residents were on blood thinners, and one resident had a change in condition on the Skilled Nursing Unit.

Based on observation, interviews and record review, it was determined the facility failed to develop and implement written policies and procedures to prohibit neglect for 1 of 10 sampled residents (Resident #1), when the facility: - Failed to ensure a physician ordered PT/INR lab value for [MEDICATION NAME] (an anticoagulant), was drawn upon admission and weekly to begin the following Monday, to ensure Resident #1's PT/INR level was therapeutic. - Failed to report results of Resident #1's stool sample positive for blood (Guaiac test, used to identify hidden blood in the stool, and an indicator of [MEDICATION NAME] toxicity), to the physician ,(i.e. FNP). As a result, six days after Resident #1 admitted to the facility, a lab test revealed she had a critical INR (19.23, then 30 minutes later 21.19), and the physician gave orders for her to be transferred to a local hospital. Resident #1 was diagnosed as having super therapeutic INR, [MEDICAL CONDITION], and hematuria (blood or blood cells in the urine). She remained in the hospital for seven days and received five units of plasma and two units of blood. This failure placed Resident #1 at risk of life-threatening bleeding or death. These failures led to the identification of Immediate Jeopardy (IJ), on 9/26/11 due to failure to develop and implement policies and procedures to ensure staff requested laboratory test for residents receiving [MEDICATION NAME] therapy, and failure to consult with their physician when tests revealed abnormal results. While the IJ was removed on 9/27/11, the facility remained out of compliance at a level of actual harm with a scope identified as a pattern. The facility was continuing to in-service nursing staff regarding ensuring physician's orders [REDACTED]. In addition, the facility was continuing monitoring of nursing staff to ensure an effective system for [MEDICATION NAME] therapy monitoring was in place. Failure to immediately report abnormal laboratory values and obtain physician ordered laboratory tests placed all 17 residents who received [MEDICATION NAME] at risk of undiagnosed critical [MEDICATION NAME] toxicity, and life threatening bleeding or death. The evidence is as follows: 1) Review of the facility's Abuse Prevention protocol dated 5/1/11, documented: - 1. The facility prohibits the neglect of residents/patients by anyone including staff, family, friends, etc. - 6. Neglect- Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. This presumes that instances of abuse/neglect of all residents/patients, even those in a coma, cause physical harm, pain, or mental anguish. - Prevention- Ensure that prevention techniques are implemented in the facility including, but not limited to, ongoing supervision of employees through visual observation of care delivery and recognition of signs of burnout, frustration, and stress. This includes and is not limited to identification/analysis of assigned staff demonstrating knowledge of individual resident/patient needs. - Identification- Identify events which may constitute neglect. 2) Review of the facility's policy titled Notification of Resident/Patient Change in Condition, dated 5/1/11, documented: - The facility clinicians will notify the resident/patient's Physician and family or legal representative immediately, if there is a crucial/significant change in the resident/patient's condition, according to guidelines developed by the American Medical Director's Association. - 3. Document in the Nurse's Notes the time notification was made and the names of the person(s) to whom you spoke. Sign entry. 3) Review of Resident #1's medical record revealed the following: - The Face Sheet documented she was admitted to the facility on [DATE]. It documented she was [AGE] years of age and admitted for skilled care with a primary [DIAGNOSES REDACTED]. - A list of Resident #1's medications provided by a local pharmacy dated 9/2/11, documented Resident #1 was prescribed [MEDICATION NAME] ([MEDICATION NAME]), 7.5 mg, 1 tablet daily, ordered by Physician "D" on 8/31/11. - A physician's orders [REDACTED]. The order did not indicate the reason the test was ordered. - The September, 2011 MAR indicated [REDACTED]. The nurses notes documented no evidence the physician or FNP had been consulted regarding the positive test result. - Physician's telephone orders signed by the FNP on 9/2/11 at 11:00 a.m., documented orders for a PT/INR now and weekly labs (CBC, CMP, and PT/INR), on Monday. - The record contained no evidence of the results of the PT/INR for 9/2/11, or the following Monday (9/5/11). - Physician's telephone orders dated 9/6/11, written by RN "C" at 9:00 a.m., documented KUB for abdominal pain. The order was signed by the FNP on 9/6/11 at 5:00 p.m. - The KUB laboratory results dated [DATE], documented she had a "mild" ileus (obstruction of the bowel). - A late entry nurses note dated 9/7/11 at 6:21 a.m., for 7:45 p.m. on 9/6/11, documented the FNP had arrived at the facility and it had been discovered a PT/INR test ordered on [DATE] had not been obtained, and there was no requisition in the lab book for the test. It documented a KUB (kidney, ureter, bladder) test, was done earlier in the day and reported a mild ileus. It further documented Resident #1 was complaining her stomach still hurt, and upon assessment was confused and oriented to her name only. It documented the FNP ordered a STAT PT/INR, the results of which was INR 19.23. The FNP then contacted Physician "D", who ordered 10 mg of Vitamin K (a clotting agent), IM and Resident #1's transfer to the emergency room . Additionally, a second lab draw was requested to verify lab data. That lab result was INR 21.19. Resident #1 left the facility via ambulance at 10:00 p.m. - A laboratory result, dated 9/6/11 at 7:35 p.m., confirmed a critical INR value of 19.23 (normal range 2.0-3.0). A second result obtained 30 minutes later at 9:05 p.m., documented a value of 21.19. 4) The Geriatric Dosage Handbook Including Clinical Recommendations and Monitoring Guidelines, 12th edition, copyright 2007, page 1783, documented a target INR for [MEDICATION NAME] (i.e., [MEDICATION NAME]), therapy as 2.5 (2.0-3.0).Page 1784, documented an INR greater than 9.0 could result in life-threatening bleeding or serious [MEDICATION NAME] ([MEDICATION NAME]), overdose. 5) Review of Resident #1's closed hospital record revealed a History and Physical, dated 9/8/11, documented she was admitted to the hospital on [DATE] with a supratherapeutic INR, hematuria (blood in the urine), and abdominal pain. It documented she received Vitamin K, five units of fresh frozen plasma (fluid part of blood), and two units of blood. 6) During an interview on 9/22/11 at 11:15 a.m., Physician "D" said the FNP on 9/2/11 at 11:00 a.m., wrote orders for weekly PT/INRs and other labs starting on the following Monday (9/5/11). Physician "D" said "They get those labs on the morning after a new admit, that's what I expect." During a subsequent interview on 9/23/11 at 12:30 p.m., when it was brought to his attention that his lab protocol for newly admitted residents was not documented on his standing orders, Physician "D" said the protocol was posted at the nurses' stations, adding it documented to obtain CBC, CMP, UA with C&S, and PT/INR if on [MEDICATION NAME], and TSH if [MEDICAL CONDITION] issues. 7) Observation on 9/23/11 at 2:15 p.m., on the Nurses Station on 2 C South, revealed a hand written note in pink highlight pen which read "Q Mondays for Physician "D" and Physician "E" patients. CBC, CMP, and (PT/INR if [MEDICATION NAME] patients). Also hand written in black permanent marker: (TSH 1st lab), and UA/C&S with 1st lab. Note: When Resident #1 initially admitted to the facility on [DATE], she was admitted to 2 C South. She was Physician "D's" patient. 8) During an interview on 9/23/11 at 2:15 p.m., at the 2 C South nurses station, LVN "J" said she was unaware of any lab work protocol for new admissions. Regarding the handwritten posted note written in pink highlight pen, LVN "J" said, "That's what we do for new admits." 9) Observational rounds on 9/26/11 between 11:45 a.m. and 11:53 a.m., with ADON "F" present, revealed only 1 of 4 remaining nurses stations had Physician "D's" lab protocols for newly admitted residents posted. 10) During a telephone interview on 9/23/11 at 8:25 a.m., the FNP said Resident #1 was admitted to the facility on [DATE], adding it was a "cluster" from the beginning because there were no medication orders and the facility was having difficulties obtaining orders from the hospital and from Resident #1's former facility. He said the orders were obtained from Resident #1's pharmacy. The FNP said on 9/1/11 he wrote orders for a PT/INR now, and other weekly labs to begin the following Monday (9/5/11), adding he was on call over the weekend. The FNP said he made rounds on Tuesday (9/6/11), morning and saw Resident #1 at 7:30 a.m. He continued, when he returned Tuesday afternoon, Resident #1 was lethargic and her daughter reported her to be more confused. The FNP said he ordered a KUB and at that time noticed there weren't any labs. The FNP said, "It's kind of a common occurrence, they (nurses), overlook orders." The FNP said nurses reported to him on 9/1/11 that Resident #1 may have had blood in her stools, so he ordered a Guaiac test, but the nurses did not report that it was positive until he inquired about it on 9/6/11. 11) During a telephone interview on 9/23/11 at 11:43 a.m., LVN "H" said she called the lab on 9/6/11 and was informed there had been no PT/INR drawn on 9/1/11. She continued, stating there was also no requisition in the lab book, and there should have been one. 12) During interviews on 9/26/11 at 10:45 a.m., the Administrator and ADON "F" were unable to provide evidence of a policy related to ensuring care and services were provided for residents receiving [MEDICATION NAME] therapy. 13) The facility Administrator and ADON "F" were notified on 9/26/11 at 10:50 a.m., that an Immediate Jeopardy situation had been identified due to the facility's failure to ensure Resident #1 had been monitored for [MEDICATION NAME] toxicity for a total of 6 days. 14) On 9/27/11 at 10:50 a.m., the facility's action plan was accepted. The action plan documented the following: - The facility identified 17 residents who had orders for [MEDICATION NAME]. Resident #1, who was identified on the Immediate Jeopardy, remained in the facility and no longer had an elevated PT/INR. - The facility Medical Director (Physician "D"), re-wrote the facility's standing protocols to include a [MEDICATION NAME] protocol (9/27/11). - Daily monitoring by the ADONs was begun for all abnormal labs and values of the PT/INRs (9/23/11). - Daily monitoring by the ADONs or designee was begun for all residents who were receiving [MEDICATION NAME] therapy (9/23/11). - Daily chart audits were begun on all residents who were receiving [MEDICATION NAME] therapy (9/23/11). - All nursing staff were to be educated on the new [MEDICATION NAME] therapy policy before returning to work (9/27/11). - All nurses were educated on the use of the 24 hour report before returning to work (9/27/11). - The management team began checks of the shift to shift report during the morning meetings (9/27/11). - All new residents who were prescribed [MEDICATION NAME] were to be discussed during the morning meetings (9/27/11). - New physician's protocols were added to the protocol books, located at each nurses station (9/27/11). 15) Prior to removal if the IJ, 11 of 17 records were reviewed to verify residents who were receiving [MEDICATION NAME] therapy, had been audited by the facility according to the action plan. The majority of staff on all shifts were interviewed to confirm they had been educated according to the action plan as submitted, and observations of the nurses stations revealed new protocol notebooks had been placed at each station. 16) The Administrator was informed the IJ was removed on 9/27/11 at 10:50 a.m. However, the facility remained out of compliance at a level of actual harm with a scope identified as a pattern. The facility was continuing to in-service nursing staff regarding ensuring physician's orders [REDACTED]. In addition, the facility was continuing monitoring of nursing staff to ensure an effective system for [MEDICATION NAME] therapy monitoring was in place. 17) Review of the list (undated), of residents who required PT/INR testing, provided by the facility on 9/22/11, documented 17 residents who required PT/INR labs.

Based on interviews and records reviewed, it was determined that for 1 of 10 sampled residents (Resident #1), the facility failed to immediately consult with the physician regarding an abnormal laboratory result. Resident #1, who was on anticoagulant therapy (receiving [MEDICATION NAME], a blood thinner), received a Guaiac test on 9/2/11, which was positive for occult (hidden), blood in the resident's stool (bowel movement). The physician was not immediately consulted regarding the abnormal laboratory value. Four days later (on 9/6/11), the physician's FNP discovered the Guaiac test had revealed she had occult blood in her stools. Failure to consult with Resident #1's physician (i.e., physician's FNP), immediately after the test results revealed hidden blood in her stools, potentially contributed to failure to identify that a PT/INR laboratory test had not been obtained. This failure resulted in the facility being unaware Resident #1 had a critical level of [MEDICATION NAME] in her system. Resident #1 was hospitalized as a result of a critical INR value of 19.23, with a subsequent value obtained 30 minutes later of 21.19. Resident #1 was diagnosed as having a super therapeutic INR, [MEDICAL CONDITION], and hematuria (blood or blood cells in the urine). Resident #1 remained in the hospital for seven days and five units of plasma and two units of blood. This failure placed Resident #1 at risk of life-threatening bleeding or death. This failure led to the identification of Immediate Jeopardy (IJ), on 9/26/11 due to failure to identify and implement corrective procedures to ensure staff immediately consulted physician's regarding abnormal laboratory values for residents receiving anticoagulant therapy. While the IJ was removed on 9/27/11, the facility remained out of compliance at a level of actual harm, with a scope identified as a pattern. The facility was continuing to in-service nursing staff regarding ensuring physician's orders [REDACTED]. In addition, the facility was continuing monitoring of nursing staff to ensure an effective system for [MEDICATION NAME] therapy monitoring was in place. Failure to ensure staff immediately consulted with physician's regarding laboratory test(s), for residents receiving anticoagulant therapy, placed 17 residents who received [MEDICATION NAME] at risk of life-threatening bleeding or death. The evidence is as follows: 1) Resident #1's clinical record revealed the following: - The face sheet documented she was a [AGE] year old female who admitted to the facility on [DATE] at 10:00 p.m., with a [DIAGNOSES REDACTED]. - A list or Resident #1's medications, provided by a local pharmacy, dated 9/2/11, documented her attending physician (Physician "D"), had prescribed one 7.5 mg tablet of [MEDICATION NAME] ([MEDICATION NAME], a blood thinner), to be received daily. - The September 2011 MAR indicated [REDACTED]. - A physician's orders [REDACTED]. The order did not indicate the reason the test was ordered. - The September 2011 MAR indicated [REDACTED]. - The nurses' notes provided no evidence why the test was needed and provided no evidence the physician was immediately consulted regarding the abnormal test result. 2) During an interview with the physician's FNP on 9/23/11 at 8:25 a.m., the FNP said a nurse called him on 9/1/11 and told him Resident #1 "might" have blood in her stools. He said he gave an order for [REDACTED]. He said on 9/6/11, he specifically asked about the Guaiac tests results and a nurse told him the tests had been positive for occult blood in Resident #1's stools. 3) During an interview with LVN "G" on 9/26/11 at 11:10 a.m., she said she conducted the first Guaiac test which was positive. She confirmed she did not notify the physician or the physician's FNP because the test was performed in the middle of the night. She said she told LVN "A" when she gave report the following morning. 4) During an interview with LVN "A" on 9/26/11 at 2:05 p.m., she confirmed LVN "G" notified of Resident #1's positive Guaiac test during morning report. She said she did not consult with Resident #1's physician because she thought LVN "G" had notified the physician. 5) During an interview with LVN "H" on 9/23/11 at 11:43 a.m., she said Resident #1's physician's FNP asked her about the results of the Guaiac test on the evening of 9/6/11. She said she told him the resident had a positive test. She said the FNP asked why he had not been notified and she said she thought he had been notified. 6) During an interview with Resident #1's physician on 9/22/11 at 11:15 a.m., Physician "D" said staff did not consult with him regarding the positive Guaiac test, which indicated she had blood in her stool. 7) Further review of Resident #1's clinical record revealed the following: - A physician's telephone order (no date), but signed by the physician's FNP on 9/2/11 at 11:00 a.m., documented to obtain a PT/INR laboratory test and weekly obtain a PT/INR laboratory test on Mondays. - The record contained no evidence of the results of the PT/INR for 9/2/11 or the following Monday (9/5/11). - A late entry nurse's note, dated 9/7/11, for Tuesday (9/6/11), at 7:45 p.m., documented Resident #1 was confused and oriented to her name only. It documented Resident #1 complained of her stomach still hurting. It documented the physician's FNP was present and ordered a STAT laboratory test of her PT/INR. - A laboratory result, dated 9/6/11, (collected on 9/6/11 at 9:05 p.m.), revealed Resident #1 had a critical INR value of 19.23. 8) The Geriatric Dosage Handbook Including Clinical Recommendations and Monitoring Guidelines, 12th edition, copyright 2007, page 1783, documented a target INR for [MEDICATION NAME] (i.e., [MEDICATION NAME]), therapy as 2.5 (2.0-3.0).Page 1784, documented an INR greater than 9.0 could result in life-threatening bleeding or serious [MEDICATION NAME] ([MEDICATION NAME]), overdose. 9) Continued review of Resident #1's clinical record documented the following: - A physician's progress note, dated 9/6/11 and completed by the physician's FNP, documented at 5:30 p.m., Resident #1's daughter said the resident was "not the same, more confused." At 8:45 p.m., the physician's FNP documented he had reviewed the PT/INR results. It documented the physician's FNP consulted with Physician "D", by telephone, and orders were given for Resident #1 to receive a STAT injection of 10 mg of Vitamin K, and a second STAT PT/INR test was again ordered. - The late entry nurses' note, dated 9/7/11, then documented the second lab draw revealed Resident #1's INR was now at 21.19. It documented Resident #1 transferred to a local hospital via ambulance on 9/6/11 at 10:00 p.m. 10) Review of Resident #1's closed hospital record revealed the following: - A History and Physical, dated 9/8/11, documented she was admitted to the hospital on [DATE] with a supratherapeutic INR, hematuria (blood in the urine), and abdominal pain. It documented she received Vitamin K, five units of fresh frozen plasma (fluid part of blood), and two units of blood. - A Progress Note, dated 9/12/11. documented her INR was 21 at admission. It documented her stool was positive for occult blood. - Discharge Orders, dated 9/13/11, documented Resident #1 was discharged back to the nursing home that day and to continue to monitor her INR until the level was therapeutic (2.0-3.0), at which point anticoagulant therapy could be resumed. 11) During a telephone interview with the physician's FNP on 9/23/11 at 8:25 a.m., he said Resident #1 was admitted to the facility on [DATE]. The FNP said on 9/1/11, he wrote orders for a PT/INR to be obtained now and other weekly labs to begin the following Monday (9/5/11). The FNP said he made rounds on Tuesday morning (9/6/11), and saw Resident #1 at 7:30 a.m. He said when he returned Tuesday afternoon, Resident #1 was lethargic and her daughter reported her to be more confused. The FNP further said he ordered a KUB and at that time noticed there were not any lab results on the chart. He said the nurses reported to him that on 9/1/11, Resident #1 may have had blood in her stools, so he ordered a Guaiac test, but the nurses did not report the test was positive until he inquired about it on 9/6/11. 12) During an interview with LVN "A" on 9/26/11 at 2:05 p.m., LVN "A" said there was a protocol to obtain labs for newly admitted residents, however no labs were obtained for Resident #1 because she was admitted without medication orders. 13) Review of the facility's policy titled Notification of Resident/Patient Change in Condition, dated 5/1/11, documented: - The facility clinicians will notify the resident/patient's Physician and family or legal representative immediately, if there is a crucial/significant change in the resident/patient's condition, according to guidelines developed by the American Medical Director's Association. - 3. Document in the Nurse's Notes the time notification was made and the names of the person(s) to whom you spoke. Sign entry. 14) The Administrator and ADON "F" were notified on 9/26/11 at 10:50 a.m., that an Immediate Jeopardy situation had been identified due to the facility's failure to ensure Resident #1 had been monitored for [MEDICATION NAME] toxicity for a total of 6 days. 15) On 9/27/11 at 10:50 a.m., the facility's action plan was accepted. The action plan documented the following: - The facility identified 17 residents who had orders for [MEDICATION NAME]. Resident #1, who was identified on the Immediate Jeopardy, remained in the facility and no longer had an elevated PT/INR. - The facility Medical Director (Physician "D"), re-wrote the facility's standing protocols to include a [MEDICATION NAME] protocol (9/27/11). - Daily monitoring by the ADONs was begun for all abnormal labs and values of the PT/INRs (9/23/11). - Daily monitoring by the ADONs or designee was begun for all residents who were receiving [MEDICATION NAME] therapy (9/23/11). - Daily chart audits were begun on all residents who were receiving [MEDICATION NAME] therapy (9/23/11). - All nursing staff were to be educated on the new [MEDICATION NAME] therapy policy before returning to work (9/27/11). - All nurses were educated on the use of the 24 hour report before returning to work (9/27/11). - The management team began checks of the shift to shift report during the morning meetings (9/27/11). - All new residents who were prescribed [MEDICATION NAME] were to be discussed during the morning meetings (9/27/11). - New physician's protocols were added to the protocol books, located at each nurses station (9/27/11). 16) Prior to removal if the IJ, 11 of 17 residents' clinical records were reviewed to verify all residents, who were receiving [MEDICATION NAME] therapy, had been audited by the facility according to the action plan. The majority of staff on all shifts were interviewed to confirm they had been educated according to the action plan as submitted, and observations of the nurses stations revealed new protocol notebooks had been placed at each station. 17) The Administrator was informed the IJ was removed on 9/27/11 at 10:50 a.m. However, the facility remained out of compliance at a level of actual harm with a scope identified as a pattern. The facility was continuing to in-service nursing staff regarding ensuring physician's orders [REDACTED]. In addition, the facility was continuing monitoring of nursing staff to ensure an effective system for [MEDICATION NAME] therapy monitoring was in place. 18) Review of the form titled "Residents Who Require PT/INR laboratory tests", received from the facility on 9/22/11, documented 17 residents required PT/INR testing.

Based on observation, interviews and record review, it was determined the facility failed to develop and implement policies and procedures to prohibit neglect for 1 of 10 sampled residents (Resident #1), when the facility: - Failed to ensure a physician ordered PT/INR lab value for [MEDICATION NAME] (an anticoagulant), was drawn upon admission and weekly beginning on Mondays, to ensure Resident #1's PT/INR level was therapeutic 6 days later. - Failed to report results of the resident's stool sample positive for blood (Guaiac test, used to identify hidden blood in the stool, and an indicator of [MEDICATION NAME] toxicity), to the physician (i.e. FNP). As a result, six days after Resident #1 admitted to the facility, a lab test revealed she had a critical INR (19.23, then 30 minutes later 21.19), and the physician gave orders for her to be transferred to a local hospital. Resident #1 was diagnosed as having super therapeutic INR, [MEDICAL CONDITION], and hematuria (blood or blood cells in the urine). She remained in the hospital for seven days and received five units of plasma and two units of blood. This failure placed Resident #1 at risk of life-threatening bleeding or death. These failures led to the identification of Immediate Jeopardy (IJ) on 9/26/11 due to failure to develop and implement policies and procedures to ensure staff requested laboratory test for residents receiving [MEDICATION NAME] therapy, and failure to consult with their physician when tests revealed abnormal results. While the IJ was removed on 9/27/11, the facility remained out of compliance at a level of actual harm with a scope identified as a pattern. The facility was continuing to in-service nursing staff regarding ensuring physician's orders [REDACTED]. In addition, the facility was continuing monitoring of nursing staff to ensure an effective system for [MEDICATION NAME] therapy monitoring was in place. Failure to immediately report abnormal laboratory values and obtain physician ordered laboratory tests placed all 17 residents who received [MEDICATION NAME] at risk of undiagnosed critical [MEDICATION NAME] toxicity, and life threatening bleeding or death. The evidence is as follows: 1) Review of Resident #1's medical record revealed the following: - The Face Sheet documented she was admitted to the facility on [DATE]. It documented she was [AGE] years of age and admitted for skilled care with a primary [DIAGNOSES REDACTED]. - A list of Resident #1's medications provided by a local pharmacy dated 9/2/11, documented Resident #1 was prescribed [MEDICATION NAME] ([MEDICATION NAME]), 7.5 mg, 1 tablet daily, ordered by Physician "D" on 8/31/11. - A physician's orders [REDACTED]. The order did not indicate the reason the test was ordered. - The September, 2011 MAR indicated [REDACTED]. The nurses notes documented no evidence the physician or FNP had been consulted regarding the positive test result. - Physician's telephone orders signed by the FNP on 9/2/11 at 11:00 a.m., documented orders for a PT/INR now and weekly labs (CBC, CMP, and PT/INR), on Monday. The record contained no evidence of the results of the PT/INR for 9/2/11 or the following Monday (9/5/11). - Physician's telephone orders dated 9/6/11, written by RN "C" at 9:00 a.m., documented KUB for abdominal pain. The order was signed by the FNP on 9/6/11 at 5:00 p.m. - The KUB laboratory results dated [DATE], documented she had a "mild" ileus (obstruction of the bowel). - A late entry nurses note dated 9/7/11 at 6:21 a.m., for 7:45 p.m. on 9/6/11, documented the FNP had arrived at the facility and it had been discovered a PT/INR test ordered on [DATE] had not been obtained, and there was no requisition in the lab book for the test. It documented a KUB (kidney, ureter, bladder) test, was done earlier in the day and reported a mild ileus. It further documented Resident #1 was complaining her stomach still hurt, and upon assessment was confused and oriented to her name only. It documented the FNP ordered a STAT PT/INR, the results of which was INR 19.23. The FNP then contacted Physician "D", who ordered 10 mg of Vitamin K (a clotting agent), IM and Resident #1's transfer to the emergency room . Additionally, a second lab draw was requested to verify lab data. That lab result was INR 21.19. Resident #1 left the facility via ambulance at 10:00 p.m. - A laboratory result, dated 9/6/11 at 7:35 p.m., confirmed a critical INR value of 19.23 (normal range 2.0-3.0). A second result obtained 30 minutes later at 9:05 p.m., documented a value of 21.19. 2) The Geriatric Dosage Handbook Including Clinical Recommendations and Monitoring Guidelines, 12th edition, copyright 2007, page 1783, documented a target INR for [MEDICATION NAME] (i.e., [MEDICATION NAME]), therapy as 2.5 (2.0-3.0).Page 1784, documented an INR greater than 9.0 could result in life-threatening bleeding or serious [MEDICATION NAME] ([MEDICATION NAME]), overdose. 3) Review of Resident #1's closed hospital record revealed a History and Physical, dated 9/8/11, documented she was admitted to the hospital on [DATE] with a supratherapeutic INR, hematuria (blood in the urine), and abdominal pain. It documented she received Vitamin K, five units of fresh frozen plasma (fluid part of blood), and two units of blood. 4) During an interview on 9/22/11 at 11:15 a.m., Physician "D" said the FNP on 9/2/11 at 11:00 a.m., wrote orders for weekly PT/INRs and other labs starting on the following Monday (9/5/11). Physician "D" said "They get those labs on the morning after a new admit, that's what I expect." During a subsequent interview on 9/23/11 at 12:30 p.m., when it was brought to his attention that his lab protocol for newly admitted residents was not documented on his standing orders, Physician "D" said the protocol was posted at the nurses' stations, adding it documented to obtain CBC, CMP, UA with C&S, and PT/INR if on [MEDICATION NAME], and TSH if [MEDICAL CONDITION] issues. 5) Observation on 9/23/11 at 2:15 p.m., on the Nurses Station on 2 C South, revealed a hand written note in pink highlight pen which read "Q Mondays for Physician "D" and Physician "E" patients. CBC, CMP, and (PT/INR if [MEDICATION NAME] patients). Also hand written in black permanent marker: (TSH 1st lab), and UA/C&S with 1st lab. Note: When Resident #1 initially admitted to the facility on [DATE], she was admitted to 2 C South. She was Physician "D's" patient. 6) During an interview on 9/23/11 at 2:15 p.m., at the 2 C South nurses station, LVN "J" said she was unaware of any lab work protocol for new admissions. Regarding the handwritten posted note written in pink highlight pen, LVN "J" said, "That's what we do for new admits." 7) Observational rounds on 9/26/11 between 11:45 a.m. and 11:53 a.m., with ADON "F" present, revealed only 1 of 4 remaining nurses stations had Physician "D's" lab protocols for newly admitted residents posted. 8) During a telephone interview on 9/23/11 at 8:25 a.m., the FNP said Resident #1 was admitted to the facility on [DATE], adding it was a "cluster" from the beginning because there were no medication orders and the facility was having difficulties obtaining orders from the hospital and from Resident #1's former facility. He said the orders were obtained from Resident #1's pharmacy. The FNP said on 9/1/11 he wrote orders for a PT/INR now, and other weekly labs to begin the following Monday (9/5/11), adding he was on call over the weekend. The FNP said he made rounds on Tuesday ( 9/6/11), morning and saw Resident #1 at 7:30 a.m. He continued, when he returned Tuesday afternoon, Resident #1 was lethargic and her daughter reported her to be more confused. The FNP said he ordered a KUB and at that time noticed there weren't any labs. The FNP said, "It's kind of a common occurrence, they (nurses), overlook orders." The FNP said nurses reported to him on 9/1/11 that Resident #1 may have had blood in her stools, so he ordered a Guaiac test, but the nurses did not report that it was positive until he inquired about it on 9/6/11. 9) During a telephone interview on 9/23/11 at 11:43 a.m., LVN "H" said she called the lab on 9/6/11 and was informed there had been no PT/INR drawn on 9/1/11. She continued, stating there was also no requisition in the lab book, and there should have been one. 10) During interviews on 9/26/11 at 10:45 a.m., the Administrator and ADON "F" were unable to provide evidence of a policy related to ensuring care and services were provided for residents receiving [MEDICATION NAME] therapy. 11) Review of the facility's Abuse Prevention protocol dated 5/1/11, documented: - 1. The facility prohibits the neglect of residents/patients by anyone including staff, family, friends, etc. - 6. Neglect- Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. This presumes that instances of abuse/neglect of all residents/patients, even those in a coma, cause physical harm, pain, or mental anguish. - Prevention- Ensure that prevention techniques are implemented in the facility including, but not limited to, ongoing supervision of employees through visual observation of care delivery and recognition of signs of burnout, frustration, and stress. This includes and is not limited to identification/analysis of assigned staff demonstrating knowledge of individual resident/patient needs. - Identification- Identify events which may constitute neglect. 12) Review of the facility's policy titled Notification of Resident/Patient Change in Condition, dated 5/1/11, documented: - The facility clinicians will notify the resident/patient's Physician and family or legal representative immediately, if there is a crucial/significant change in the resident/patient's condition, according to guidelines developed by the American Medical Director's Association. - 3. Document in the Nurse's Notes the time notification was made and the names of the person(s) to whom you spoke. Sign entry. 13) The facility Administrator and ADON "F" were notified on 9/26/11 at 10:50 a.m., that an Immediate Jeopardy situation had been identified due to the facility's failure to ensure Resident #1 had been monitored for [MEDICATION NAME] toxicity for a total of 6 days. 14) On 9/27/11 at 10:50 a.m., the facility's action plan was accepted. The action plan documented the following: - The facility identified 17 residents who had orders for [MEDICATION NAME]. Resident #1, who was identified on the Immediate Jeopardy, remained in the facility and no longer had an elevated PT/INR. - The facility Medical Director (Physician "D"), re-wrote the facility's standing protocols to include a [MEDICATION NAME] protocol (9/27/11). - Daily monitoring by the ADONs was begun for all abnormal labs and values of the PT/INRs (9/23/11). - Daily monitoring by the ADONs or designee was begun for all residents who were receiving [MEDICATION NAME] therapy (9/23/11). - Daily chart audits were begun on all residents who were receiving [MEDICATION NAME] therapy (9/23/11). - All nursing staff were to be educated on the new [MEDICATION NAME] therapy policy before returning to work (9/27/11). - All nurses were educated on the use of the 24 hour report before returning to work (9/27/11). - The management team began checks of the shift to shift report during the morning meetings (9/27/11). - All new residents who were prescribed [MEDICATION NAME] were to be discussed during the morning meetings (9/27/11). - New physician's protocols were added to the protocol books, located at each nurses station (9/27/11). 15) Prior to removal if the IJ, 11 of 17 records were reviewed to verify residents who were receiving [MEDICATION NAME] therapy, had been audited by the facility according to the action plan. The majority of staff on all shifts were interviewed to confirm they had been educated according to the action plan as submitted, and observations of the nurses stations revealed new protocol notebooks had been placed at each station. 16) The Administrator was informed the IJ was removed on 9/27/11 at 10:50 a.m. However, the facility remained out of compliance at a level of actual harm with a scope identified as a pattern. The facility was continuing to in-service nursing staff regarding ensuring physician's orders [REDACTED]. In addition, the facility was continuing monitoring of nursing staff to ensure an effective system for [MEDICATION NAME] therapy monitoring was in place. 17) Review of the list (undated), of residents who required PT/INR testing, provided by the facility on 9/22/11, documented 17 residents who required PT/INR labs.

Based on observation, interviews and record review, it was determined that for 1 of 10 sampled residents, the facility failed to ensure Resident #1's drug regimen was free from a potentially unnecessary medication, when they - - Failed to consult with Resident #1's physician regarding results of a positive Guaiac test to the physician ( i.e. FNP). - Failed to obtain PT/ INR tests for Resident #1 as ordered by the physician on 9/2/11 and 9/5/11. Resident #1, who was on anticoagulant therapy (receiving [MEDICATION NAME], a blood thinner), received a Guaiac test on 9/2/11, which was positive for occult (hidden), blood in the resident's stool (bowel movement). The physician's FNP was not consulted regarding the abnormal laboratory value, which potentially contributed to failure to identify that the PT/INR test had not been obtained. Four days later (on 9/6/11), the physician's FNP discovered the Guaiac test had revealed she had occult blood in her stools. Also on 9/6/11, the FNP inquired about results of a 9/2/11 PT/INR test, at which time it was discovered the PT/INR test had not been obtained. As a result, six days after Resident #1 admitted to the facility, a lab test revealed she had a critical INR (19.23, then 30 minutes later 21.19), and the physician gave orders for her to be transferred to a local hospital. Resident #1 was diagnosed as having super therapeutic INR, [MEDICAL CONDITION], and hematuria (blood or blood cells in the urine). She remained in the hospital for seven days and received five units of plasma and two units of blood. This failure placed Resident #1 at risk of life-threatening bleeding or death. These failures led to the identification of Immediate Jeopardy (IJ), on 9/26/11 due to failure to develop and implement policies and procedures to ensure staff requested laboratory test for residents receiving [MEDICATION NAME] therapy, and failure to consult with their physician when tests revealed abnormal results. While the IJ was removed on 9/27/11, the facility remained out of compliance at a level of actual harm with a scope identified as a pattern. The facility was continuing to in-service nursing staff regarding ensuring physician's orders [REDACTED]. In addition, the facility was continuing monitoring of nursing staff to ensure an effective system for [MEDICATION NAME] therapy monitoring was in place. Failure to ensure drug regimens were free from a potentially unnecessary medication placed all 17 residents who received [MEDICATION NAME] at risk of undiagnosed critical [MEDICATION NAME] toxicity, and life threatening bleeding or death. The evidence is as follows: 1) Review of Resident #1's medical record revealed the following: - The Face Sheet documented she was admitted to the facility on [DATE]. It documented she was [AGE] years of age and admitted for skilled care with a primary [DIAGNOSES REDACTED]. - A list of Resident #1's medications provided by a local pharmacy dated 9/2/11, documented Resident #1 was prescribed [MEDICATION NAME] ([MEDICATION NAME]), 7.5 mg, 1 tablet daily, ordered by Physician "D" on 8/31/11. - A physician's orders [REDACTED]. The order did not indicate the reason the test was ordered. - The September, 2011 MAR indicated [REDACTED]. The nurses notes documented no evidence the physician or FNP had been consulted regarding the positive test result. - Physician's telephone orders signed by the FNP on 9/2/11 at 11:00 a.m., documented orders for a PT/INR now and weekly labs (CBC, CMP, and PT/INR), on Monday. - The record contained no evidence of the results of the PT/INR for 9/2/11, or the following Monday (9/5/11). - Physician's telephone orders dated 9/6/11, written by RN "C" at 9:00 a.m., documented KUB for abdominal pain. The order was signed by the FNP on 9/6/11 at 5:00 p.m. - The KUB laboratory results dated [DATE], documented she had a "mild" ileus (obstruction of the bowel). - A late entry nurses note dated 9/7/11 at 6:21 a.m., for 7:45 p.m. on 9/6/11, documented the FNP had arrived at the facility and it had been discovered a PT/INR test ordered on [DATE] had not been obtained, and there was no requisition in the lab book for the test. It documented a KUB (kidney, ureter, bladder) test, was done earlier in the day and reported a mild ileus. It further documented Resident #1 was complaining her stomach still hurt, and upon assessment was confused and oriented to her name only. It documented the FNP ordered a STAT PT/INR, the results of which was INR 19.23. The FNP then contacted Physician "D", who ordered 10 mg of Vitamin K (a clotting agent), IM and Resident #1's transfer to the emergency room . Additionally, a second lab draw was requested to verify lab data. That lab result was INR 21.19. Resident #1 left the facility via ambulance at 10:00 p.m. - A laboratory result, dated 9/6/11 at 7:35 p.m., confirmed a critical INR value of 19.23 (normal range 2.0-3.0). A second result obtained 30 minutes later at 9:05 p.m., documented a value of 21.19. 2) The Geriatric Dosage Handbook Including Clinical Recommendations and Monitoring Guidelines, 12th edition, copyright 2007, page 1783, documented a target INR for [MEDICATION NAME] (i.e., [MEDICATION NAME]), therapy as 2.5 (2.0-3.0).Page 1784, documented an INR greater than 9.0 could result in life-threatening bleeding or serious [MEDICATION NAME] ([MEDICATION NAME]), overdose. 3) Review of Resident #1's closed hospital record revealed a History and Physical, dated 9/8/11, documented she was admitted to the hospital on [DATE] with a supratherapeutic INR, hematuria (blood in the urine), and abdominal pain. It documented she received Vitamin K, five units of fresh frozen plasma (fluid part of blood), and two units of blood. 4) During an interview on 9/22/11 at 11:15 a.m., Physician "D" said the FNP on 9/2/11 at 11:00 a.m., wrote orders for weekly PT/INRs and other labs starting on the following Monday (9/5/11). Physician "D" said "They get those labs on the morning after a new admit, that's what I expect." During a subsequent interview on 9/23/11 at 12:30 p.m., when it was brought to his attention that his lab protocol for newly admitted residents was not documented on his standing orders, Physician "D" said the protocol was posted at the nurses' stations, adding it documented to obtain CBC, CMP, UA with C&S, and PT/INR if on [MEDICATION NAME], and TSH if [MEDICAL CONDITION] issues. 5) Observation on 9/23/11 at 2:15 p.m., on the Nurses Station on 2 C South, revealed a hand written note in pink highlight pen which read "Q Mondays for Physician "D" and Physician "E" patients. CBC, CMP, and (PT/INR if [MEDICATION NAME] patients). Also hand written in black permanent marker: (TSH 1st lab), and UA/C&S with 1st lab. Note: When Resident #1 initially admitted to the facility on [DATE], she was admitted to 2 C South. She was Physician "D's" patient. 6) During an interview on 9/23/11 at 2:15 p.m., at the 2 C South nurses station, LVN "J" said she was unaware of any lab work protocol for new admissions. Regarding the handwritten posted note written in pink highlight pen, LVN "J" said, "That's what we do for new admits." 7) Observational rounds on 9/26/11 between 11:45 a.m. and 11:53 a.m., with ADON "F" present, revealed only 1 of 4 remaining nurses stations had Physician "D's" lab protocols for newly admitted residents posted. 8) During a telephone interview on 9/23/11 at 8:25 a.m., the FNP said Resident #1 was admitted to the facility on [DATE], adding it was a "cluster" from the beginning because there were no medication orders and the facility was having difficulties obtaining orders from the hospital and from Resident #1's former facility. He said the orders were obtained from Resident #1's pharmacy. The FNP said on 9/1/11 he wrote orders for a PT/INR now, and other weekly labs to begin the following Monday (9/5/11), adding he was on call over the weekend. The FNP said he made rounds on Tuesday (9/6/11), morning and saw Resident #1 at 7:30 a.m. He continued, when he returned Tuesday afternoon, Resident #1 was lethargic and her daughter reported her to be more confused. The FNP said he ordered a KUB and at that time noticed there weren't any labs. The FNP said, "It's kind of a common occurrence, they (nurses), overlook orders." The FNP said nurses reported to him on 9/1/11 that Resident #1 may have had blood in her stools, so he ordered a Guaiac test, but the nurses did not report that it was positive until he inquired about it on 9/6/11. 9) During a telephone interview on 9/23/11 at 11:43 a.m., LVN "H" said she called the lab on 9/6/11 and was informed there had been no PT/INR drawn on 9/1/11. She continued, stating there was also no requisition in the lab book, and there should have been one. 10) During interviews on 9/26/11 at 10:45 a.m., the Administrator and ADON "F" were unable to provide evidence of a policy related to ensuring care and services were provided for residents receiving [MEDICATION NAME] therapy. 11) The facility Administrator and ADON "F" were notified on 9/26/11 at 10:50 a.m., that an Immediate Jeopardy situation had been identified due to the facility's failure to ensure Resident #1 had been monitored for [MEDICATION NAME] toxicity for a total of 6 days. 12) On 9/27/11 at 10:50 a.m., the facility's action plan was accepted. The action plan documented the following: - The facility identified 17 residents who had orders for [MEDICATION NAME]. Resident #1, who was identified on the Immediate Jeopardy, remained in the facility and no longer had an elevated PT/INR. - The facility Medical Director (Physician "D"), re-wrote the facility's standing protocols to include a [MEDICATION NAME] protocol (9/27/11). - Daily monitoring by the ADONs was begun for all abnormal labs and values of the PT/INRs (9/23/11). - Daily monitoring by the ADONs or designee was begun for all residents who were receiving [MEDICATION NAME] therapy (9/23/11). - Daily chart audits were begun on all residents who were receiving [MEDICATION NAME] therapy (9/23/11). - All nursing staff were to be educated on the new [MEDICATION NAME] therapy policy before returning to work (9/27/11). - All nurses were educated on the use of the 24 hour report before returning to work (9/27/11). - The management team began checks of the shift to shift report during the morning meetings (9/27/11). - All new residents who were prescribed [MEDICATION NAME] were to be discussed during the morning meetings (9/27/11). - New physician's protocols were added to the protocol books, located at each nurses station (9/27/11). 13) Prior to removal if the IJ, 11 of 17 records were reviewed to verify residents who were receiving [MEDICATION NAME] therapy had been audited by the facility according to the action plan. The majority of staff on all shifts were interviewed to confirm they had been educated according to the action plan as submitted, and observations of the nurses stations revealed new protocol notebooks had been placed at each station. 14) The Administrator was informed the IJ was removed on 9/27/11 at 10:50 a.m. However, the facility remained out of compliance at a level of actual harm with a scope identified as a pattern. The facility was continuing to in-service nursing staff regarding ensuring physician's orders [REDACTED]. In addition, the facility was continuing monitoring of nursing staff to ensure an effective system for [MEDICATION NAME] therapy monitoring was in place. 15) Review of the list (undated), of residents who required PT/INR testing, provided by the facility on 9/22/11, documented 17 residents who required PT/INR labs.