Every finding on record at Louisiana War Veterans Home

Based on record review and interviews the facility failed to electronically submit payroll information for direct care staffing as required. Findings: Review of the facility's Payroll Base Journal (PBJ) Staffing Data Report for Fiscal Year Quarter 2 2023 (January 1-March 31) revealed, in part, the facility failed to submit staffing data for the quarter. On 06/19/2023 at 12:48 p.m., an interview was conducted with S2DON. She stated in February she received an email from the Medicare Quality Improvement Organization concerning PBJ submissions. She stated when the responsibility was moved from Human Resources, the facility stopped submitting the PBJ report. She confirmed the PBJ report was not submitted for Quarter 2 of 2023 (January- March) and should have been.

Based on record review and interviews, the facility failed to ensure residents' responsible party were notified of positive COVID-19 cases in the facility in a timely matter. The facility had a total census of 97 residents. There were 6 residents (R19, R20, R29, R30, R31, R32, and R33) residing in 10 designated certified beds. Findings: Review of the facility's Notification of Positive COVID-19 In-house Resident Standard Operating Procedure dated 03/24/2020 revealed in part: Standard Operating Procedure: 3. The Facility Administrator of Director of Nursing will then notify the family or responsible party of the resident who tested positive for COVID-19 of the results of the test . Review of the facility's Notification of Positive COVID-19 In-House Resident Standard Operating Procedure dated 03/24/2020 revealed no details on how or when the resident's responsible party would be notified. Review of the Facility Staff Tracker for Coronavirus Testing form revealed one employee (S7) tested positive for COVID on 07/09/2020. Review of the Interdisciplinary Progress Notes revealed no documented evidence Resident R29's responsible party was not notified of the facility's positive COVID test results. Review of the Facility Staff Tracker for Coronavirus Testing form revealed one employee (S8) tested positive for COVID on 08/06/2020. Review of the Interdisciplinary Progress Notes revealed no documented evidence Resident R29's responsible party was notified of the facility's positive COVID test results. Review of the Facility Staff Tracker for Coronavirus Testing form revealed two employees (S13, S14) tested positive for COVID on 08/24/2020. Review of the Interdisciplinary Progress Notes revealed no documented evidence Resident R29's responsible party was notified of the facility's positive COVID test results. Review of the Facility Staff Tracker for Coronavirus Testing form revealed one employee (S15) tested positive for COVID on 08/25/2020. Review of the Interdisciplinary Progress Notes revealed no documented evidence Resident R29's responsible party was notified of the facility's positive COVID test results. Review of the Facility Staff Tracker for Coronavirus Testing form revealed two employees (S16, S17) tested positive for COVID on 08/26/2020. Review of the Interdisciplinary Progress Notes revealed no documented evidence Resident R29's responsible party was notified of the facility's positive COVID test results. Review of the Facility Staff Tracker for Coronavirus Testing form revealed one employee (S18) tested positive for COVID on 08/28/2020. Review of the Interdisciplinary Progress Notes revealed no documented evidence Resident R29's responsible party was not notified of the facility's positive COVID test results. Review of the Facility Staff Tracker for Coronavirus Testing form revealed two employees (S19, S20) tested positive for COVID on 08/29/2020. Review of the Interdisciplinary Progress Notes revealed no documented evidence Resident R29's responsible party was notified of the facility's positive COVID test results. Review of the facility's COVID-19 tracking form revealed two residents (R10, R11) tested positive for COVID on 08/23/2020. Review of the Interdisciplinary Progress Notes revealed no documented evidence Resident R29's responsible party was not notified of the facility's positive COVID test results. Review of the facility's COVID-19 tracking form revealed one resident (R12) tested positive for COVID on 08/24/2020. Review of the Interdisciplinary Progress Notes revealed no documented evidence Resident R29's responsible party was notified of the facility's positive COVID test results. Review of the facility's COVID-19 tracking form revealed 10 residents (R13, R14, R15, R16, R17, R18, R19, R20, R21, and R22) tested positive for COVID on 08/25/2020. Review of the Interdisciplinary Progress Notes revealed no documented evidence Resident R29's responsible party was notified of the facility's positive COVID test results. Review of the facility's COVID-19 tracking form revealed five residents (R23, R24, R25, R26, and R27) tested positive for COVID on 08/26/2020. Review of the Interdisciplinary Progress Notes revealed no documented evidence Resident R29's responsible party was notified of the facility's positive COVID test results. A telephone interview was conducted with Resident R29's sister on 09/01/2020 at 11:00 a.m. She stated she received one phone call weekly about the COVID-19 activity in the facility. She stated about three weeks ago, she was notified by the facility there was one positive case of COVID-19 in the facility. She stated she was informed by facility staff last week that there was a total of nine positive cases in the facility. When questioned whether she was notified last week that there were nine new cases of COVID-19 in the building, she stated no, she was notified there were a total of nine cases of COVID-19 in the building. An interview was conducted with S2DON on 08/31/2020 at 2:15 p.m. She stated she was not aware of the requirement to inform residents residing in certified beds, their representatives, and families of the occurrence of confirmed COVID-19 infection of the staff and residents in the facility. An interview was conducted with S1Adm on 08/31/2020 at 2:30 p.m. She stated she was not aware of the requirement to inform residents residing in certified beds, their representatives, and families of the occurrence of confirmed COVID-19 infection of the staff and residents in the facility.

Based on observations, interview and record reviews, the facility failed to ensure infection control measures were practiced to provide a safe, sanitary environment and help prevent the development and transmission of infection for 2 (#2, #210) of 2 (#2, #210) residents observed with indwelling urinary catheters. Findings: Resident #2 On 06/03/2019 at 10:10 a.m., Resident #2 was observed sitting in his wheelchair attending a recreational event in the Dining Room. His indwelling urinary catheter drainage bag was in a cloth pouch fastened beneath his wheelchair. The catheter tubing was skimming the floor's surface. The cloth pouch was touching the floor. On 06/04/2019 at 7:05 a.m., Resident #2 was observed sitting in his wheelchair in the hallway outside of the Dining Room. His indwelling urinary catheter tubing was touching the floor. On 06/04/2019 at 7:25 a.m., Resident #2 was observed seated in his wheelchair at the dining table eating breakfast. His indwelling urinary catheter tubing was touching the floor. On 06/04/2019 at 3:17 p.m., Resident #2 was observed in his wheelchair propelling himself down the hallway. His indwelling urinary catheter tubing was rubbing against the floor as he moved down the hallway and into the dining room. On 06/05/2019 at 8:30 a.m., Resident #2 was observed seated in his wheelchair at the dining table. His indwelling urinary catheter drainage bag was in a cloth pouch and the bottom of the pouch was touching the floor. His indwelling urinary catheter tubing was touching the floor. On 06/05/2019 at 9:25 a.m., Resident #2 was observed transporting himself in his wheelchair. The bottom of the pouch containing his indwelling urinary catheter drainage bag was dragging on the floor. The indwelling urinary catheter tubing intermittently touched the floor as he propelled himself down the hallway from Therapy to the Dining Room. On 06/05/19 at 10:30 a.m., Resident #2 was seated in his wheelchair attending a recreational event in the Dining Room. His indwelling urinary catheter collection bag was in a pouch and the bottom of the pouch was touching the floor. His indwelling catheter tubing was rubbing against floor. On 06/05/2019 at 10:37 a.m., an observation/interview was conducted with S1DON. S1DON observed Resident #2's indwelling urinary catheter bag pouch and indwelling urinary catheter tubing touching the floor. Resident #210 Review of Resident #210's urine culture lab results, dated 06/01/2019, revealed Resident #210 was positive for Extended Spectrum Beta-Lactamase. On 06/03/2019 at 11:12 a.m., Resident #210 was observed with his indwelling urinary catheter drainage bag in a cloth bag, fastened beneath the wheelchair with the cloth bag resting on the floor. On 06/04/2019 at 7:25 a.m., Resident #210 was sitting in the dining room in his wheelchair. His urinary catheter drainage tubing was resting on the dining room floor. On 06/05/2019 at 10:37 a.m., an interview was conducted with S1DON. She verified indwelling urinary catheter bag pouches and tubing should not touch the floor.

Based on observations and interviews, the facility failed to prepare, distribute and serve food under sanitary conditions by failing to ensure 3 (S3DIET, S4DIET, S5DIET) of 4 (S3DIET, S4DIET, S5DIET, S8DIET) male dietary staff wore hair restraints to keep their facial hair from contacting exposed foods. There were a total of 6 residents that were provided meals and beverages from the facility's kitchen. Findings: An observation was conducted on 05/08/2017 at 08:35 AM of S3DIET in the kitchen area, standing next to the trays of bread that were to be served for lunch. He was not wearing a hair restraint covering his facial hair. An observation was conducted on 05/08/2017 at 08:40 AM of S4DIET in the kitchen area, near the dishwashing sinks. He was not wearing a hair restraint covering his facial hair. An observation was conducted on 05/08/2017 at 10:20 AM of dietary staff, S5DIET working in the kitchen near the serving line. He was not wearing a hair restraint covering his facial hair. An observation was made on 05/08/2017 at 10:21 AM of S3DIET and S4DIET in the kitchen area, without hair restraints covering their facial hair. An interview was conducted on 05/08/2017 at 10:25 AM with S2DIET. She verified male dietary staff with facial hair should have facial hair restraints. She verified S3DIET, S4DIET, and S5DIET did not have facial hair restraints covering their facial hair while working in the kitchen area. She said it was their policy to cover facial hair or to be clean shaven while in the kitchen area. An interview was conducted on 05/08/2017 3:00 PM with S1AADM. He verified the kitchen's policy is to wear facial hair restraints. He verified he did not have any facial hair restraints in the building. He verified S2DIET was the supervisor enforcing the use of facial hair restraints and it was the facilities policy to wear facial hair restraints.

Based on interview and record review, the facility failed to ensure a resident was notified, in writing, prior to receiving a new roommate for 1 (#7) of 5 (#4, #7, #16, #17, #19) residents interviewed in Stage 1. The facility had a total of 6 residents residing in certified beds. Findings: Review of the facility's Transfer Within Facility Policy included the following, in part, Procedure: D. During normal working hours, the unit nurse informs Social Services of the transfer. Social Services will notify a resident and/or his authorized representative of a change in room or roommate assignment. An interview was conducted with Resident #7 on 05/08/2017 at 12:28 PM. He stated he had several roommate changes within the last nine months. He stated he was not always notified by staff prior to his roommate change. Review of the MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 3/2/17 revealed BIMS (Brief Interview for Mental Status) = 15 (Cognitively Intact) An interview was conducted with S7SSC on 05/09/2017 at 11:41 AM. She stated she verbally notified Resident #7 that he was to receive a new roommate on 05/01/2017. An interview was conducted with S7SSC on 05/09/2017 at 1:25 PM. She confirmed the facility's policy is to verbally inform the resident of the roommate change. An interview was conducted with S6SSM on 05/09/2017 at 2:00 PM. She verified the process of notifying a resident of a room/roommate change is by verbal notification. She said the facility's Transfer Within Facility Policy needed to be revised. She verified Resident #7 had a roommate change on 05/01/2017.

Based on observation, record review and interview, the facility failed to identify quality deficiencies and develop and implement plans of action to correct these quality deficiencies, including monitoring the effect of implemented changes and making needed revisions to the action plans. The deficient practice resulted in the QAA committee's failure to identify concerns with the quality of facility systems involving interventions aimed at decreasing number of resident's with Urinary Tract Infections(UTIs). The facility failed to: 1) Ensure a resident(#3) did not keep getting repeated UTIs positive for E. Coli without interventions/measures put in place to decrease occurrences. 2) Ensure CNA's(S5CNA Supervisor, S6CNA, S7CNA, S8CNA) provide incontinent care to prevent cross contamination for 2(#4, #5) of 2(#4, #5) residents observed. 3) Ensure interventions/measures were put in place for 1(#3) of 5(#1, #2, #3) sampled resident's reviewed who had 9 episodes of UTIs with E. Coli within 8 months. 4) Ensure 2(S7CNA, S8CNA) of 4(S5CNA Supervisor, S6CNA, S7CNA, S8CNA) CNA's observed for Incontinence Care performed proper handwashing after coming in contact with a soiled diaper before touching a resident's curtain(S8CNA) and door(S7CNA). 5) Ensure 1(S8CNA) of 4(S5CNA Supervisor, S6CNA, S7CNA, S8CNA) CNA's thoroughly cleaned a resident's(#4) buttock after a Bowel Movement(BM) and dry before placing clean diaper. 6)Ensure 1(S5CNA Supervisor) of 1(S5CNA Supervisor) CNA Supervisor's was trained and competent on properly performing Incontinent Care before training other CNA's. 7) Ensure 3(S6CNA, S7CNA, S8CNA) of 4(S5CNA Supervisor, S6CNA, S7CNA, S8CNA) CNA's observed were properly trained/competent before providing Incontinence Care on residents. 8) Ensure CNA's(S5CNA Supervisor, S6CNA, S7CNA, S8CNA) followed the Incontinent Briefs Policy when providing Incontinence Care for residents. 9) Ensure CNA's(S5CNA Supervisor, S6CNA, S7CNA, S8CNA) removed blue pads from underneath resident's when providing Incontinence Care after touching with gloves used to clean BM. 10) Ensure the facility had an effective tracking and trending process to track Urinary Tract Infections(UTIs) and trend any patterns that were established to decrease occurrence throughout the facility. Findings: Resident #3 Resident #3 was a [AGE] year old male admitted to the facility September 10, 2010 with [DIAGNOSES REDACTED]. Review of the facility's Incontinence Briefs Policy dated 10/08 revealed the following in part: Policy Nursing Service was to ensure that residents incontinent of bowel and or bladder are kept clean, dry, comfortable, and their dignity maintained. Procedure F. Wipe away as much feces as possible using toilet tissue. G. Wash the area from front to back and rinse with water. H. Pat dry with a towel and apply a clean brief. I. Place soiled brief and supplies in a plastic bag and tie the bag. Place the bag in receptacle for soiled briefs. Review of Resident #3's Laboratory Results revealed the following in part: 10/19/12 Urinalysis Clarity: Slightly cloudy (Clear) Leukocyte(Leuk) Esterase 2 plus (Negative)(Neg) Microscopic White Blood Cell(WBC) greater than 100 High(H) (0-5 average) Bacteria Many (Neg) 10/21/12 Final culture Escherichia(E) Coli 11/5/12 Urinalysis Clarity Very cloudy Leuk Esterase 2 plus Microscopic WBC greater than 90 H Bacteria Many Resident #3 was sent out a local hospital 11/8/12 for a psychiatric evaluation and returned same day. A urine culture was done. Resident returned to facility same day from hospital. Diagnosis: [REDACTED]. 11/8/12 Hospital Return Record hospitalization Reason: Anxiety UTI Medical Information-Admission Reassessment Cognition: Alert oriented to person Mood/Behavior: Cheerful Elimination: Incontinent-Bowel/Bladder Brief Transfer of Care Instructions Discharge location: Facility Functional Status/Mental Status At Time of Discharge: Alert, Oriented 1, 2 11/10/12 Culture results received from local hospital. Resident's urine was positive for E Coli. Review of Resident #3's clinical record revealed the following in part: 11/21/12 Hospital Transfer Record Reason for Transfer: Suicide Ideation As needed(PRN) meds given prior to transfer: [MEDICATION NAME] 0.25 mg at 11 a.m. Diagnoses: [REDACTED]. Reason for Admission: Danger to self. Gravely Disabled. Admit to acute psychiatric if still having symptoms. Making hopeless, statements. Further review of the records revealed the resident was discharged back to the facility 12/4/12 with same UTI and not on Antibiotic. 12/5/12 Urinalysis Leuk Esterase 2 plus Microscopic WBC greater than 100 H Bacteria Moderate 12/8/12 Final culture E. Coli 12/17/12 Urinalysis Leuk Esterase Trace Microscopic WBC greater than 50 H Bacteria Rare Mucous Few 12/20/12 Final culture E. Coli 12/21/12 Urinalysis Leuk Esterase 2 plus [MEDICATION NAME] positive Hemoglobin 3 plus Microscopic WBC greater than 100 H Bacteria Moderate 12/23/12 Final culture E. Coli 1/9/13 Urinalysis Leuk Esterase 2 plus Hemoglobin 2 plus Microscopic WBC greater than 100 H Bacteria Many 1/9/13 Final culture E. Coli 1/28/13 Urinalysis Leuk Esterase 2 plus Hemoglobin 1 plus Microscopic WBC greater than 100 H Bacteria Many 1/30/13 Final culture E. Coli 3/6/13 Urinalysis Clarity: Slightly cloudy` Leuk Esterase 2 plus [MEDICATION NAME]: Positive Hemoglobin: 1 plus 3/8/13 Final Culture E. Coli 5/8/13 Urinalysis Clarity: Slightly cloudy Leuk Esterase 2 plus [MEDICATION NAME]: Positive [MEDICATION NAME]: Trace Microscopic: WBC greater than 100 H Bacteria: Many 5/10/13 Final culture E. Coli. 5/28/13 Urinalysis Color: Green Clarity: Slightly Cloudy Leuk Esterase 2 plus [MEDICATION NAME] 1 plus Microscopic WBC 40 Bacteria Trace Mucous Few 5/31/13 Final Culture E. Coli. Review of Resident #3's clinical record revealed the resident was admitted to a local hospital on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's Comprehensive Plan of Care revealed the following in part: Actual Infection related to UTI meds: Amakacin and [MEDICATION NAME] Begin date: 5/14/13 Goal: Will be free of infection. Approaches: 1) Refer to Medical Director(MD) if symptoms worsen or remain unresolved after completion of antibiotic. 2) Ensure as clean an environment as possible, using universal precautions and handwashing. 3) Administer meds as ordered. 4) Monitor site for increased for increased redness, swelling warmth, drainage or pain and notify MD. Further review of the resident's care plan noted "resolved" and a line drawn through the care plan. The resident did not have a care plan for reoccurring UTIs or patient specific interventions aimed at preventing or decreasing the resident's occurrences of UTIs with E. Coli. Resident #5 Resident #5 was a was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/9/13 2 observations of Incontinent Care was done as follows: Observation #1 12:21 p.m. Performed by S6CNA assisted by S7CNA A Hall S6CNA Put a pair of clean gloves on Unfastened Resident #5's brief and folded diaper down between his legs Wiped Resident #5's front area from top to bottom Repeated above step again Turned resident on right side Wiped in between Resident #5's buttocks from bottom to top with wet wipe Folded same wet wipe over and wiped in between resident's buttocks again Pulled soiled diaper from under the resident and touched and straightened disposable blue pad under resident Picked clean diaper up and put near soiled diaper Took soiled diaper and put in the resident's trash can Took clean diaper with same soiled gloves on and put under resident Retrieved bottle of Aloe Vista Cream(protective ointment) Applied Aloe Vista Cream Fastened brief on left side Touched resident S7CNA assisted S6CNA with fastening brief on right side with gloves on S7CNA retrieved clear bag out resident's garbage can with soiled diaper Tied bag up Folded glove on right hand half way and opened door with right hand Put clear bag in container on outside of resident's door On 9/9/13 at 12:30 p.m. an interview was conducted with S6CNA. She stated she had been working at the facility for [AGE] years and a couple of months. She acknowledged when she wiped Resident #5's buttocks she wiped twice with the same soiled wet wipe. She said the second time she wiped it with the clean side of the wipe. S6CNA confirmed she applied the resident's diaper and applied Aloe Vista cream with the same gloves she cleaned the resident's BM with. She confirmed she also placed the resident's clean diaper by the soiled diaper and touched the blue pad and left it under the resident because it was still clean. On 9/9/13 at 12:33 p.m. an interview was conducted with S7CNA. She acknowledged she didn't wash her hands after she assisted S6CNA with changing Resident #5's incontinent brief before retrieving the clear bag from the resident's garbage can. She also confirmed she folded the glove on her right hand and opened the door to take the clear bag to the container on the hall. She said she was supposed to wash her hands after performing incontinent care on a resident before touching the resident's door and verified she did not. Resident #4 Resident #4 was a was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation #2 12:45 p.m. Performed by S8CNA and assisted by S5CNA Supervisor B Hall S8CNA Applied hand sanitizer Applied gloves Folded Resident #4's soiled brief between legs Wiped resident's front area from top to bottom with wet wipe Discarded wet wipe Touched and straightened resident's disposable blue pad under resident touching blue pad with soiled diaper Turned resident on right side Handed soiled diaper to S5CNA Supervisor S5CNA Supervisor grabbed soiled diaper with left hand; placing it down by clean diaper trying to assist with positioning clean diaper under resident with right hand Turned resident on left side S8CNA wiped resident's outer buttocks with wet wipe(did not clean inner buttocks) leaving resident's buttock's wet from wipe S8CNA placed clean diaper under resident to side near right side S5CNA Supervisor with same gloves BM cleaned with S8CNA placed resident placed on back and secured left side of diaper while S5CNA Supervisor secured right side S8CNA removed gloves S5CNA Supervisor placed soiled diaper in clear bag in resident's trash can S8CNA removed clear bag from resident's trash can, opened door and discarded clear trash bag in container outside resident's door Applied hand sanitizer On 9/9/13 at 12:59 a.m. an interview was conducted with S8CNA. She acknowledged she applied Resident #4's clean diaper with the same gloves used to clean the resident's BM. She also confirmed she did not spread the resident's buttocks apart when she cleaned BM from the resident's outer buttocks. She verified when she wiped the resident with the wet wipe, she did not dry the resident's buttocks leaving the resident wet before placing the clean diaper. She said she was nervous. She confirmed she took her gloves off after changing the resident and removed the trash liner out of the resident's trash can, touched the door and discarded of the clear trash bag without washing her hands. On 9/10/13 at 1:02 p.m. an interview was conducted with S5CNA Supervisor. She confirmed she picked the soiled diaper up with her left hand placing it down by clean diaper while trying to assist S8CNA with positioning clean diaper under resident with right hand. She acknowledged the soiled diaper should not have come in contact with the clean diaper. Review of the facility's Infection Control Report revealed the following in part: March 2013 3 UTIs A Hall 2 UTIs B Hall April 2013 5 UTIs A Hall 1 UTI B Hall 2 Location not recorded 8 UTIs recorded May 2013 1 UTI A Hall 5 UTIs B Hall June 2013 5 UTIs A Hall 3 UTIs B Hall July 2012 7 UTIs A Hall 3 UTIs B Hall Farther review of the Infection Control Report did not reveal Resident #3 had UTIs in May 2013, and his labs indicate he had 2; May 8th and May 28 th 2013. There was documented evidence of Infection Control Tracking and Trending Logs for August 2013. On 9/11/13 at 11:41 a.m. an interview was conducted with S4RN. She said the resident kept getting repeated UTIs and they could not figure out why. She said he was placed on several different medications from October 2012 to July 2013 because he had tested 9 times for UTIs positive for E. Coli. She said everytime they did a UA/CS, the results came back positive. She stated the resident was allergic to [MEDICATION NAME], Bactrim, [MEDICATION NAME], Keflex and Sulfa and it was hard to treat him. She said the staff at the facility called the resident's wife to find out why the resident got anxious anytime he got a UTI. She said the wife informed staff the resident displayed psychotic episodes when he got UTIs. S4RN said the most of the UTIs were on B Hall; because that's where most of the resident's with catheters were. She acknowledged there was no care plan that addressed how the facility were going to decrease Resident #3's reoccurring UTIs with E Coli or the increased number of UTIs on A and B Hall. She confirmed the resident's had 9 back to back UTIs positive for E. Coli from October. She said she called 2 aides into Resident #3's room because he would not let the CNA's change him because they spreaded his legs too far apart and made him uncomfortable due to his back problems. She said the facility did not inservice the CNA staff on Incontinent Care aimed at decreasing the number of UTIs throughout the facility. She said she did not have knowledge of the Infection Control tracking and trending Log because she would have been aware and looked at addressing UTIs at the facility as a whole instead of thinking it was isolated to Resident #3. On 9/11/13 at 2:23 p.m. an interview was conducted with S2DON. He confirmed they did not have documentation the facility put interventions in place to eliminate or decrease Resident #3's UTIs positive for E. Coli; nor did they QA UTIs. He also acknowledged they did not develop a recurrent UTI care plan with interventions to address the 9 times Resident #3 was diagnosed with [REDACTED]. He acknowledged there was an increased number of UTIs in from April 2013 to July 2013 but the facility staff did not perform inservices specific to addressing the increased number of UTIs on A and B Hall the facility. S2DON said he did not know whether competencies had been done on the CNA staff to see if they were competent in performing Incontinent Care properly. He said the only inservice the CNA staff had was when an outside vendor came and did one on briefs and they had documents being passed around to the supervisors to inservice CNA's to get ready for their VA survey but not specifically to address the increased number of UTIs from April 2013 to July 2013 noted in the Infection Control Log.

Based on observations, interview and record review the facility failed to establish and maintain an Infection Control Program designed to prevent the development and transmission of disease and infection by failing to: 1) Ensure a resident(#3) did not keep getting repeated UTIs positive for E. Coli without interventions/measures put in place to decrease occurrences. 2) Ensure CNAs(S5CNA Supervisor, S6CNA, S7CNA, S8CNA) provide incontinent care to prevent cross contamination for 2(#4, #5) of 2(#4, #5) residents observed. 3) Ensure interventions/measures were put in place for 1(#3) of 5(#1, #2, #3) sampled residents reviewed who had 9 episodes of UTIs with E. Coli within 8 months. 4) Ensure 2(S7CNA, S8CNA) of 4(S5CNA Supervisor, S6CNA, S7CNA, S8CNA) CNAs observed for Incontinence Care performed proper handwashing after coming in contact with a soiled diaper before touching a resident's curtain(S8CNA) and door(S7CNA). 5) Ensure 1(S8CNA) of 4(S5CNA Supervisor, S6CNA, S7CNA, S8CNA) CNAs thoroughly cleaned a resident's(#4) buttocks after a Bowel Movement(BM) and dry before placing clean diaper. 6)Ensure 1(S5CNA Supervisor) of 1(S5CNA Supervisor) CNA Supervisors was trained and competent on properly performing Incontinent Care before training other CNAs. 7) Ensure 3(S6CNA, S7CNA, S8CNA) of 4(S5CNA Supervisor, S6CNA, S7CNA, S8CNA) CNAs observed were properly trained/competent before providing Incontinence Care on residents. 8) Ensure CNAs(S5CNA Supervisor, S6CNA, S7CNA, S8CNA) followed the Incontinent Briefs Policy when providing Incontinence Care for residents. 9) Ensure CNAs(S5CNA Supervisor, S6CNA, S7CNA, S8CNA) removed blue pads from underneath residents when providing Incontinence Care after touching with gloves used to clean BM. 10) Ensure the facility had an effective tracking and trending process to track Urinary Tract Infections(UTIs) and trend any patterns that were established to decrease occurrence throughout the facility. Findings: Resident #3 Resident #3 was a [AGE] year old male admitted to the facility September 10, 2010 with [DIAGNOSES REDACTED]. and Bipolar Disorder, Coronary Atherosclerosis, Anxiety, Acute Gastritis, [DIAGNOSES REDACTED]and [DIAGNOSES REDACTED]. Review of the facility's Incontinence Briefs Policy dated 10/08 revealed the following in part: Policy Nursing Service was to ensure that residents incontinent of bowel and or bladder are kept clean, dry, comfortable, and their dignity maintained. Procedure F. Wipe away as much feces as possible using toilet tissue. G. Wash the area from front to back and rinse with water. H. Pat dry with a towel and apply a clean brief. I. Place soiled brief and supplies in a plastic bag and tie the bag. Place the bag in receptacle for soiled briefs. Review of Resident #3's Laboratory Results revealed the following in part: 10/19/12 Urinalysis Clarity: Slightly cloudy (Clear) Leukocyte(Leuk) Esterase 2 plus (Negative)(Neg) Microscopic White Blood Cell(WBC) greater than 100 High(H) (0-5 average) Bacteria Many (Neg) 10/21/12 Final culture Escherichia(E) Coli 11/5/12 Urinalysis Clarity Very cloudy Leuk Esterase 2 plus Microscopic WBC greater than 90 H Bacteria Many Resident #3 was sent out a local hospital 11/8/13 for a psychiatric evaluation and returned same day. A urine culture was done. Resident returned to facility same day from hospital. Diagnosis: [REDACTED]. 11/8/12 Hospital Return Record hospitalization Reason: Anxiety UTI Medical Information-Admission Reassessment Cognition: Alert oriented to person Mood/Behavior: Cheerful Elimination: Incontinent-Bowel/Bladder Brief Transfer of Care Instructions Discharge location: Facility Functional Status/Mental Status At Time of Discharge: Alert, Oriented 1, 2 11/10/12 Culture results received from local hospital. Resident's urine was positive for E. Coli. Review of Resident #3's clinical record revealed the following in part: 11/21/12 Hospital Transfer Record Reason for Transfer: Suicide Ideation As needed(PRN) meds given prior to transfer: [MEDICATION NAME] 0.25 mg at 11 a.m. Diagnoses: [REDACTED]. Reason for Admission: Danger to self. Gravely Disabled. Admit to acute psychiatric if still having symptoms. Making hopeless, statements. Further review of the records revealed the resident was discharged back to the facility 12/4/12 with same UTI and not on Antibiotic. 12/5/12 Urinalysis Leuk Esterase 2 plus Microscopic WBC greater than 100 H Bacteria Moderate 12/8/12 Final culture E. Coli 12/17/12 Urinalysis Leuk Esterase Trace Microscopic WBC greater than 50 H Bacteria Rare Mucous Few 12/20/12 Final culture E. Coli 12/21/12 Urinalysis Leuk Esterase 2 plus [MEDICATION NAME] positive Hemoglobin 3 plus Microscopic WBC greater than 100 H Bacteria Moderate 12/23/12 Final culture E. Coli 1/9/13 Urinalysis Leuk Esterase 2 plus Hemoglobin 2 plus Microscopic WBC greater than 100 H Bacteria Many 1/9/13 Final culture E. Coli 1/28/13 Urinalysis Leuk Esterase 2 plus Hemoglobin 1 plus Microscopic WBC greater than 100 H Bacteria Many 1/30/13 Final culture E. Coli 3/6/13 Urinalysis Clarity: Slightly cloudy` Leuk Esterase 2 plus [MEDICATION NAME]: Positive Hemoglobin: 1 plus 3/8/13 Final Culture E. Coli 5/8/13 Urinalysis Clarity: Slightly cloudy Leuk Esterase 2 plus [MEDICATION NAME]: Positive [MEDICATION NAME]: Trace Microscopic: WBC greater than 100 H Bacteria: Many 5/10/13 Final culture E. Coli. 5/28/13 Urinalysis Color: Green Clarity: Slightly Cloudy Leuk Esterase 2 plus [MEDICATION NAME] 1 plus Microscopic WBC 40 Bacteria Trace Mucous Few 5/31/13 Final Culture E. Coli. Review of Resident #3's clinical record revealed the resident was admitted to a local hospital on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's Comprehensive Plan of Care revealed the following in part: Actual Infection related to UTI meds: Amakacin and [MEDICATION NAME] Begin date: 5/14/13 Goal: Will be free of infection. Approaches: 1) Refer to Medical Director(MD) if symptoms worsen or remain unresolved after completion of antibiotic. 2) Ensure as clean an environment as possible, using universal precautions and handwashing. 3) Administer meds as ordered. 4) Monitor site for increased for increased redness, swelling warmth, drainage or pain and notify MD. Further review of the resident's care plan noted "resolved" and a line drawn through the care plan. The resident did not have a care plan for reoccurring UTIs or patient specific interventions aimed at preventing or decreasing the resident's occurrences of UTIs with E. Coli. Resident #5 Resident #5 was a was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/9/13 2 observations of Incontinent Care was done as follows: Observation #1 12:21 p.m. Performed by S6CNA assisted by S7CNA A Hall S6CNA Put a pair of clean gloves on Unfastened Resident #5's brief and folded diaper down between his legs Wiped Resident #5's front area from top to bottom Repeated above step again Turned resident on right side Wiped in between Resident #5's buttocks from bottom to top with wet wipe Folded same wet wipe over and wiped in between resident's buttocks again Pulled soiled diaper from under the resident and touched and straightened disposable blue pad under resident Picked clean diaper up and put near soiled diaper Took soiled diaper and put in the resident's trash can Took clean diaper with same soiled gloves on and put under resident Retrieved bottle of Aloe Vista Cream(protective ointment) Applied Aloe Vista Cream Fastened brief on left side Touched resident S7CNA assisted S6CNA with fastening brief on right side with gloves on S7CNA retrieved clear bag out resident's garbage can with soiled diaper Tied bag up Folded glove on right hand half way and opened door with right hand Put clear bag in container on outside of resident's door On 9/9/13 at 12:30 p.m. an interview was conducted with S6CNA. She stated she had been working at the facility for [AGE] years and a couple of months. She acknowledged when she wiped Resident #5's buttocks, she wiped twice with the same soiled wet wipe. She said the second time she wiped it with the clean side of the wipe. S6CNA confirmed she applied the resident's diaper and applied Aloe Vista cream with the same gloves she cleaned the resident's BM with. She confirmed she also placed the resident's clean diaper by the soiled diaper and touched the blue pad and left it under the resident because it was still clean. On 9/9/13 at 12:33 p.m. an interview was conducted with S7CNA. She acknowledged she didn't wash her hands after she assisted S6CNA with changing Resident #5's incontinent brief before retrieving the clear bag from the resident's garbage can. She also confirmed she folded the glove on her right hand and opened the door to take the clear bag to the container on the hall. She said she was supposed to wash her hands after performing incontinent care on a resident before touching the resident's door and verified she did not. Resident #4 Resident #4 was a was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation #2 12:45 p.m. Performed by S8CNA and assisted by S5CNA Supervisor B Hall S8CNA Applied hand sanitizer Applied gloves Folded Resident #4's soiled brief between legs Wiped resident's front area from top to bottom with wet wipe Discarded wet wipe Touched and straightened resident's disposable blue pad under resident touching blue pad with soiled diaper Turned resident on right side Handed soiled diaper to S5CNA Supervisor S5CNA Supervisor grabbed soiled diaper with left hand; placing it down by clean diaper trying to assist with positioning clean diaper under resident with right hand Turned resident on left side S8CNA wiped resident's outer buttocks with wet wipe(did not clean inner buttocks) leaving resident's buttock's wet from wipe S8CNA placed clean diaper under resident to side near right side S5CNA Supervisor with same gloves BM cleaned with S8CNA placed resident placed on back and secured left side of diaper while S5CNA Supervisor secured right side S8CNA removed gloves S5CNA Supervisor placed soiled diaper in clear bag in resident's trash can S8CNA removed clear bag from resident's trash can, opened door and discarded clear trash bag in container outside resident's door Applied hand sanitizer On 9/9/13 at 12:59 a.m. an interview was conducted with S8CNA. She acknowledged she applied Resident #4's clean diaper with the same gloves used to clean the resident's BM. She also confirmed she did not spread the resident's buttocks apart when she cleaned BM from the resident's outer buttocks. She verified when she wiped the resident with the wet wipe, she did not dry the resident's buttocks leaving the resident wet before placing the clean diaper. She said she was nervous. She confirmed she took her gloves off after changing the resident and removed the trash liner out of the resident's trash can, touched the door and discarded of the clear trash bag without washing her hands. On 9/10/13 at 1:02 p.m. an interview was conducted with S5CNA Supervisor. She confirmed she picked the soiled diaper up with her left hand placing it down by clean diaper while trying to assist S8CNA with positioning clean diaper under resident with right hand. She acknowledged the soiled diaper should not have come in contact with the clean diaper. Review of the facility's Infection Control Report revealed the following in part: March 2013 3 UTIs A Hall 2 UTIs B Hall April 2013 5 UTIs A Hall 1 UTI B Hall 2 Location not recorded 8 UTIs recorded May 2013 1 UTI A Hall 5 UTIs B Hall June 2013 5 UTIs A Hall 3 UTIs B Hall July 2012 7 UTIs A Hall 3 UTIs B Hall Farther review of the Infection Control Report did not reveal Resident #3 had UTIs in May 2013, and his labs indicate he had 2; May 8th and May 28th 2013. There was documented evidence of Infection Control Tracking and Trending Logs for August 2013. On 9/11/13 at 11:41 a.m. an interview was conducted with S4RN. She said the resident kept getting repeated UTIs and they could not figure out why. She said he was placed on several different medications from October 2012 to July 2013 because he had tested 9 times for UTIs positive for E. Coli. She said everytime they done a UA/CS, the results came back positive. She stated the resident was allergic to [MEDICATION NAME], Bactrim, [MEDICATION NAME], Keflex and Sulfa and it was hard to treat him. She stated the facility sent the resident to a Neurologist because he did not have a catheter and he was never clear of the UTIs. S4RN said she had no documented evidence of the visit with Neurologist. She said the staff at the facility called the resident's wife to find out why the resident got anxious anytime he got a UTI. She said the wife informed staff the resident displayed psychotic episodes when he got UTIs. S4RN said the most of the UTIs were on B Hall; because that's where most of the resident's with catheters were. She acknowledged there was no care plan that addressed how the facility were going to decrease Resident #3's reoccurring UTIs with E Coli or the increased number of UTIs on A and B Hall. She confirmed the resident's had 9 back to back UTIs positive for E. Coli from October. She said she called 2 aides into Resident #3's room because he would not let the CNA's change him because they spreaded his legs too far apart and made him uncomfortable due to his back problems. She said the facility did not inservice the CNA staff on Incontinent Care aimed at decreasing the number of UTIs throughout the facility. She said she did not have knowledge of the Infection Control tracking and trending Log because she would have been aware and looked at addressing UTIs at the facility as a whole instead of thinking it was isolated to Resident #3. On 9/11/13 at 2:23 p.m. an interview was conducted with S2DON. He confirmed they did not have documentation the facility put interventions in place to eliminate or decrease Resident #3's UTIs positive for E. Coli. He also acknowledged they did not develop a recurrent UTI care plan with interventions to address the 9 times Resident #3 was diagnosed with [REDACTED]. He acknowledged there was an increased number of UTIs in from April 2013 to July 2013 but the facility staff did not perform inservices specific to addressing the increased number of UTIs on A and B Hall the facility. S2DON said he did not know whether competencies had been done on the CNA staff to see if they were competent in performing Incontinent Care properly. He said the only inservice the CNA staff had was when an outside vendor came and did one on briefs and they had documents being passed around to the supervisors to inservice CNA's to get ready for their VA survey, but not specifically to address the increased number of UTIs from April 2013 to July 2013 noted in the Infection Control Log.

Based on observation and interview, the facility failed to ensure 4(S5CNA Supervisor, S6CNA, S7CNA, S8CNA) of 4(S5CNA Supervisor, S6CNA, S7CNA, S8CNA) Certified Nursing Assistants were competent in skills and techniques necessary to care for residents who required incontinent care for 2(#5, #4) of 2(#5, #4) sampled residents observed for Incontinent Care. Findings: Resident #5 Resident #5 was a was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility's Incontinence Briefs Policy dated 10/08 revealed the following in part: Policy Nursing Service was to ensure that residents incontinent of bowel and or bladder are kept clean, dry, comfortable, and their dignity maintained. Procedure F. Wipe away as much feces as possible using toilet tissue. G. Wash the area from front to back and rinse with water. H. Pat dry with a towel and apply a clean brief. I. Place soiled brief and supplies in a plastic bag and tie the bag. Place the bag in receptacle for soiled briefs. On 9/9/13 2 observations of Incontinent Care was done as follows: Observation #1 12:21 p.m. Performed by S6CNA assisted by S7CNA A Hall S6CNA Put a pair of clean gloves on Unfastened Resident #5's brief and folded diaper down between his legs Wiped Resident #5's front area from top to bottom Repeated above step again Turned resident on right side Wiped in between Resident #5's buttocks from bottom to top with wet wipe Folded same wet wipe over and wiped in between resident's buttocks again Pulled soiled diaper from under the resident and touched and straightened disposable blue pad under resident Picked clean diaper up and put near soiled diaper Took soiled diaper and put in the resident's trash can Took clean diaper with same soiled gloves on and put under resident Retrieved bottle of Aloe Vista Cream(protective ointment) Applied Aloe Vista Cream Fastened brief on left side Touched resident S7CNA assisted S6CNA with fastening brief on right side with gloves on S7CNA retrieved clear bag out resident's garbage can with soiled diaper Tied bag up Folded glove on right hand half way and opened door with right hand Put clear bag in container on outside of resident's door On 9/9/13 at 12:30 p.m. an interview was conducted with S6CNA. She stated she had been working at the facility for [AGE] years and a couple of months. She acknowledged when she wiped Resident #5's buttocks she wiped twice with the same soiled wet wipe. She said the second time she wiped it with the clean side of the wipe. S6CNA confirmed she applied the resident's diaper and applied Aloe Vista cream with the same gloves she cleaned the resident's BM with. She confirmed she also placed the resident's clean diaper by the soiled diaper and touched the blue pad and left it under the resident because it was still clean. On 9/9/13 at 12:33 p.m. an interview was conducted with S7CNA. She acknowledged she didn't wash her hands after she assisted S6CNA with changing Resident #5's incontinent brief before retrieving the clear bag from the resident's garbage can. She also confirmed she folded the glove on her right hand and opened the door to take the clear bag to the container on the hall. She said she was supposed to wash her hands after performing incontinent care on a resident before touching the resident's door and verified she did not. Resident #4 Resident #4 was a was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation #2 12:45 p.m. Performed by S8CNA and assisted by S5CNA Supervisor B Hall S8CNA Applied hand sanitizer Applied gloves Folded Resident #4's soiled brief between legs Wiped resident's front area from top to bottom with wet wipe Discarded wet wipe Touched and straightened resident's disposable blue pad under resident touching blue pad with soiled diaper Turned resident on right side Handed soiled diaper to S5CNA Supervisor S5CNA Supervisor grabbed soiled diaper with left hand; placing it down by clean diaper trying to assist with positioning clean diaper under resident with right hand Turned resident on left side S8CNA wiped resident's outer buttocks with wet wipe(did not clean inner buttocks) leaving resident's buttock's wet from wipe S8CNA placed clean diaper under resident to side near right side S5CNA Supervisor with same gloves BM cleaned with S8CNA placed resident placed on back and secured left side of diaper while S5CNA Supervisor secured right side S8CNA removed gloves S5CNA Supervisor placed soiled diaper in clear bag in resident's trash can S8CNA removed clear bag from resident's trash can, opened door and discarded clear trash bag in container outside resident's door Applied hand sanitizer On 9/9/13 at 12:59 a.m. an interview was conducted with S8CNA. She acknowledged she applied Resident #4's clean diaper with the same gloves used to clean the resident's BM. She also confirmed she did not spread the resident's buttocks apart when she cleaned BM from the resident's outer buttocks. She verified when she wiped the resident with the wet wipe, she did not dry the resident's buttocks leaving the resident wet before placing the clean diaper. She said she was nervous. She confirmed she took her gloves off after changing the resident and removed the trash liner out of the resident's trash can, touched the door and discarded of the clear trash bag without washing her hands. On 9/10/13 at 1:02 p.m. an interview was conducted with S5CNA Supervisor. She confirmed she picked the soiled diaper up with her left hand placing it down by clean diaper while trying to assist S8CNA with positioning clean diaper under resident with right hand. She acknowledged the soiled diaper should not have come in contact with the clean diaper. On 9/11/13 at 11:41 a.m. an interview was conducted with S4RN. She said the facility did not inservice the CNA staff on Incontinent Care aimed at decreasing the number of UTI's throughout the facility and said she wasn't if the CNA's were competent in performing Incontinence Care.

Based on record review and interview, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 1(#3) of 5(#1, #2, #3, #4, #5) sampled residents reviewed for Urinary Tract Infections(UTIs). Findings: Resident #3 Resident #3 was a [AGE] year old male admitted to the facility September 10, 2010 with [DIAGNOSES REDACTED]. and [MEDICAL CONDITION] Disorder, Coronary [MEDICAL CONDITION], Anxiety, Acute Gastritis, [MEDICAL CONDITION] Fibrillation and [MEDICAL CONDITION]. Review of the facility's Incontinence Briefs Policy dated 10/08 revealed the following in part: Policy Nursing Service was to ensure that residents incontinent of bowel and or bladder are kept clean, dry, comfortable, and their dignity maintained. Procedure F. Wipe away as much feces as possible using toilet tissue. G. Wash the area from front to back and rinse with water. H. Pat dry with a towel and apply a clean brief. I. Place soiled brief and supplies in a plastic bag and tie the bag. Place the bag in receptacle for soiled briefs. Review of Resident #3's Laboratory Results revealed the following in part: 10/19/12 Urinalysis Clarity: Slightly cloudy (Clear) Leukocyte(Leuk) Esterase 2 plus (Negative)(Neg) Microscopic White Blood Cell(WBC) greater than 100 High(H) (0-5 average) Bacteria Many (Neg) 10/21/12 Final culture Escherichia(E) Coli 11/5/12 Urinalysis Clarity Very cloudy Leuk Esterase 2 plus Microscopic WBC greater than 90 H Bacteria Many Resident #3 was sent out a local hospital 11/8/12 for a psychiatric evaluation and returned same day. A urine culture was done. Resident returned to facility same day from hospital. Diagnosis: [REDACTED]. 11/8/12 Hospital Return Record hospitalization Reason: Anxiety UTI Medical Information-Admission Reassessment Cognition: Alert oriented to person Mood/Behavior: Cheerful Elimination: Incontinent-Bowel/Bladder Brief Transfer of Care Instructions Discharge location: Facility Functional Status/Mental Status At Time of Discharge: Alert, Oriented 1, 2 11/10/12 Culture results received from local hospital. Resident's urine was positive for E Coli Review of Resident #3's clinical record revealed the following in part: 11/21/12 Hospital Transfer Record Reason for Transfer: Suicide Ideation As needed(PRN) meds given prior to transfer: [MEDICATION NAME] 0.25 mg at 11 a.m. Diagnoses: [REDACTED]. Reason for Admission: Danger to self. Gravely Disabled. Admit to acute psychiatric if still having symptoms. Making hopeless, statements. Further review of the records revealed the resident was discharged back to the facility 12/4/12 with same UTI and not on Antibiotic. 12/5/12 Urinalysis Leuk Esterase 2 plus Microscopic WBC greater than 100 H Bacteria Moderate 12/8/12 Final culture E. Coli 12/17/12 Urinalysis Leuk Esterase Trace Microscopic WBC greater than 50 H Bacteria Rare Mucous Few 12/20/12 Final culture E. Coli 12/21/12 Urinalysis Leuk Esterase 2 plus [MEDICATION NAME] positive Hemoglobin 3 plus Microscopic WBC greater than 100 H Bacteria Moderate 12/23/12 Final culture E. Coli 1/9/13 Urinalysis Leuk Esterase 2 plus Hemoglobin 2 plus Microscopic WBC greater than 100 H Bacteria Many 1/9/13 Final culture E. Coli 1/28/13 Urinalysis Leuk Esterase 2 plus Hemoglobin 1 plus Microscopic WBC greater than 100 H Bacteria Many 1/30/13 Final culture E. Coli 3/6/13 Urinalysis Clarity: Slightly cloudy` Leuk Esterase 2 plus [MEDICATION NAME]: Positive Hemoglobin: 1 plus 3/8/13 Final Culture E. Coli 5/8/13 Urinalysis Clarity: Slightly cloudy Leuk Esterase 2 plus [MEDICATION NAME]: Positive [MEDICATION NAME]: Trace Microscopic: WBC greater than 100 H Bacteria: Many 5/10/13 Final culture E. Coli. 5/28/13 Urinalysis Color: Green Clarity: Slightly Cloudy Leuk Esterase 2 plus [MEDICATION NAME] 1 plus Microscopic WBC 40 Bacteria Trace Mucous Few 5/31/13 Final Culture E Coli. Review of Resident #3's clinical record revealed the resident was admitted to a local hospital on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's Comprehensive Plan of Care revealed the following in part: Actual Infection related to UTI meds: Amakacin and [MEDICATION NAME] Begin date: 5/14/13 Goal: Will be free of infection. Approaches: 1) Refer to Medical Director(MD) if symptoms worsen or remain unresolved after completion of antibiotic. 2) Ensure as clean an environment as possible, using universal precautions and handwashing. 3) Administer meds as ordered. 4) Monitor site for increased for increased redness, swelling warmth, drainage or pain and notify MD. Further review of the resident's care plan noted "resolved" and a line drawn through the care plan. The resident did not have a care plan for reoccurring UTIs or patient specific interventions aimed at preventing or decreasing the resident's occurrences of UTIs with E Coli. Resident #5 Resident #5 was a was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/9/13 2 observations of Incontinent Care was done as follows: Observation #1 12:21 p.m. Performed by S6CNA assisted by S7CNA A Hall S6CNA Put a pair of clean gloves on Unfastened Resident #5's brief and folded diaper down between his legs Wiped Resident #5's front area from top to bottom Repeated above step again Turned resident on right side Wiped in between Resident #5's buttocks from bottom to top with wet wipe Folded same wet wipe over and wiped in between resident's buttocks again Pulled soiled diaper from under the resident and touched and straightened disposable blue pad under resident Picked clean diaper up and put near soiled diaper Took soiled diaper and put in the resident's trash can Took clean diaper with same soiled gloves on and put under resident Retrieved bottle of Aloe Vista Cream(protective ointment) Applied Aloe Vista Cream Fastened brief on left side Touched resident S7CNA assisted S6CNA with fastening brief on right side with gloves on S7CNA retrieved clear bag out resident's garbage can with soiled diaper Tied bag up Folded glove on right hand half way and opened door with right hand Put clear bag in container on outside of resident's door On 9/9/13 at 12:30 p.m. an interview was conducted with S6CNA. She stated she had been working at the facility for [AGE] years and a couple of months. She acknowledged when she wiped Resident #5's buttocks, she wiped twice with the same soiled wet wipe. She said the second time she wiped it with the clean side of the wipe. S6CNA confirmed she applied the resident's diaper and applied Aloe Vista cream with the same gloves she cleaned the resident's BM with. She confirmed she also placed the resident's clean diaper by the soiled diaper and touched the blue pad and left it under the resident because it was still clean. On 9/9/13 at 12:33 p.m. an interview was conducted with S7CNA. She acknowledged she didn't wash her hands after she assisted S6CNA with changing Resident #5's incontinent brief before retrieving the clear bag from the resident's garbage can. She also confirmed she folded the glove on her right hand and opened the door to take the clear bag to the container on the hall. She said she was supposed to wash her hands after performing incontinent care on a resident before touching the resident's door and verified she did not. Resident #4 Resident #4 was a was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation #2 12:45 p.m. Performed by S8CNA and assisted by S5CNA Supervisor B Hall S8CNA Applied hand sanitizer Applied gloves Folded Resident #4's soiled brief between legs Wiped resident's front area from top to bottom with wet wipe Discarded wet wipe Touched and straightened resident's disposable blue pad under resident touching blue pad with soiled diaper Turned resident on right side Handed soiled diaper to S5CNA Supervisor S5CNA Supervisor grabbed soiled diaper with left hand; placing it down by clean diaper trying to assist with positioning clean diaper under resident with right hand Turned resident on left side S8CNA wiped resident's outer buttocks with wet wipe(did not clean inner buttocks) leaving resident's buttock's wet from wipe S8CNA placed clean diaper under resident to side near right side S5CNA Supervisor with same gloves BM cleaned with S8CNA placed resident placed on back and secured left side of diaper while S5CNA Supervisor secured right side S8CNA removed gloves S5CNA Supervisor placed soiled diaper in clear bag in resident's trash can S8CNA removed clear bag from resident's trash can, opened door and discarded clear trash bag in container outside resident's door Applied hand sanitizer On 9/9/13 at 12:59 a.m. an interview was conducted with S8CNA. She acknowledged she applied Resident #4's clean diaper with the same gloves used to clean the resident's BM. She also confirmed she did not spread the resident's buttocks apart when she cleaned BM from the resident's outer buttocks. She verified when she wiped the resident with the wet wipe, the resident's buttocks was wet but she did not dry the resident's buttocks before placing the clean diaper. She said she was nervous. She confirmed she took her gloves off after changing the resident and removed the trash liner out of the resident's trash can, touched the door and discarded of the clear trash bag without washing her hands. On 9/10/13 at 1:02 p.m. an interview was conducted with S5CNA Supervisor. She confirmed she picked the soiled diaper up with her left hand placing it down by clean diaper while trying to assist S8CNA with positioning clean diaper under resident with right hand. She acknowledged the soiled diaper should not have come in contact with the clean diaper. Review of the facility's Infection Control Report revealed the following in part: March 2013 3 UTIs A Hall 2 UTIs B Hall April 2013 5 UTIs A Hall 1 UTI B Hall 2 Location not recorded 8 UTI's recorded May 2013 1 UTI A Hall 5 UTIs B Hall June 2013 5 UTIs A Hall 3 UTIs B Hall July 2012 7 UTI's A Hall 3 UTIs B Hall Farther review of the Infection Control Report did not reveal Resident #3 had UTI's in May 2013, and his labs indicate he had 2; May 8th and May 28 th 2013. There was documented evidence of Infection Control Tracking and Trending Logs for August 2013. On 9/11/13 at 11:41 a.m. an interview was conducted with S4RN. She said the resident kept getting repeated UTIs and they could not figure out why. She said he was placed on several different medications from October 2012 to July 2013 because he had tested 9 times for UTIs positive for E. Coli. She said everytime they did a UA/CS, the results came back positive. She stated the resident was allergic to [MEDICATION NAME], Bactrim, [MEDICATION NAME], Keflex and Sulfa and it was hard to treat him. She said the staff at the facility called the resident's wife to find out why the resident got anxious anytime he got a UTI. She said the wife informed staff the resident displayed psychotic episodes when he got UTIs. S4RN said the most of the UTIs were on B Hall; because that's where most of the resident's with catheters were. She acknowledged there was no care plan that addressed how the facility were going to decrease Resident #3's reoccurring UTIs with E Coli or the increased number of UTIs on A and B Hall. She confirmed the resident had 9 back to back UTIs positive for E. Coli from October. She said she called 2 aides into Resident #3's room because he would not let the CNA's change him because they spreaded his legs too far apart and made him uncomfortable due to his back problems. She said the facility did not inservice the CNA staff on Incontinent Care aimed at decreasing the number of UTIs throughout the facility. She said she did not have knowledge of the Infection Control tracking and trending Log because she would have been aware and looked at addressing UTIs at the facility as a whole instead of thinking it was isolated to Resident #3. On 9/11/13 at 2:23 p.m. an interview was conducted with S2DON. He confirmed they did not have documentation the facility put interventions in place to eliminate or decrease Resident #3's UTIs positive for E. Coli. He also acknowledged they did not develop a recurrent UTI care plan with interventions to address the 9 times Resident #3 was diagnosed with [REDACTED]. He acknowledged there was an increased number of UTIs in from April 2013 to July 2013, but the facility staff did not perform inservices specific to addressing the increased number of UTIs on A and B Hall the facility. S2DON said he did not know whether competencies had been done on the CNA staff to see if they were competent in performing Incontinent Care properly. He said the only inservice the CNA staff had was when an outside vendor came and did one on briefs and they had documents being passed around to the supervisors to inservice CNAs to get ready for their VA survey, but not specifically to address the increased number of UTIs from April 2013 to July 2013 noted in the Infection Control Log.

Based on record review and interviews, the facility failed to ensure written notifications of their bed hold policy was provided for 1(#3) of 3(#1, #2, #3) residents reviewed for transfers/discharges during closed record reviews. Findings: Resident #3 Resident #3 was a [AGE] year old male admitted to the facility September 10, 2010 with [DIAGNOSES REDACTED]. Review of the facility's Administrative Discharge Policy revealed the following in part: Policy G. Notice of bed-hold policy and readmission. 1. Notice before transfer. Before transferring a resident to the hospital or allowing the resident to go on therapeutic leave, the facility management will provide written information to the resident and a family member or authorized representative that specifies: a. The duration of the bed-hold policy during which the resident was permitted to return and resume residence in the facility; and b. The facility's policies regarding bed-hold periods. c. The facility will allow the resident whose hospitalization or therapeutic leave exceeds the bed-hold period, to be readmitted to the facility immediately upon the first availability of a bed if the resident requires the services provided by the facility. Review of the facility's Investigative Report dated 7/8/13 for Resident #3 revealed the following in part: Witness Statement: S10RN, tried to enter into Resident #3's room. The resident had placed a walker behind the door. S10RN pushed the door open. She stated the resident was in bed with a plastic bag over his head. S10RN removed the plastic bag and saw Resident #3 had twisted 3 wire hangers around his neck. His eyes were open and respirations present. S10RN said she stepped into the hall; still watching the resident and called a Code Blue. Action taken to prevent reoccurrence: Placed on 1 on 1 observation. Sent to emergency room for psychiatric evaluation(admitted to Geriatric Psychiatric). Review of Resident #3's physician's orders [REDACTED]. 7/8/13 Send to emergency room for psychiatric evaluation. Place on 1 to 1. Review of Resident #3's clinical record revealed no documented evidence a bed hold policy was given to Resident #3 or his responsible party on 7/8/13; when the resident transferred to a local psychiatric hospital for evaluation and treatment. On 9/10/13 at 11:39 a.m. an interview was conducted with S1Administrator. He acknowledged he did not give Resident #3 or his responsible party a copy of the facility's bed hold policy when the resident was sent to a local hospital for a psychiatric evaluation because he knew he was not coming back to the facility due to his attempt to harm himself.

Based on record review and interview, the facility failed to notify the responsible party of 2(#3, #1) of 3(#1, #2, #3) resident's reviewed for transfers/discharges during closed record reviews. The facility failed to: a) Notify the residents in writing at least 30 days prior to the planned discharge date ; b) Provide a statement that the resident had the right to appeal the action to the State;. c) Provide the name, address and telephone number of the State long term care ombudsman. Findings: Resident #3 Resident #3 was a [AGE] year old male admitted to the facility September 10, 2010 with [DIAGNOSES REDACTED]. Review of the facility's Administrative Discharge Policy revealed the following in part: Policy It is the policy of the facility to ensure that administrative discharges are conducted in a manner which will ensure the care is maintained. Administrative Discharges will be coordinated through the Administrator's office; however, Social Services will be notified and may be requested to assist. Procedure D. Timing of the notice The notice of transfer or discharge will be made by the facility at least 30 days before the resident was transferred or discharged . E. Contents of the notice. The written notice will include the following: a. The reason for transfer or discharge; b. The effective date of transfer or discharge; c. The location to which the resident was transferred or discharged ; d. A statement that the resident had the right to appeal the action to the State official designated by the State; and e. The name, address and telephone number of the State long term care ombudsman. F. Orientation for transfer or discharge. Facility management will provide sufficient preparation and orientation to the resident to ensure safe and orderly transfer or discharge from the facility. Review of the facility's Investigative Report, dated 7/8/13, for Resident #3 revealed the following in part: Witness Statement: S10RN, tried to enter into Resident #3's room. The resident had placed a walker behind the door. S10RN pushed the door open. She stated the resident was in bed with a plastic bag over his head. S10RN removed the plastic bag and saw Resident #3 had twisted 3 wire hangers around his neck. His eyes were open and respirations present. S10RN said she stepped into the hall; still watching the resident and called a Code Blue. Action taken to prevent reoccurrence: Placed on 1 on 1 observation. Sent to emergency room for psychiatric evaluation(admitted to Geriatric Psychiatric). Review of Resident #3's physician's orders [REDACTED]. 7/8/13 Send to emergency room for psychiatric evaluation. Place on 1 to 1. 7/22/13 Discharge from facility. Review of the letter sent from S1Administrator to Resident #3's responsible party revealed the following in part: Date: Monday, July 22, 2013 Re: Administrative Discharge for Resident #3 To: Resident #3's responsible party Dear Resident #3's responsible party: Per our conversation on 7/9/13, the day following discharge from our facility, it was with a heavy heart and the utmost concern for Resident #3 that we have chosen to follow our admissions procedures in not allowing the return admission of Resident #3 to our facility. This was due to the physical status S1Administrator personally saw the resident in on the afternoon of 7/8/13. In addition, he had no recollection that he was presenting harm to himself and even voiced that he "thought it was a good idea". In the event we are unable to continue to provide care to a Veteran because they present a significant change in their behavior, our facility reserves the right to decline re-admission or enact formal administrative discharge procedures. This was presented by Resident #3 displaying "harm to self" on the afternoon of 7/8/13. ...We loved Resident #3 and he has been a pleasure to care for. However, we are unable to provide the one-on-one care and attention that Resident #3 now required. Please advise our facility of the eventual destination for placement upon discharge from the hospital and we will be pleased to coordinate communication with the admitting facility to ensure his Veteran's Administration(VA) funding was transferred. Thank you again for the pleasure of caring for Resident #3 and you during these last several years. We hope and pray that you are able to secure placement for him that will provide him the level of care he now requires. Review of the facility's physician progress notes [REDACTED]. 7/25/13 Resident discharged from facility. 8/1/13 Family notified of transfer to hospital and eventual discharge related to suicidal ideation with attempt. Further review of the document revealed a stamp with the resident's physician name on it. On 9/9/13 at 2:25 p.m. an interview was conducted with S1Administrator. He acknowledged he did not give Resident #3's responsible party 30 days notice before the resident was discharged on [DATE]. He also confirmed he did not give the resident's responsible party a statement with the letter sent on 7/22/13 that the resident had the right to appeal the action to the State or the name, address and telephone number of the State long term care ombudsman. He said when Resident #3 tried to harm himself by putting a plastic bag over his head and 3 hangers around his neck on 7/8/13; he forwent the normal discharge procedures and executed Administrative Discharge procedures on that day. Review of the record revealed Resident #1 was a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Review of a Hospital Transfer Record dated 3/11/13 revealed the resident was transferred to a local mental hospital for unpredictable behavior, wandering, and unable to redirect. Review of a Physician's Telephone Order dated 4/24/13 read discharge to another facility. An interview was conducted with S9Social Services on 9/9/13 at 11:57 a.m. She stated the resident immediately started experiencing behaviors upon admit. She stated he exhibited wandering behaviors and was found in other residents' beds. She stated he was sent out to a behavioral hospital for medication adjustment and was readmitted to the facility. She stated after he was readmitted his behaviors continued and he was admitted to the facility's secure unit. She stated the resident's behaviors escalated and he destroyed a television and attempted to elope from the facility. She stated he was admitted to a local mental health hospital for treatment on 3/11/13. She stated the resident's behaviors continued during his stay at the local mental health hospital. She stated that S1Administrator, made the administrative decision to not allow the resident to be readmitted because his needs could not be met due to his continuing behavior. An interview was conducted on 9/9/13 at 2:26 p.m. with S1Administrator. He stated the resident was admitted to the facility and really didn't want to be there. He stated Resident #1's behaviors consisted of not being easily redirected, wandering, being combative with staff and residents. He stated the resident was sent to a behavioral hospital where his medications were readjusted. He stated the resident was readmitted to the facility to the secure unit but the symptoms exacerbated. He stated the resident became an elopement risk and was discharged to a local mental health hospital. S1Administrator stated the resident's behaviors continued while at the local mental health hospital and the decision was made that the facility could no longer meet his needs. He stated he worked with the local mental health hospital to ensure the resident was admitted to another facility. He stated the resident was not given a notice of discharge nor notified of his appeals rights. He stated since the resident was discharged due to not being able to meet his needs due to behaviors, he didn't think the discharge notice and appeals process had to be followed.

Based on record review and interview, the facility failed to reassess the effectiveness of the interventions and review and revise the plan of care for 1(#3) of 5(#1,#2, #3, #4, #5) residents reviewed for Urinary Tract Infections(UTIs). Findings: Resident #3 Resident #3 was a [AGE] year old male admitted to the facility September 10, 2010 with [DIAGNOSES REDACTED]. and [MEDICAL CONDITION] Disorder, Coronary [MEDICAL CONDITION], Anxiety, Acute Gastritis, [MEDICAL CONDITION] Fibrillation and [MEDICAL CONDITION]. Review of Resident #3's Laboratory Results revealed the following in part: 10/19/12 Urinalysis Clarity: Slightly cloudy (Clear) Leukocyte(Leuk) Esterase 2 plus (Negative)(Neg) Microscopic White Blood Cell(WBC) greater than 100 High(H) (0-5 average) Bacteria Many (Neg) 10/21/12 Final culture Escherichia(E) Coli 11/5/12 Urinalysis Clarity Very cloudy Leuk Esterase 2 plus Microscopic WBC greater than 90 H Bacteria Many Resident #3 was sent out a local hospital 11/8/12 for a psychiatric evaluation and returned same day. A urine culture was done. Resident returned to facility same day from hospital. Diagnosis: [REDACTED]. 11/8/12 Hospital Return Record hospitalization Reason: Anxiety UTI Medical Information-Admission Reassessment Cognition: Alert oriented to person Mood/Behavior: Cheerful Elimination: Incontinent-Bowel/Bladder Brief Transfer of Care Instructions Discharge location: Facility Functional Status/Mental Status At Time of Discharge: Alert, Oriented 1, 2 11/10/12 Culture results received from local hospital. Resident's urine was positive for E. Coli. Review of Resident #3's clinical record revealed the following in part: 11/21/12 Hospital Transfer Record Reason for Transfer: Suicide Ideation As needed(PRN) meds given prior to transfer: [MEDICATION NAME] 0.25 mg at 11 a.m. Diagnoses: [REDACTED]. Reason for Admission: Danger to self. Gravely Disabled. Admit to acute psychiatric if still having symptoms. Making hopeless, statements. Further review of the records revealed the resident was discharged back to the facility 12/4/12 with same UTI and not on Antibiotic. 12/5/12 Urinalysis Leuk Esterase 2 plus Microscopic WBC greater than 100 H Bacteria Moderate 12/8/12 Final culture E. Coli 12/17/12 Urinalysis Leuk Esterase Trace Microscopic WBC greater than 50 H Bacteria Rare Mucous Few 12/20/12 Final culture E. Coli 12/21/12 Urinalysis Leuk Esterase 2 plus [MEDICATION NAME] positive Hemoglobin 3 plus Microscopic WBC greater than 100 H Bacteria Moderate 12/23/12 Final culture E. Coli 1/9/13 Urinalysis Leuk Esterase 2 plus Hemoglobin 2 plus Microscopic WBC greater than 100 H Bacteria Many 1/9/13 Final culture E. Coli 1/28/13 Urinalysis Leuk Esterase 2 plus Hemoglobin 1 plus Microscopic WBC greater than 100 H Bacteria Many 1/30/13 Final culture E. Coli 3/6/13 Urinalysis Clarity: Slightly cloudy` Leuk Esterase 2 plus [MEDICATION NAME]: Positive Hemoglobin: 1 plus 3/8/13 Final Culture E. Coli 5/8/13 Urinalysis Clarity: Slightly cloudy Leuk Esterase 2 plus [MEDICATION NAME]: Positive [MEDICATION NAME]: Trace Microscopic: WBC greater than 100 H Bacteria: Many 5/10/13 Final culture E. Coli. 5/28/13 Urinalysis Color: Green Clarity: Slightly Cloudy Leuk Esterase 2 plus [MEDICATION NAME] 1 plus Microscopic WBC 40 Bacteria Trace Mucous Few 5/31/13 Final Culture E Coli. Review of Resident #3's clinical record revealed the resident was admitted to a local hospital on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's Comprehensive Plan of Care revealed the following in part: Actual Infection related to UTI meds: Amakacin and [MEDICATION NAME] Begin date: 5/14/13 Goal: Will be free of infection. Approaches: 1) Refer to Medical Director(MD) if symptoms worsen or remain unresolved after completion of antibiotic. 2) Ensure as clean an environment as possible, using universal precautions and handwashing. 3) Administer meds as ordered. 4) Monitor site for increased for increased redness, swelling warmth, drainage or pain and notify MD. Further review of the resident's care plan noted "resolved" and a line drawn through the care plan. The resident did not have a care plan for reoccurring UTIs or patient specific interventions aimed at preventing or decreasing the resident's occurrences of UTIs with E. Coli. On 9/10/13 at 11:41 a.m. an interview was conducted with S4RN. She said the resident kept getting repeated UTIs and they could not figure out why. She said he was placed on several different medications from October 2012 to July 2013 because he had tested 9 times for UTIs positive for E. Coli. She said everytime they done a UA/CS, the results came back positive. She acknowledged there was no care plan that addressed how the facility was going to decrease Resident #3's reoccurring UTIs with E Coli or the increased number of UTIs on A and B Hall. She confirmed the resident's had 9 back to back UTIs positive for E. Coli from October 2012.

Based on record review and interviews, the facility failed to provide Mental health rehabilitative services for 1 of 1 residents that demonstrated mental and psychosocial difficulties (Resident #37) reviewed from a Stage 2 sample of 29. The facility failed to: 1. provide a structured environment for a resident experiencing isolation and withdrawal; 2. provide crisis intervention service; 3. ensure the facility licensed social worker provided psychotherapy/ counseling to resident #37 for depression and suicidal ideation. 4. develop appropriate personal support networks; 5. provide formal behavior modification programs. 6. implement measures to treat the underlying factors behind isolation and withdrawal; 7. provide mental health interventions and services for depression upon resident's return to facility from hospitalization due to failed suicide attempt; 9. ensure the licensed social worker and counseling staff obtained outside counseling or rehabilitative therapy for resident #37's depression and suicidal ideation. . Resident #37 was placed in Immediate Jeopardy when he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Social service, including the licensed social worker failed to intervene when the resident (#37) displayed difficulty with mental and psychosocial adjustment regarding having a terminal illness, adjustment to a new facility, losing his son in [DATE], and expressing feelings of not wanting to live. The Immediate Jeopardy ended on [DATE] when the resident was transferred to the hospital for a psychological evaluation after self inflicting a wound to his left wrist. The Immediate Jeopardy began again when the resident returned to the facility on [DATE] and social services again did not provide interventions for resident #37 regarding depression and suicidal ideology. Findings: Resident #37 Resident #37 was a [AGE] year old army veteran that was admitted to the facility on [DATE]. The resident was admitted to the facility with [DIAGNOSES REDACTED]. While at the facility the resident underwent [REDACTED]. Further review of the clinical record revealed that in [DATE], the resident's son passed away [MEDICAL CONDITION]. Review of the admission MDS dated [DATE] revealed the resident the resident was coded as having a [DIAGNOSES REDACTED]. The resident was not coded to have any hallucinations or [MEDICAL CONDITION]. Review of the "State Home Program Application For Veteran Care" form revealed documentation made by the Physician on [DATE]. The documentation included the resident's history as a [AGE] year old male with [MEDICAL CONDITION] that had [MEDICAL CONDITION] but developed brain metastasis. He had two surgeries for metastasis of the brain. Further review of the form revealed section, "Social Work Assessment (To be completed by Social Worker)". This section was dated for [DATE] and completed by S23Counselor. The section included that the resident was "having difficulty settling in". Review of the Nursing Progress Notes revealed the following: [DATE] at 4:00 a.m. - resident was crying, stating that no one had visited him. At 5:45 a.m. the resident was "requesting to see a lawyer". The resident stated, "I have my rights and I want my family to come see me now." Review of the Comprehensive Care Plan revealed the following: Problem: Lack of participation r/t refuses to attend, dependent on staff, lack of interest, inability to perform, new admission, daytime napping, new limiting disability, inappropriate social behavior, bedfast. Problem Date: [DATE] Problem: History of Depression. Resident is on [MEDICATION NAME]. Problem Date: [DATE]. Review of form entitled, "Information Sheet" dated [DATE] and timed for 7:00 a.m. revealed documentation completed by S18CNA. Documented within the form was that when S18CNA responded to resident #37's call light, "he had it against his neck pressed down saying he wanted to hang himself.". S18CNA further documented that she left the resident's room and the resident "hit the light again". When S18CNA responded to the resident's call light, the resident was demonstrating the same behavior, and S18CNA documented that again the resident was told "not to do that". The resident asked S18CNA "to do it (hang him) for him". S18CNA documented that she removed the cord, put it on the side of the bed and notified S6CNA Supervisor and S10LPN. Review of an Incident Report dated [DATE] and timed for 9:50 a.m. that was completed by S10LPN revealed the description of the incident as, "Veteran lying in bed, calling for assistance to get up. Upon entering the room, observed right arm bleeding. Skin tears noted on arm near wrist. Veteran stated he pulled the bandaid off arm". Review of the Social Services Admission Assessment, completed by S23Counselor and dated [DATE] (not timed), revealed documentation that the resident had no previous mental health treatment and "appears upset and disoriented upon assessment". Review of a Social Services Progress Note dated [DATE] included that the resident was admitted from the hospital and appeared alert and verbal but disoriented. Further documented was the following: "Calls out frequently - confused. Family states he is depressed due to state of health. Will see needs are met." S23Counselor made no reference to either incident involving the resident on [DATE]. An interview was held with S18CNA on [DATE] at 9:15 a.m. She verified she was the CNA that responded to resident #37's call light on [DATE] and witnessed the resident display and verbalize suicidal thoughts and behaviors. S18CNA demonstrated how the resident had the call light cord positioned around his neck. She said he had the cord pulled around to the back of his neck and was holding it tightly. She recalled the resident saying he wanted to hang himself and even asked her to help him. She said she talked to him and he told her that he had no reason to live because his wife was marrying another man and his children didn't care about him. She said he talked about being in pain and that he didn't want to be in pain anymore. She said that after she talked with him, she left the room, and then she positioned herself at the door where she could see him. She said the resident could not see her. She said as soon as she left the room, the resident immediately placed the call light cord back around his neck. She said she re-entered the room, and talked more with the resident. She said she placed the call light at the side of the resident's bed and then reported the incident to S6CNA Supervisor, who told her to write a statement and report it to the nurse. S6CNA said she reported the incident to S10LPN, who told her that she "would take care of it". A telephone interview was held with S10LPN on [DATE] at 12:55 p.m. She recalled resident #37 and stated that he frequently talked about dying. She said that she related his references to dying to be nothing more than adjusting to being in the facility and/or being in pain. She stated that she had not referred the resident to the physician regarding this behavior. She verified that all referrals to a rehabilitation, including the IOP (Intensive Outpatient Program) required a physician's orders [REDACTED]. She explained that the resident would demonstrate self destructive behaviors when he wanted attention. She stated that she could not recall what interventions were put into place for the resident's behaviors. On [DATE] at 2:15 p.m. an interview was held with the S2DON. S2DON reviewed the resident's clinical record. He described the resident as being admitted to the facility with "attention seeking" behaviors that included threats of harming himself. He stated the resident talked of harming himself frequently, but he never acted on it. S2DON stated that he related the behavior and discussion of self harm to the resident's mental status. He recalled the resident had brain surgery to remove a tumor prior to being admitted to the facility and that the resident had [MEDICAL CONDITION] that had metastasized to his brain. He recalled the resident placing the call light against his neck. S2DON verified that within a few hours of the resident displaying suicidal behaviors, he was found to have bleeding "skin tears" to his right wrist area. S2DON reviewed the resident's clinical record and verified there were no documented wounds to the resident's right wrist prior to the incident on [DATE]. After reviewing all documentation related to resident #37, S2DON verified that the physician was not contacted regarding the resident's behaviors and he could not recall the resident being referred to rehabilitation services for his mental/psychosocial needs. He stated that if any counseling services were provided that this would have been done by social services. Review of the Nursing Progress Notes revealed the following: [DATE] at 10:20 a.m., S17LPN documented that the CNA reported the resident had a skin tear to his left hand. S17LPN documented that she asked the resident what happened to his arm. He stated "I tried to cut my wrist, I wanna die. I wish I had a gun." Was asked by the nurse, "are you telling me you're trying to harm yourself." He stated, "no I'm trying to kill myself do you have a gun." The nurse documented that this incident was reported to the DON. Upon returning to the room, the nurse observed a broken piece of tile with dried blood on it. The resident stated "my kids gave up on me and my wife is gone marry a black man". [DATE] at 11:30 a.m., the nurse documented the resident was "assessed for suicidal gestures", and a 2 inch superficial cut was noted to the resident's left wrist. The resident was observed to be pulling the sutures from his scalp. He complained of "severe pain" to his back and legs with movement. The physician was present and ordered the resident to be transferred to the hospital due to him being a danger to self. [DATE] at 2:30 p.m., the resident was transferred to the hospital. Review of the Incident Report dated [DATE] and timed for 10:20 a.m. revealed a description of the incident as: Veteran has skin tear to left wrist, stated "I tried to cut my wrist, I want to die." Two inch superficial skin tear noted to left wrist. Veteran also attempted to pull suture from scalp. Review of the Social Services Progress Notes dated [DATE] (no documented time) revealed documentation made by S19LCSW. The documentation included the following: "Went into vet's (veteran) room and MD, nursing staff in room with him. After staff left spoke with vet regarding cutting of his wrists. He stated he wanted 'to kill them all'. When asked by this writer who he was referring to he said 'my wife and kids'. When asked why, he stated 'my wife is having an affair with a black man and wants to marry him'. When asked about his children he stated, 'they want my money'. Vet appears to feel abandoned, angry and hopeless. He also stated he was tired of being in pain (headache and backache). He had trouble changing positions in bed due to pain. He also discussed the loss of his son (youngest) due [MEDICAL CONDITION] and how that made his wife 'go crazy'. Vet is grieving but trying to understand his wife's current behavior. He is in need of a thorough mental health assmt (assessment) as well as family tx (treatment) and pain mgmt (management) at this time. Inpt (Inpatient) hosp (hospital) recommended." Review of the Physician's Telephone Orders revealed an order dated for [DATE] to transfer the resident to the psychiatric hospital per ambulance. Review of the Physician Emergency Certificate (PEC) dated [DATE] and timed for 11:30 a.m. revealed documentation made by the physician that the resident was "suicidal" and that the resident had [MEDICAL CONDITION] with metastasis-has pain to pelvic area with movement-made attempt to cut wrists-has depression. Review of the physician progress notes [REDACTED]. The Physician referenced that the resident had [MEDICAL CONDITION] with metastasis. The Physician further documented that the resident would be transferred to psych unit for "evaluation of his depression and suggestion for better control". Review of the hospital records revealed the following: *History and Physical dated [DATE] revealed that the resident was alert and oriented x 3. That he had a history of [REDACTED]. The resident presented to the hospital for a suicide attempt at nursing home. The resident tried to cut the vein of his hands and said that he felt that there was "no sense to continue to live". *Psychiatric Evaluation dated [DATE] that was completed by the hospital's physician revealed: General Appearance and Behavior: Both wrists bandaged. Chief Complaint: When asked why he cut his wrists he states: "for fun...I had nothing else to do...I was bored". History of Psychiatric: He cut both wrists with piece of formica *physician progress notes [REDACTED]. effects of [MEDICAL CONDITION] for the last 5 years. Pt (patient) has been saying that he would kill himself b/c (because) he did not want to live like this." *Psychosocial assessment dated [DATE] that was completed by the hospital's social worker included following: Presenting Problem: Pt admitted on PEC for treatment of [REDACTED]. Other/Comments: Says he is tired of the pain and wants to get rid of it. Previous Attempts: Has had suicidal thoughts in the past but did not act on them - per daughter. Homicidal Ideations: Voiced homicidal thoughts to the doctor concerning his wife whom he thought was having an affair. Appetite Problems: Poor appetite. Family/Significant Other input relating to Present Problem: Daughter feels recent incident was impulsive and says Pt is upset with family. Feeling they do not visit him enough. Daughter says they try to visit daily. Family Origin: Married, has children (3 living and 1 deceased ), 1 brother living. Developmental History: Daughter reported Pt has been [MEDICAL CONDITION] for last 5 years. Cancer started in the lungs and is now also in the brain. Severe Grief/Loss Issues relating to: Pt's son died [DATE] (6 weeks after being diagnosed with [REDACTED]. Recommendations for Treatment and Services for Family: 1:1 as needed. Further review of the hospital records revealed the resident was discharged back to the facility on [DATE]. Review of the hospital's discharge summary revealed that the resident was "actively hallucinating". On [DATE] at 11:40 a.m., an interview was held with S5RN-MDS/Care Plan. She verified she had completed resident #37's Care Plan. She reviewed the Care Plan and verified there was no documentation to indicate the resident had suicidal behaviors or had been transferred to the hospital for suicide attempts. She reviewed the resident's clinical record and verified the resident had not been referred for any rehabilitation services. An interview was held with S19LSW on [DATE] at 1:30 p.m. S19LCW recalled resident #37. She stated the resident had behaviors of [MEDICAL CONDITION]. She recalled the resident having "paranoid" thoughts regarding his wife and another man. She verified the resident self inflicted a wound to his left wrist on [DATE] and was sent to the hospital. She verified that prior to the hospitalization and after the resident returned to the hospital on [DATE], there were no interventions put into place for the resident. She stated that the facility has a IOP (Intensive Outpatient Program) but the resident was not a candidate for the program. She explained the resident was not a candidate because a resident has to be able to sit and participate in group sessions and the resident was unable to do so. She further explained that at times, residents were sent out of the facility for therapy. She said that most residents do not like this because of the travel time (to and from Baton Rouge) was too much for them to tolerate. S19LSW stated resident #37 was never referred to an outside source because he would not have been able to tolerate the ride to and from the office. When asked if resident #37 was provided any counseling services by the herself or the other counselors, S19LCW responded that she "didn't have time to counsel". Review of the job description for S19LSW revealed the following:*Provides individual supportive counseling to veterans with medically complex conditions, including, but not limited to terminal illness, mental illness, dementia, [MEDICAL CONDITION], substance abuse, [MEDICAL CONDITION]. Assess and documents therapeutic progress and actions taken to resolve problems or conflicts. Remains apprized of veteran's progress, actions, and behavior. Documents problems, incidents and actions taken, or any pertinent information in medical charts as needed. *Gathers and evaluates information to compile and develop written psycho social assessments and social histories through personal observations and interviews with the veteran and his family/responsible party. *Provides crisis intervention, grief and loss counseling to assist family/responsible party in coping with seriously ill dying patients as well as adjustment issues related to initial nursing care placement. Further review of the Social Services Progress Notes revealed the following dates/documentation: [DATE]: Resident returned from the hospital on [DATE] with [DIAGNOSES REDACTED]. [DATE]: "Stated to RN that he wanted to die." S22Counselor documented that she spoke with the resident and asked him about depression and thoughts of dying, but the resident denied the feelings with a response of "no, I just go with the flow". S22Counselor documented that she suggested and IOP visit to the RN. [DATE]: S22Counselor documented that she met with the resident's daughter as the daughter read over a book from hospice. The resident's daughter informed S22Counselor that "they recently lost a brother [MEDICAL CONDITION] and did not think their mother (resident's spouse) could handle another death at home at this time. Review of the Physician's Progress Notes included documentation dated [DATE]. The Note included that the resident had become increasingly confused and aggressive towards other residents. Another interview was held with S19LSW on [DATE] at 2:30 p.m. She said that the staff and other counselors would refer residents to her when needed. She further stated that she was not made aware of the incidents that occurred on [DATE] involving the resident's behavior of placing call cord around neck or of the staff finding skin tears to the resident's right wrists on [DATE]. She reviewed the resident's clinical record and verified that upon admission, S23Counselor documented the resident was "having difficulty settling in". She verified the resident had a terminal illness upon admission and had recently lost one of his children [MEDICAL CONDITION]. As S19LCW further reviewed the social notes, she verified that there was documentation indicating the resident had underwent a craniectomy which resulted in loss of vision in his right eye while residing in the facility. After review of all records for resident #37, S19LCW verified that the facility had identified the resident was having difficulty coping and that there had been no interventions, including rehabilitative services, provided to the resident. An interview was held with S22Counselor on [DATE] at 3:30 p.m. S22Counselor explained that the facility had the IOP for residents with counseling needs. She further explained that a resident must be able to sit in groups for up to three hours, three times a week. She said some residents were sent to outside sources for their psychological needs. She reviewed the Social Services Progress Notes and verified that she documented on [DATE] that resident #37 "stated to RN that he wanted to die". S22Counselor stated that when she spoke with the resident, that he denied suicidal thoughts. She said she could not recall the nurse that had informed her of the resident's comment. She said that on [DATE], she recommended the resident visit the IOP. She stated she did not follow up with the resident to see if he participated in the IOP. She said the resident was probably not a candidate for the IOP because he was confused and would not be able to sit in a group. She reviewed the resident's clinical records and verified there had been no social service interventions provided for the resident while he resided at the facility. On [DATE] at 8:45 a.m. an interview was held with S24IOP Technician. She stated that to be a patient in IOP (Intensive Outpatient Program) the resident must be referred by the physician and have clinical signs of depression, anxiety, or psychological issues. She stated resident #37 never received IOP. She reviewed the physician's orders [REDACTED]. She stated the resident was not treated because he was on hospice. She stated they do not treat resident's receiving hospice. In conclusion, the facility failed to intervene with interventions that included rehabilitation to meet the psychosocial and mental needs of resident #37 with coping with his terminal illness, the loss of his son, adjustment to a new facility, and that had expressed feelings of not wanting to live.

Based on record reviews, interviews and review of the social services job description, the facility failed to provide medically-related social services to attain the highest practicable mental and psychosocial well-being for 1 of 29 sampled residents reviewed for the Stage 2 sample. The facility failed to: 1. Provide social service interventions for resident #37 after he was admitted to the facility with a [DIAGNOSES REDACTED].. 2. Provide social service interventions for resident # 37 after he verbalized feelings of not wanting to live and demonstrating suicidal behaviors. 3. Provide social service interventions for resident # 37 for depression and suicidal ideology upon his return from hospital stay for failed suicide attempt. These failed practices resulted in an Immediate Jeopardy for resident #37 that began when the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Social service, including the licensed social worker failed to initiate interventions when the resident (#37) displayed difficulty with mental and psychosocial adjustment regarding having a terminal illness, adjustment to a new facility, losing his son in [DATE], and expressing feelings of not wanting to live The Immediate Jeopardy ended on [DATE] when the resident was transferred to the hospital for a psychological evaluation after self inflicting a wound to his left wrist. The Immediate Jeopardy began again when the resident returned to the facility on [DATE] and social services again did not provide interventions for resident # 37 regarding depression and suicidal ideology. The Immediate Jeopardy ended on [DATE] when the resident expired while residing in the facility. The deficient practice continued as an Actual Harm for resident #37 and will remain as a level II deficiency for all other residents residing within the facility and for all newly admitted residents. Findings: Resident #37 Resident #37 was a [AGE] year old army veteran that was admitted to the facility on [DATE] and was discharged from the facility on [DATE] by death. The resident was admitted to the facility with [DIAGNOSES REDACTED]. While at the facility the resident underwent [REDACTED]. Further review of the clinical record revealed that in [DATE], the resident's son passed away from cancer. Review of the "State Home Program Application For Veteran Care" form revealed documentation made by the Physician on [DATE]. The documentation included the resident's history as a [AGE] year old male with lung cancer that had radiation but developed brain metastasis. He had two surgeries for metastasis of the brain. Further review of the form revealed section, "Social Work Assessment (To be completed by Social Worker)". This section was dated for [DATE] and completed by S23Counselor. The section included that the resident was "having difficulty settling in". Review of the Nursing Progress Notes revealed the following: [DATE] at 4:00 a.m. - resident was crying, stating that no one had visited him. At 5:45 a.m. the resident was "requesting to see a lawyer". The resident stated, "I have my rights and I want my family to come see me now." Review of form entitled, "Information Sheet" dated [DATE] and timed for 7:00 a.m. revealed documentation completed by S18CNA (Certified Nursing Assistant). Documented within the form was that when S18CNA responded to resident #37's call light, "he had pulled it out and had it against his neck pressed down saying he wanted to hang himself. I told him, don't do that". S18CNA further documented that she left the resident's room and the resident "hit the light again". When S18CNA responded to the resident's call light, the resident was demonstrating the same behavior, and S18CNA documented that again the resident was told "not to do that". The resident asked S18CNA "to do it (hang him) for him". S18CNA documented that she removed the cord, put it on the side of the bed and notified S6CNA Supervisor and S10LPN. Review of a Incident Report dated [DATE] and timed for 9:50 a.m. that was completed by S10LPN (Licensed Practical Nurse) revealed the description of the incident as, "Veteran lying in bed, calling for assistance to get up. Upon entering the room, observed right arm bleeding. Skin tears noted on arm near wrist. Veteran stated he pulled the bandaid off arm". Review of the Social Services Admission Assessment, completed by S23Counselor and dated [DATE] (not timed), revealed documentation that the resident had no previous mental health treatment and "appears upset and disoriented upon assessment". Review of a Social Services Progress Note dated [DATE] included that the resident was admitted from the hospital and appeared alert and verbal but disoriented. Further documented was the following: "Calls out frequently - confused. Family states he is depressed due to state of health. Will see needs are met." S23Counselor made no reference to either incident involving the resident on [DATE]. Review of the Nursing Progress Notes revealed the following: [DATE] at 10:20 a.m., S17LPN documented that the CNA reported the resident had skin tear to left hand. Upon assessing the resident, was asked what happened to his arm. He stated "I tried to cut my wrist, I wanna die. I wish I had a gun." Was asked by the nurse, "are you telling me you're trying to harm yourself." He stated, "no I'm trying to kill myself do you have a gun." The nurse reported this to the DON (Director of Nursing). Upon returning to the room, the nurse observed a broken piece of tile with dry blood on it. The resident stated "my kids gave up on me and my wife is gone marry a black man". At 11:30 a.m., the resident was assessed for suicidal gestures, and a 2 inch superficial cut was noted to the resident's left wrist. The resident was observed to be pulling the sutures from his scalp. He complained of "severe pain" to his back and legs with movement. The physician was present and PEC'd the resident due to him being a danger to self. At 2:30 p.m., the resident was transferred to the hospital. Review of the Incident Report dated [DATE] and timed for 10:20 a.m. revealed a description of the incident as: Veteran has skin tear to left wrist, stated "I tried to cut my wrist, I want to die." Two inch superficial skin tear noted to left wrist. Veteran also attempted to pull suture from scalp. Review of the Social Services Progress Notes dated [DATE] (no documented time) revealed documentation made by S19LSW (Licensed Social Worker). The documentation included the following: "Went into vet's (veteran) room and MD (Medical Doctor), nursing staff in room with him. After staff left spoke with vet regarding cutting of his wrists. He stated he wanted 'to kill them all'. When asked by this writer who he was referring to he said 'my wife and kids'. When asked why, he stated 'my wife is having an affair with a black man and wants to marry him'. When asked about his children he stated, 'they want my money'. Vet appears to feel abandoned, angry and hopeless. He also stated he was tired of being in pain (headache and backache). He had trouble changing positions in bed due to pain. He also discussed the loss of his son (youngest) due to cancer and how that made his wife 'go crazy'. Vet is grieving but trying to understand his wife's current behavior. He is in need of a thorough mental health assmt (assessment) as well as family tx (treatment) and pain mgmt (management) at this time. Inpt (Inpatient) hosp (hospital) recommended." Review of the Physician's Telephone Orders revealed an order dated for [DATE] to transfer the resident to the psychiatric hospital per ambulance. Review of the Physician Emergency Certificate dated [DATE] and timed for 11:30 a.m. revealed documentation made by the physician that the resident was "suicidal" and that the resident had lung cancer with metastasis-has pain to pelvic area with movement-made attempt to cut wrists-has depression. Review of the physician progress notes [REDACTED]. The Physician referenced that the resident had lung cancer with metastasis. The Physician further documented that the resident would be transferred to psych unit for "evaluation of his depression and suggestion for better control". Review of the hospital History and Physical dated [DATE] revealed that the resident was alert and oriented x 3. That he had a history of [REDACTED]. The resident presented to the hospital for a suicide attempt at nursing home. The resident tried to cut the vein of his hands and said that he felt that there was "no sense to continue to live". Review of the hospital's physician progress notes [REDACTED]. effects of lung cancer for the last 5 years. Pt (patient) has been saying that he would kill himself b/c (because) he did not want to live like this." Review of the Psychosocial assessment dated [DATE] that was completed by the hospital's social worker revealed the following: Presenting Problem: Pt admitted on PEC (Physician Emergency Certificate) for treatment of [REDACTED]. Other/Comments: Says he is tired of the pain and wants to get rid of it. Previous Attempts: Has had suicidal thoughts in the past but did not act on them - per daughter. Homicidal Ideations: Voiced homicidal thoughts to the doctor concerning his wife whom he thought was having an affair. Appetite Problems: Poor appetite. Family/Significant Other input relating to Present Problem: Daughter feels recent incident was impulsive and says Pt is upset with family. Feeling they do not visit him enough. Daughter says they try to visit daily. Family Origin: Married, has children (3 living and 1 deceased ), 1 brother living. Developmental History: Daughter reported Pt has been fighting cancer for last 5 years. Cancer started in the lungs and is now also in the brain. Severe Grief/Loss Issues relating to: Pt's son died [DATE] (6 weeks after being diagnosed with [REDACTED]. Recommendations for Treatment and Services for Family: 1:1 as needed. Review of the hospital's Psychiatric Evaluation dated [DATE] that was completed by the hospital's physician revealed: General Appearance and Behavior: Both wrists bandaged. Chief Complaint: When asked why he cut his wrists he states: "for fun...I had nothing else to do...I was bored". History of Psychiatric: He cut both wrists with piece of formica Further review of the hospital records revealed the resident was discharged back to the facility on [DATE]. Further review of the Social Services Progress Notes revealed the following dates/documentation: [DATE]: Resident returned from the hospital on [DATE] with [DIAGNOSES REDACTED]. [DATE]: "Stated to RN that he wanted to die." S22Counselor documented that she spoke with the resident and asked him about depression and thoughts of dying, but the resident denied the feelings with a response of "no, I just go with the flow". S22Counselor documented that she suggested and IOP (Intensive Outpatient Program) visit to the RN (Registered Nurse). [DATE]: S22Counselor documented that she met with the resident's daughter as the daughter read over a book from hospice. The resident's daughter informed S22Counselor that "they recently lost a brother to cancer and did not think their mother (resident's spouse) could handle another death at home at this time. Review of the Physician's Progress Notes revealed the following: On [DATE], the resident had become increasingly confused and aggressive towards other residents. On [DATE], the physician was notified of the resident minimally responding. The physician documented the Impression/Plan as: Altered Mental Status: stop Duragesic, Lortab, Haldol, and Metformin. Monitor mental status. With hospice...continue supportive care. An interview was held with S4RN Unit Supervisor on [DATE] at 12:00 p.m. She stated that social services were responsible for the planning of care for residents' behaviors. An interview was held with S19LSW on [DATE] at 1:30 p.m. She stated the social service department was responsible for developing and revising a resident's plan of care that involved behaviors. She stated that she was the only licensed social worker employed at the facility, however, there were two counselors that worked with her to provide the necessary treatment needed to the residents. She stated that S23Counselor would not be available throughout the week due to being on vacation. S19LSW recalled resident #37. She stated the resident had behaviors of suicidal ideations. She recalled the resident having "paranoid" thoughts regarding his wife and another man. She verified the resident self inflicted a wound to his left wrist on [DATE] and was sent to the hospital. She verified that prior to the hospitalization and after the resident returned to the hospital on [DATE], there were no interventions put into place for the resident. She stated that the facility had an IOP (Intensive Outpatient Program) but the resident was not a candidate for the program. She explains the resident was not a candidate because a resident has to be able to sit and participate in group sessions and the resident was unable to do so. She further explained that at times, residents were sent out of the facility for therapy. She said that most residents do not like this because of the travel time (to and from Baton Rouge) was too much for them to tolerate. S19LSW stated resident #37 was never referred to an outside source because he would not have been able to tolerate the ride to and from the office. When asked if resident #37 was provided any counseling services by the herself or the other counselors, S19LSW responded that she "didn't have time to counsel". Review of the job description for S19LSW revealed the following:*Incumbent manages the social services program and directly supervises two Social Services Counselors. *Provides individual supportive counseling to veterans with medically complex conditions, including, but not limited to terminal illness, mental illness, dementia, Alzheimer's disease, substance abuse, post traumatic stress disorder. Assess and documents therapeutic progress and actions taken to resolve problems or conflicts. Remains apprized of veteran's progress, actions, and behavior. Documents problems, incidents and actions taken, or any pertinent information in medical charts as needed. *Gathers and evaluates information to compile and develop written psycho social assessments and social histories through personal observations and interviews with the veteran and his family/responsible party. *Provides crisis intervention, grief and loss counseling to assist family/responsible party in coping with seriously ill dying patients as well as adjustment issues related to initial nursing care placement. Another interview was held with S19LSW on [DATE] at 2:30 p.m. She said that the staff and other counselors would refer residents to her when needed. She reviewed the resident's clinical record and verified that she visited the resident on [DATE], after he had cut his wrists. She further stated that she was not made aware of the incidents that occurred on [DATE] involving the resident's behavior of placing call cord around neck or of the staff finding skin tears to the resident's right wrists on [DATE]. She reviewed the resident's clinical record and verified that upon admission, S23Counselor documented the resident was "having difficulty settling in". She verified the resident had a terminal illness upon admission and had recently lost one of his children to cancer. As S19LSW further reviewed the social notes, she verified that there was documentation indicating the resident had underwent a craniectomy which resulted in loss of vision in his right eye while residing in the facility. After review of all records for resident #37, S19LSW verified that there had been no social service interventions provided to the resident. An interview was held with S22Counselor on [DATE] at 3:30 p.m. S22Counselor explained that the facility had the IOP for residents with counseling needs. She further explained that a resident must be able to sit in groups for up to three hours, three times a week. She said some residents were sent to outside sources for their psychological needs. She reviewed the Social Services Progress Notes and verified that she documented on [DATE] that resident #37 "stated to RN that he wanted to die". S22Counselor stated that when she spoke with the resident, that he denied suicidal thoughts. She said she could not recall the nurse that had informed her of the resident's comment. She said that on [DATE], she recommended the resident visit the IOP. She stated she did not follow up with the resident to see if he participated in the IOP. She said the resident was probably not a candidate for the IOP because he was confused and would not be able to sit in a group. She reviewed the resident's clinical records and verified there had been no social service interventions provided for the resident while he resided at the facility. On [DATE] at 8:45 a.m. an interview was held with S24IOP Technician. She stated that to be a patient in IOP the resident must be referred by the physician and have clinical signs of depression, anxiety, or psychological issues. She stated resident #37 never received IOP. She reviewed the physician's orders [REDACTED]. She stated the resident was not treated because he was on hospice. She stated they do not treat resident's receiving hospice. Review of job descriptions for the social service counselors (S22 and S23) revealed in part: *Conduct ongoing counseling sessions with veterans and their family/responsible party to assess individual and family/responsible party inter-relationships to identify specific [DIAGNOSES REDACTED]. *Provide individual supportive counseling to veterans with medically complex conditions, including, but not limited to terminal illness, dementia, Alzheimer's disease, substance abuse, post traumatic stress disorder. Assess and documents therapeutic progress and actions taken to resolve problems or conflicts. *Remains apprized of veterans progress, actions, and behavior. Document problems, incidents and actions taken, or any pertinent information in medical charts as needed. *Provide crisis intervention, grief and loss counseling to assist family/responsible party in coping with seriously ill, dying patients as well as adjustment issues related to initial nursing care placement. In conclusion, the facility failed to provide medical related social services to maintain resident #37's mental and psychosocial well-being while he resided in the facility.

Based on record review, interviews, and review of facility policies, the facility failed to provide the necessary care and services to attain a resident's highest practicable mental and psychosocial well-being for 1 of 1 sampled residents with depression, mental, and psychosocial difficulties (#37) out of a Stage 2 sample of 29. The facility failed to: 1. Recognize, assess, care plan and implement approaches for a resident admitted with a terminal illness and [DIAGNOSES REDACTED]. 2. increase supervision when the resident said he wanted to hang himself and asked the CNA to hang him to prevent a self inflicted injury from occurring; 3. Notify the physician when the resident said he wanted to hang himself and asked the CNA to hang him. 4. Update the Comprehensive Care Plan to reflect the resident ' s mental status and interventions for his self destructive behaviors after the resident ' s return to the facility following a hospital stay for attempted suicide. 5. provide social service interventions for resident #37 regarding depression and suicidal ideology. Resident #37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility failed to recognize, assess, and implement interventions to address the resident's mental and psychosocial needs regarding having a terminal illness, adjustment to a new facility, losing his son [MEDICAL CONDITION] in [DATE], losing his vision in his right eye, and expressing feelings of not wanting to live. Resident #37 was placed in Immediate Jeopardy when he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility failed to increase supervision and notify the physician when the resident said he wanted to hang himself and asked the CNA to hang him. The Immediate Jeopardy ended on [DATE] when the resident was transferred to the hospital for a psychological evaluation after self inflicting a wound to his left wrist. The Immediate Jeopardy began again when the resident returned to the facility on [DATE] and the facility failed to assess and implement interventions to meet the resident's mental and psychosocial needs after the resident had been determined to be depressed. The Immediate Jeopardy ended on [DATE] when the resident expired while residing in the facility. The deficient practice continued as an Actual Harm for resident #37 and at a level II deficiency for all other residents residing within the facility that verbalize [MEDICAL CONDITION] or behaviors. The facility census was 76. Findings: Resident #37 Resident #37 was a [AGE] year old army veteran admitted to the facility on [DATE]. The resident was admitted to the facility with [DIAGNOSES REDACTED]. While at the facility the resident underwent [REDACTED]. Further review of the clinical record revealed that in [DATE], the resident's son passed away [MEDICAL CONDITION]. Review of the admission MDS dated [DATE] revealed the resident was coded as having a [DIAGNOSES REDACTED]. The resident was not coded to have any hallucinations or [MEDICAL CONDITION]. Review of the State Home Program Application For Veteran Care Form revealed documentation made by the Physician on [DATE]. The documentation included the resident's history as a [AGE] year old male with [MEDICAL CONDITION] that had [MEDICAL CONDITION] but developed brain metastasis. He had two surgeries for metastasis of the brain. Further review of the Form revealed section Social Work Assessment (To be completed by Social Worker). This section was dated [DATE] and completed by S23Counselor. The section included that the resident was "having difficulty settling in". Review of the Nursing Progress Notes revealed the following: [DATE] at 4:00 a.m. - resident was crying, stating that no one had visited him. At 5:45 a.m. the resident was "requesting to see a lawyer". The resident stated, "I have my rights and I want my family to come see me now." Review of the Comprehensive Care Plan revealed the following: Problem: Lack of participation r/t refuses to attend, dependent on staff, lack of interest, inability to perform, new admission, daytime napping, new limiting disability, inappropriate social behavior, bedfast. Problem Date: [DATE] Problem: History of Depression. Resident is on [MEDICATION NAME]. Problem Date: [DATE]. Review of form entitled Information Sheet dated [DATE] and timed for 7:00 a.m. revealed documentation completed by S18CNA. The documentation on the Form revealed that when S18CNA responded to resident #37's call light, "he had it against his neck pressed down saying he wanted to hang himself.". S18CNA further documented that she left the resident's room and the resident "hit the light again". When S18CNA responded to the resident's call light, the resident was demonstrating the same behavior, and S18CNA documented that again the resident was told "not to do that". The resident asked S18CNA "to do it (hang him) for him". S18CNA documented that she removed the cord, put it on the side of the bed and notified S6CNA Supervisor and S10LPN. Review of the facility's policy entitled Suicidal Precautions revealed the following: "A suicidal resident is defined as the resident who has given some indication that he/she may take his own life as a possible course of action in the immediate or near future. Any indication of such shall be communicated immediately to the charge nurse who will contact the physician. The physician will determine the level of care needed and may order Suicidal Precautions.... B. Staff will check the resident at least every fifteen (15) minutes to ascertain safety. Safety checks will be documented on the Observation/Precaution Monitoring Record." Review of the Observation/Precaution Monitoring Record revealed instructions that included: 1. Carefully check resident every 15 minutes for precaution measures ordered by the physician. For close observation measures, check every 30 minutes. "Close Observation" was checked as the applicable observation/precaution to be monitored. Further review of the Monitoring Record revealed the resident was monitored on the following dates/times: [DATE] from 7:30 a.m. to 3:00 p.m. The resident was monitored every 15 minutes until [DATE] at 3:00 p.m. when S2DON documented that the resident was without [MEDICAL CONDITION] and changed the monitoring to every 30 minutes. [DATE] at 3:00 p.m. to [DATE] at 12:00 a.m., the resident was monitored every 30 minutes. [DATE] at 12:00 a.m. to [DATE] at 1:00 p.m., the resident was monitored every hour. [DATE] at 1:00 p.m. to [DATE] at 11:00 p.m., the resident was monitored every 2 hours. [DATE] at 11:00 p.m. through [DATE] at 6:00 a.m., the resident was monitored hourly. The monitoring was stopped on [DATE] at 6:00 a.m. Review of an Incident Report dated [DATE] and timed for 9:50 a.m. that was completed by S10LPN revealed the description of the incident as, "Veteran lying in bed, calling for assistance to get up. Upon entering the room, observed right arm bleeding. Skin tears noted on arm near wrist. Veteran stated he pulled the bandaid off arm". Review of the Social Services Admission Assessment, completed by S23Counselor and dated [DATE] (not timed), revealed documentation that the resident had no previous mental health treatment and "appears upset and disoriented upon assessment". Review of a Social Services Progress Note dated [DATE] included that the resident was admitted from the hospital and appeared alert and verbal but disoriented. Further documented was the following: "Calls out frequently - confused. Family states he is depressed due to state of health. Will see needs are met." Record review revealed S23Counselor made no reference to either incident involving the resident on [DATE] (call light to resident's neck or skin tears found to resident's right wrist). An interview was held with S18CNA on [DATE] at 9:15 a.m. She verified she was the CNA that responded to resident #37's call light on [DATE] and witnessed the resident display and verbalize suicidal thoughts and behaviors. S18CNA demonstrated how the resident had the call light cord positioned around his neck. She said he had the cord pulled around to the back of his neck and was holding it tightly. She recalled the resident saying he wanted to hang himself and even asked her to help him. She said she talked to him and he told her that he had no reason to live because his wife was marrying another man and his children didn't care about him. She said he talked about being in pain and that he didn't want to be in pain anymore. She said that after she talked with him, she left the room, and then she positioned herself at the door where she could see him. She said the resident could not see her. She said as soon as she left the room, the resident immediately placed the call light cord back around his neck. She said she re-entered the room, and talked more with the resident. She said she placed the call light at the side of the resident's bed and then reported the incident to S6CNA Supervisor, who told her to write a statement and report it to the nurse. S6CNA said she reported the incident to S10LPN, who told her that she "would take care of it". On [DATE] at 11:20 a.m., an interview was held with S6CNA Supervisor. He recalled being notified of resident #37's behavior that involved the call light cord ([DATE] incident). He said he informed the nurse, but was unable to recall the name of the nurse on duty at the time. He stated the resident was monitored for behaviors. When asked to explain how the resident was monitored, he replied that approximately every 30 minutes a staff member would check on the resident. He further stated that that was the only incident he was informed of that involved the resident's behaviors. A telephone interview was held with S10LPN on [DATE] at 12:55 p.m. She recalled resident #37 and stated that he frequently talked about dying. She said that she related his references to dying to be nothing more than adjusting to being in the facility and/or being in pain. She recalled the incident ([DATE]) of the resident having the call light up to his neck and of the resident having "skin tears" to his right wrist area. She explained that the resident would demonstrate self destructive behaviors when he wanted attention. She stated that she could not recall what interventions were put into place for the resident's behaviors. She said she did not recall the resident being on 1:1 supervision. She said that she had not notified the physician on [DATE] when the resident presented with suicidal thoughts and behaviors, then within a few hours was found to have unexplained "skin tears" to his right wrist area. On [DATE] at 2:15 p.m. an interview was held with the S2DON. S2DON reviewed the resident's clinical record. He described the resident as being admitted to the facility with "attention seeking" behaviors that included threats of harming himself. He stated the resident talked of harming himself frequently, but he never acted on it. S2DON stated that he related the behavior and discussion of self harm to the resident's mental status. He recalled the resident had brain surgery to remove a tumor, prior to being admitted to the facility and that the resident had [MEDICAL CONDITION] that had metastasized to his brain. He recalled the resident placing the call light against his neck. He said he thought a "High Risk" meeting was held regarding the resident's behavior. He said the High Risk Committee meeting would include the intervention of additional monitoring. He explained the additional monitoring would be hourly monitoring of the resident. S2DON verified that within a few hours of the resident displaying suicidal behaviors, he was found to have bleeding "skin tears" to his right wrist area. S2DON reviewed the resident's clinical record and verified there were no documented wounds to the resident's right wrist prior to the incident on [DATE]. After reviewing all documentation related to resident #37, S2DON verified that the physician was not contacted regarding the resident's behaviors and skin tears to the right wrist area. Review of the facility's policy entitled Incident/Accident Investigation, revealed in part: An incident/accident is defined as an event or series of unplanned events that causes or could have caused personal injury or property damage. 5. During normal duty hours, the nurse will place the resident on the Communication Log to be seen by the physician unless there is a medical emergency. Review of the Nursing Progress Notes revealed the following: [DATE] at 10:20 a.m., S17LPN documented that the CNA reported the resident had skin tear to left hand. Upon assessing the resident, was asked what happened to his arm. He stated "I tried to cut my wrist, I wanna die. I wish I had a gun." Was asked by the nurse, "are you telling me you're trying to harm yourself", he stated "no I'm trying to kill myself do you have a gun?" The nurse reported this to the DON. Upon returning to the room, the nurse observed a broken piece of tile with dried blood on it. The resident stated "my kids gave up on me and my wife is gone marry a black man". At 11:30 a.m., the resident was assessed for suicidal gestures, and a 2 inch superficial cut was noted to the resident's left wrist. The resident was observed to be pulling the sutures from his scalp. He complained of "severe pain" to his back and legs with movement. The physician was present and ordered the resident to be transferred to the hospital due to him being a danger to self. At 2:30 p.m., the resident was transferred to the hospital. Review of the Incident Report dated [DATE] and timed for 10:20 a.m. revealed a description of the incident as: Veteran has skin tear to left wrist, stated "I tried to cut my wrist, I want to die." Two inch superficial skin tear noted to left wrist. Veteran also attempted to pull suture from scalp. Review of the Social Services Progress Notes dated [DATE] (no documented time) revealed documentation made by S19LCSW. The documentation included the following: "Went into vet's (veteran) room and MD, nursing staff in room with him. After staff left spoke with vet regarding cutting of his wrists. He stated he wanted 'to kill them all'. When asked by this writer who he was referring to he said 'my wife and kids'. When asked why, he stated 'my wife is having an affair with a black man and wants to marry him'. When asked about his children he stated, 'they want my money'. Vet appears to feel abandoned, angry and hopeless. He also stated he was tired of being in pain (headache and backache). He had trouble changing positions in bed due to pain. He also discussed the loss of his son (youngest) due [MEDICAL CONDITION] and how that made his wife 'go crazy'. Vet is grieving but trying to understand his wife's current behavior. He is in need of a thorough mental health assmt (assessment) as well as family tx (treatment) and pain mgmt (management) at this time. Inpt (Inpatient) hosp (hospital) recommended." Review of the Physician's Telephone Orders revealed an order dated for [DATE] to transfer the resident to the psychiatric hospital per ambulance. Review of the Physician Emergency Certificate (PEC) dated [DATE] and timed for 11:30 a.m. revealed documentation made by the physician that the resident was "suicidal" and that the resident had [MEDICAL CONDITION] with metastasis-has pain to pelvic area with movement-made attempt to cut wrists-has depression. Review of the physician progress notes [REDACTED]. The Physician referenced that the resident had [MEDICAL CONDITION] with metastasis. The Physician further documented that the resident would be transferred to psych unit for "evaluation of his depression and suggestion for better control". An interview was held with S17LPN on [DATE] at 11:30 a.m. She verified she was the nurse caring for the resident on [DATE] when he self inflicted a wound to his left wrist. She reviewed the resident's clinical record and verified the incident occurred at 10:20 a.m. and the resident did not leave the facility until 2:30 p.m. She stated she could not be sure that the resident was supervised during that time frame. She stated that the resident was not on any increased monitoring prior, during, or after this incident. On [DATE] at 1:00 p.m. an interview was held with S2DON. He again verified that the resident was removed from "close observation" monitoring on the morning of [DATE] after determining that he had no behaviors. S2DON then reviewed the incident report dated [DATE] and timed for 9:50 a.m. and verified that this incident occurred after the "close observation" monitoring was initiated (at 7:30 a.m.). S2DON stated that with the resident having no previous injuries to the right wrist, this was considered a new incident. He verified that the resident had behaviors while being closely monitored and the day after the monitoring was discontinued the resident cut his left wrist. S2DON verified that after the resident cut his left wrist on [DATE], an order to transfer to the hospital was received at 11:30 a.m. and the resident was transferred out of the facility at 2:30 p.m. S2DON reviewed all records for resident #37 and verified that after the resident self inflicted an injury to his left wrist on [DATE], an order was written to transfer the resident to the hospital. The order was timed for 11:30 a.m., however the resident was not transferred until 2:30 p.m. S2DON verified there was not an increase in supervision provided to the resident during the times of 11:30 a.m. and 2:30 p.m. Review of the hospital records revealed the following: History and Physical dated [DATE] revealed that the resident was alert and oriented x 3. That he had a history of [REDACTED]. The resident presented to the hospital for a suicide attempt at nursing home. The resident tried to cut the vein of his hands and said that he felt that there was "no sense to continue to live". Psychiatric Evaluation dated [DATE] that was completed by the hospital's physician revealed: General Appearance and Behavior: Both wrists bandaged. Chief Complaint: When asked why he cut his wrists he states: "for fun...I had nothing else to do...I was bored". History of Psychiatric: He cut both wrists with piece of formica physician progress notes [REDACTED]. effects of [MEDICAL CONDITION] for the last 5 years. Pt (patient) has been saying that he would kill himself b/c (because) he did not want to live like this." Psychosocial assessment dated [DATE] that was completed by the hospital's social worker included following: Presenting Problem: Pt admitted on PEC for treatment of [REDACTED]. Other/Comments: Says he is tired of the pain and wants to get rid of it. Previous Attempts: Has had suicidal thoughts in the past but did not act on them - per daughter. Homicidal Ideations: Voiced homicidal thoughts to the doctor concerning his wife whom he thought was having an affair. Appetite Problems: Poor appetite. Family/Significant Other input relating to Present Problem: Daughter feels recent incident was impulsive and says Pt is upset with family. Feeling they do not visit him enough. Daughter says they try to visit daily. Family Origin: Married, has children (3 living and 1 deceased ), 1 brother living. Developmental History: Daughter reported Pt has been [MEDICAL CONDITION] for last 5 years. Cancer started in the lungs and is now also in the brain. Severe Grief/Loss Issues relating to: Pt's son died [DATE] (6 weeks after being diagnosed with [REDACTED]. Recommendations for Treatment and Services for Family: 1:1 as needed. Further review of the hospital records revealed the resident was discharged back to the facility on [DATE]. Review of the hospital's discharge summary revealed that the resident was "actively hallucinating". Review of the nursing Documentation Record dated [DATE] included that the resident was receiving routine wound care (RWC) to three skin tears on his left arm, one to his right hand, and a laceration to his right forearm. Upon return to the facility, review of the resident's Comprehensive Care Plan revealed no updates or changes in the resident's plan of care. On [DATE] at 11:40 a.m., an interview was held with S5RN-MDS/Care Plan. She verified she had completed resident #37's Care Plan. She reviewed the Care Plan and verified there was no documentation to indicate the resident had suicidal behaviors or had been transferred to the hospital for suicide attempts. An interview was held with S4RN Unit Supervisor on [DATE] at 12:00 p.m. She reviewed the resident's Comprehensive Care Plan and verified the Care Plan did not reflect the resident's mental status or interventions for his behaviors. She stated that social services were responsible for the planning of care for a residents' behaviors. An interview was held with S19LSW on [DATE] at 1:30 p.m. She stated the social service department was responsible for developing and revising a resident's plan of care that involved behaviors. She stated that she was the only licensed social worker employed at the facility, however, there were two counselors that worked with her to provide the necessary treatment needed to the residents. She stated that S23Counselor would not be available throughout the week due to being on vacation. S19LCW recalled resident #37. She stated the resident had behaviors of [MEDICAL CONDITION]. She recalled the resident having "paranoid" thoughts regarding his wife and another man. She verified the resident self inflicted a wound to his left wrist on [DATE] and was sent to the hospital. She verified that prior to the hospitalization and after the resident returned to the hospital on [DATE], there were no interventions put into place for the resident. She stated that the facility has a IOP (Intensive Outpatient Program) but the resident was not a candidate for the program. She explained the resident was not a candidate because a resident has to be able to sit and participate in group sessions and the resident was unable to do so. She further explained that at times, residents were sent out of the facility for therapy. She said that most residents do not like this because of the travel time (to and from Baton Rouge) was too much for them to tolerate. S19LSW stated resident #37 was never referred to an outside source because he would not have been able to tolerate the ride to and from the office. When asked if resident #37 was provided any counseling services by the herself or the other counselors, S19LCW responded that she "didn't have time to counsel". Further review of the Social Services Progress Notes revealed the following dates/documentation: [DATE]: Resident returned from the hospital on [DATE] with [DIAGNOSES REDACTED]. [DATE]: "Stated to RN that he wanted to die." S22Counselor documented that she spoke with the resident and asked him about depression and thoughts of dying, but the resident denied the feelings with a response of "no, I just go with the flow". S22Counselor documented that she suggested and IOP visit to the RN. [DATE]: S22Counselor documented that she met with the resident's daughter as the daughter read over a book from hospice. The resident's daughter informed S22Counselor that "they recently lost a brother [MEDICAL CONDITION] and did not think their mother (resident's spouse) could handle another death at home at this time. Review of the Physician's Progress Notes included documentation dated [DATE]. The Note included that the resident had become increasingly confused and aggressive towards other residents. An interview was held with S4RN Unit Supervisor on [DATE] at 11:00 a.m. She stated that the nursing staff communicate problems to the physician by using the Communication Log. Each nursing unit maintains a Communication Log within the nursing station. A review of the communication book was done with S4RN Unit Supervisor. She verified documentation that she had made within the Communication Log regarding resident #37. The documentation was not dated, but was noted to be between two other entries dated for [DATE]. S4RN Unit Supervisor stated that she was certain her documentation was for [DATE] as well. The documentation was as follows: "Needs RSO (Routine Standing Orders) for scratch to R(right) arm/wrist." S4RN Unit Supervisor could not state why she had written this within the Communication Log. She reviewed resident #37's clinical record and verified there was no documentation to indicate the resident had a wound to his right arm or wrist prior to the incident on [DATE]. S4RN Unit Supervisor further verified that the physician had not addressed the documentation related to resident #37. She stated that one of the nurses must have told her that resident #37 had a scratch and needed routine wound care to the area. She further verified that the only entry related to resident #37 and dated for [DATE] revealed, "Please order schedule pain med, stronger med per family request." There was no documentation to notify the physician of the resident's behavior (placing call light to neck, suicidal thoughts) or of the skin tears to the resident's right wrist area after the behaviors occurred. Another interview was held with S19LSW on [DATE] at 2:30 p.m. She said that the staff and other counselors would refer residents to her when needed. She reviewed the resident's clinical record and verified that she visited the resident on [DATE], after he had cut his wrists. She further stated that she was not made aware of the incidents that occurred on [DATE] involving the resident's behavior of placing call cord around neck or of the staff finding skin tears to the resident's right wrists on [DATE]. She reviewed the resident's clinical record and verified that upon admission, S23Counselor documented the resident was "having difficulty settling in". She verified the resident had a terminal illness upon admission and had recently lost one of his children [MEDICAL CONDITION]. As S19LCW further reviewed the social notes, she verified that there was documentation indicating the resident had underwent a craniectomy which resulted in loss of vision in his right eye while residing in the facility. After review of all records for resident #37, S19LCW verified that there had been no social service interventions provided to the resident. An interview was held with S22Counselor on [DATE] at 3:30 p.m. S22Counselor explained that the facility had the IOP for residents with counseling needs. She further explained that a resident must be able to sit in groups for up to three hours, three times a week. She said some residents were sent to outside sources for their psychological needs. She reviewed the Social Services Progress Notes and verified that she documented on [DATE] that resident #37 "stated to RN that he wanted to die". S22Counselor stated that when she spoke with the resident, that he denied suicidal thoughts. She said she could not recall the nurse that had informed her of the resident's comment. She said that on [DATE], she recommended the resident visit the IOP. She stated she did not follow up with the resident to see if he participated in the IOP. She said the resident was probably not a candidate for the IOP because he was confused and would not be able to sit in a group. She reviewed the resident's clinical records and verified there had been no social service interventions provided for the resident while he resided at the facility. On [DATE] at 8:45 a.m. an interview was held with S24IOP Technician. She stated that to be a patient in IOP the resident must be referred by the physician and have clinical signs of depression, anxiety, or psychological issues. She stated resident #37 never received IOP. She reviewed the physician's orders [REDACTED]. She stated the resident was not treated because he was on hospice. She stated they do not treat resident's receiving hospice.

Based on record review and interviews the facility failed to ensure a resident who displayed mental and psychosocial adjustment difficulty received approprate treatment and services for 1 of 1 residents with depression, mental, and psychosocial difficulties (#37) reviewed from a Stage 2 sample of 29. The facility failed to: 1. Implement interventions and services for depression when the resident (#37) displayed difficulty with mental and psychosocial adjustment with having a terminal illness, adjustment to a new facility, losing his son in [DATE], and expressing feelings of not wanting to live; 2. immediately notify and consult with the physician and the staff LSW of a resident's verbalizing [MEDICAL CONDITION] and demonstrating suicidal behaviors; 3. provide interventions and services for depression upon resident's return to facility from hospitalization due to failed suicide attempt; 4. ensure the facility licensed social worker provided counseling to resident #37; 5. ensure the licensed social worker and counseling staff obtained outside counseling for resident #37's suicidal idealizations and suicidal attempts. Resident #37 was placed in Immediate Jeopardy when he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Immediate Jeopardy ended on [DATE] when the resident was transferred to the hospital for a psychological evaluation after self inflicting a wound to his left wrist. The Immediate Jeopardy began again when the resident returned to the facility on [DATE] and the facility failed to ensure interventions were in place after the resident (#37) had been determined to be depressed. The Immediate Jeopardy ended on [DATE] when the resident expired while residing in the facility. The deficient practice continued as an Actual Harm for resident #37 and will remain at a level II deficiency for all other residents residing within the facility that have displayed difficulty with mental and psychosocial adjustment. The facility census was 76. Findings: Resident #37 Resident #37 was a [AGE] year old army veteran that was admitted to the facility on [DATE]. The resident was admitted to the facility with [DIAGNOSES REDACTED]. While at the facility the resident underwent [REDACTED]. Further review of the clinical record revealed that in [DATE], the resident's son passed away [MEDICAL CONDITION]. Review of the admission MDS dated [DATE] revealed the resident was coded as having a [DIAGNOSES REDACTED]. The resident was not coded to have any hallucinations or [MEDICAL CONDITION]. Review of the "State Home Program Application For Veteran Care" form revealed documentation made by the Physician on [DATE]. The documentation included the resident's history as a [AGE] year old male with [MEDICAL CONDITION] that had [MEDICAL CONDITION] but developed brain metastasis. He had two surgeries for metastasis of the brain. Further review of the form revealed section, "Social Work Assessment (To be completed by Social Worker)". This section was dated for [DATE] and completed by S23Counselor. The section included that the resident was "having difficulty settling in". Review of the Nursing Progress Notes revealed the following: [DATE] at 4:00 a.m. - resident was crying, stating that no one had visited him. At 5:45 a.m. the resident was "requesting to see a lawyer". The resident stated, "I have my rights and I want my family to come see me now." Review of the Comprehensive Care Plan revealed the following: Problem: Lack of participation r/t refuses to attend, dependent on staff, lack of interest, inability to perform, new admission, daytime napping, new limiting disability, inappropriate social behavior, bedfast. Problem Date: [DATE] Problem: History of Depression. Resident is on [MEDICATION NAME]. Problem Date: [DATE]. Review of form entitled, "Information Sheet" dated [DATE] and timed for 7:00 a.m. revealed documentation completed by S18CNA. Documented within the form was that when S18CNA responded to resident #37's call light, "he had it against his neck pressed down saying he wanted to hang himself.". S18CNA further documented that she left the resident's room and the resident "hit the light again". When S18CNA responded to the resident's call light, the resident was demonstrating the same behavior, and S18CNA documented that again the resident was told "not to do that". The resident asked S18CNA "to do it (hang him) for him". S18CNA documented that she removed the cord, put it on the side of the bed and notified S6CNA Supervisor and S10LPN. Review of an Incident Report dated [DATE] and timed for 9:50 a.m. that was completed by S10LPN revealed the description of the incident as, "Veteran lying in bed, calling for assistance to get up. Upon entering the room, observed right arm bleeding. Skin tears noted on arm near wrist. Veteran stated he pulled the bandaid off arm". Review of the Social Services Admission Assessment, completed by S23Counselor and dated [DATE] (not timed), revealed documentation that the resident had no previous mental health treatment and "appears upset and disoriented upon assessment". Review of a Social Services Progress Note dated [DATE] included that the resident was admitted from the hospital and appeared alert and verbal but disoriented. Further documented was the following: "Calls out frequently - confused. Family states he is depressed due to state of health. Will see needs are met." S23Counselor made no reference to either incident involving the resident on [DATE]. An interview was held with S18CNA on [DATE] at 9:15 a.m. She verified she was the CNA that responded to resident #37's call light on [DATE] and witnessed the resident display and verbalize suicidal thoughts and behaviors. S18CNA demonstrated how the resident had the call light cord positioned around his neck. She said he had the cord pulled around to the back of his neck and was holding it tightly. She recalled the resident saying he wanted to hang himself and even asked her to help him. She said she talked to him and he told her that he had no reason to live because his wife was marrying another man and his children didn't care about him. She said he talked about being in pain and that he didn't want to be in pain anymore. She said that after she talked with him, she left the room, and then she positioned herself at the door where she could see him. She said the resident could not see her. She said as soon as she left the room, the resident immediately placed the call light cord back around his neck. She said she re-entered the room, and talked more with the resident. She said she placed the call light at the side of the resident's bed and then reported the incident to S6CNA Supervisor, who told her to write a statement and report it to the nurse. S6CNA said she reported the incident to S10LPN, who told her that she "would take care of it". A telephone interview was held with S10LPN on [DATE] at 12:55 p.m. She recalled resident #37 and stated that he frequently talked about dying. She said that she related his references to dying to be nothing more than adjusting to being in the facility and/or being in pain. She stated that she had not referred the resident to the physician regarding this behavior. She verified that all referrals to rehabilitation, including the IOP (Intensive Outpatient Program) required a physician's orders [REDACTED]. She explained that the resident would demonstrate self destructive behaviors when he wanted attention. She stated that she could not recall what interventions were put into place for the resident's behaviors. On [DATE] at 2:15 p.m. an interview was held with the S2DON. S2DON reviewed the resident's clinical record. He described the resident as being admitted to the facility with "attention seeking" behaviors that included threats of harming himself. He stated the resident talked of harming himself frequently, but he never acted on it. S2DON stated that he related the behavior and discussion of self harm to the resident's mental status. He recalled the resident had brain surgery to remove a tumor, prior to being admitted to the facility and that the resident had [MEDICAL CONDITION] that had metastasized to his brain. He recalled the resident placing the call light against his neck. S2DON verified that within a few hours of the resident displaying suicidal behaviors, he was found to have bleeding "skin tears" to his right wrist area. S2DON reviewed the resident's clinical record and verified there were no documented wounds to the resident's right wrist prior to the incident on [DATE]. After reviewing all documentation related to resident #37, S2DON verified that the physician was not contacted regarding the resident's behaviors and could not recall the resident being referred to rehabilitation services for his mental/psycosocial needs. He stated that if any counseling services were provided that this would have been done by social services. Review of the Nursing Progress Notes revealed the following: [DATE] at 10:20 a.m., S17LPN documented that the CNA reported the resident had skin tear to left hand. Upon assessing the resident, was asked what happened to his arm. He stated "I tried to cut my wrist, I wanna die. I wish I had a gun." Was asked by the nurse, "are you telling me you're trying to harm yourself." He stated, "no I'm trying to kill myself do you have a gun." The nurse reported this to the DON. Upon returning to the room, the nurse observed a broken piece of tile with dried blood on it. The resident stated "my kids gave up on me and my wife is gone marry a black man". At 11:30 a.m., the resident was assessed for suicidal gestures, and a 2 inch superficial cut was noted to the resident's left wrist. The resident was observed to be pulling the sutures from his scalp. He complained of "severe pain" to his back and legs with movement. The physician was present and ordered the resident to be transferred to the hospital due to him being a danger to self. At 2:30 p.m., the resident was transferred to the hospital. Review of the Incident Report dated [DATE] and timed for 10:20 a.m. revealed a description of the incident as: Veteran has skin tear to left wrist, stated "I tried to cut my wrist, I want to die." Two inch superficial skin tear noted to left wrist. Veteran also attempted to pull suture from scalp. Review of the Social Services Progress Notes dated [DATE] (no documented time) revealed documentation made by S19LCSW. The documentation included the following: "Went into vet's (veteran) room and MD, nursing staff in room with him. After staff left spoke with vet regarding cutting of his wrists. He stated he wanted 'to kill them all'. When asked by this writer who he was referring to he said 'my wife and kids'. When asked why, he stated 'my wife is having an affair with a black man and wants to marry him'. When asked about his children he stated, 'they want my money'. Vet appears to feel abandoned, angry and hopeless. He also stated he was tired of being in pain (headache and backache). He had trouble changing positions in bed due to pain. He also discussed the loss of his son (youngest) due [MEDICAL CONDITION] and how that made his wife 'go crazy'. Vet is grieving but trying to understand his wife's current behavior. He is in need of a thorough mental health assmt (assessment) as well as family tx (treatment) and pain mgmt (management) at this time. Inpt (Inpatient) hosp (hospital) recommended." Review of the Physician's Telephone Orders revealed an order dated for [DATE] to transfer the resident to the psychiatric hospital per ambulance. Review of the Physician Emergency Certificate (PEC) dated [DATE] and timed for 11:30 a.m. revealed documentation made by the physician that the resident was "suicidal" and that the resident had [MEDICAL CONDITION] with metastasis-has pain to pelvic area with movement-made attempt to cut wrists-has depression. Review of the physician progress notes [REDACTED]. The Physician referenced that the resident had [MEDICAL CONDITION] with metastasis. The Physician further documented that the resident would be transferred to psych unit for "evaluation of his depression and suggestion for better control". Review of the hospital records revealed the following: *History and Physical dated [DATE] revealed that the resident was alert and oriented x 3. That he had a history of [REDACTED]. The resident presented to the hospital for a suicide attempt at nursing home. The resident tried to cut the vein of his hands and said that he felt that there was "no sense to continue to live". *Psychiatric Evaluation dated [DATE] that was completed by the hospital's physician revealed: General Appearance and Behavior: Both wrists bandaged. Chief Complaint: When asked why he cut his wrists he states: "for fun...I had nothing else to do...I was bored". History of Psychiatric: He cut both wrists with piece of formica *physician progress notes [REDACTED]. effects of [MEDICAL CONDITION] for the last 5 years. Pt (patient) has been saying that he would kill himself b/c (because) he did not want to live like this." *Psychosocial assessment dated [DATE] that was completed by the hospital's social worker included following: Presenting Problem: Pt admitted on PEC for treatment of [REDACTED]. Other/Comments: Says he is tired of the pain and wants to get rid of it. Previous Attempts: Has had suicidal thoughts in the past but did not act on them - per daughter. Homicidal Ideations: Voiced homicidal thoughts to the doctor concerning his wife whom he thought was having an affair. Appetite Problems: Poor appetite. Family/Significant Other input relating to Present Problem: Daughter feels recent incident was impulsive and says Pt is upset with family. Feeling they do not visit him enough. Daughter says they try to visit daily. Family Origin: Married, has children (3 living and 1 deceased ), 1 brother living. Developmental History: Daughter reported Pt has been [MEDICAL CONDITION] for last 5 years. Cancer started in the lungs and is now also in the brain. Severe Grief/Loss Issues relating to: Pt's son died [DATE] (6 weeks after being diagnosed with [REDACTED]. Recommendations for Treatment and Services for Family: 1:1 as needed. Further review of the hospital records revealed the resident was discharged back to the facility on [DATE]. Review of the hospital's discharge summary revealed that the resident was "actively hallucinating". On [DATE] at 11:40 a.m., an interview was held with S5RN-MDS/Care Plan. She verified she had completed resident #37's Care Plan. She reviewed the Care Plan and verified there was no documentation to indicate the resident had suicidal behaviors or had been transferred to the hospital for suicide attempts. An interview was held with S19LSW on [DATE] at 1:30 p.m. S19LCW recalled resident #37. She stated the resident had behaviors of [MEDICAL CONDITION]. She recalled the resident having "paranoid" thoughts regarding his wife and another man. She verified the resident self inflicted a wound to his left wrist on [DATE] and was sent to the hospital. She verified that prior to the hospitalization and after the resident returned to the hospital on [DATE], there were no interventions put into place for the resident. She stated that the facility has a IOP (Intensive Outpatient Program) but the resident was not a candidate for the program. She explained the resident was not a candidate because a resident has to be able to sit and participate in group sessions and the resident was unable to do so. She further explained that at times, residents were sent out of the facility for therapy. She said that most residents do not like this because of the travel time (to and from Baton Rouge) was too much for them to tolerate. S19LSW stated resident #37 was never referred to an outside source because he would not have been able to tolerate the ride to and from the office. When asked if resident #37 was provided any counseling services by the herself or the other counselors, S19LCW responded that she "didn't have time to counsel". Review of the job description for S19LSW revealed the following:*Provides individual supportive counseling to veterans with medically complex conditions, including, but not limited to terminal illness, mental illness, dementia, [MEDICAL CONDITION], substance abuse, [MEDICAL CONDITION]. Assess and documents therapeutic progress and actions taken to resolve problems or conflicts. Remains apprized of veteran's progress, actions, and behavior. Documents problems, incidents and actions taken, or any pertinent information in medical charts as needed. *Gathers and evaluates information to compile and develop written psycho social assessments and social histories through personal observations and interviews with the veteran and his family/responsible party. *Provides crisis intervention, grief and loss counseling to assist family/responsible party in coping with seriously ill dying patients as well as adjustment issues related to initial nursing care placement. Further review of the Social Services Progress Notes revealed the following dates/documentation: [DATE]: Resident returned from the hospital on [DATE] with [DIAGNOSES REDACTED]. [DATE]: "Stated to RN that he wanted to die." S22Counselor documented that she spoke with the resident and asked him about depression and thoughts of dying, but the resident denied the feelings with a response of "no, I just go with the flow". S22Counselor documented that she suggested and IOP visit to the RN. [DATE]: S22Counselor documented that she met with the resident's daughter as the daughter read over a book from hospice. The resident's daughter informed S22Counselor that "they recently lost a brother [MEDICAL CONDITION] and did not think their mother (resident's spouse) could handle another death at home at this time. Review of the Physician's Progress Notes included documentation dated [DATE]. The Note included that the resident had become increasingly confused and aggressive towards other residents. Another interview was held with S19LSW on [DATE] at 2:30 p.m. She said that the staff and other counselors would refer residents to her when needed. She further stated that she was not made aware of the incidents that occurred on [DATE] involving the resident's behavior of placing call cord around neck or of the staff finding skin tears to the resident's right wrists on [DATE]. She reviewed the resident's clinical record and verified that upon admission, S23Counselor documented the resident was "having difficulty settling in". She verified the resident had a terminal illness upon admission and had recently lost one of his children [MEDICAL CONDITION]. As S19LCW further reviewed the social notes, she verified that there was documentation indicating the resident had underwent a craniectomy which resulted in loss of vision in his right eye while residing in the facility. After review of all records for resident #37, S19LCW verified that the facility had identified the resident was having difficulty coping and there had been no interventions provided. An interview was held with S22Counselor on [DATE] at 3:30 p.m. S22Counselor explained that the facility had the IOP for residents with counseling needs. She further explained that a resident must be able to sit in groups for up to three hours, three times a week. She said some residents were sent to outside sources for their psychological needs. She reviewed the Social Services Progress Notes and verified that she documented on [DATE] that resident #37 "stated to RN that he wanted to die". S22Counselor stated that when she spoke with the resident, that he denied suicidal thoughts. She said she could not recall the nurse that had informed her of the resident's comment. She said that on [DATE], she recommended the resident visit the IOP. She stated she did not follow up with the resident to see if he participated in the IOP. She said the resident was probably not a candidate for the IOP because he was confused and would not be able to sit in a group. She reviewed the resident's clinical records and verified there had been no social service interventions provided for the resident while he resided at the facility. On [DATE] at 8:45 a.m. an interview was held with S24IOP Technician. She stated that to be a patient in IOP the resident must be referred by the physician and have clinical signs of depression, anxiety, or psychological issues. She stated resident #37 never received IOP. She reviewed the physician's orders [REDACTED]. She stated the resident was not treated because he was on hospice. She stated they do not treat resident's receiving hospice. In conclusion, the facility failed to intervene with interventions to assist resident #37 with coping with his terminal illness, the loss of his son, adjustment to a new facility, and that had expressed feelings of not wanting to live.

Based on observation, clinical record review, review of the facility's Skin Care Policy and Procedure, and interviews, the facility failed to ensure that residents received the necessary treatment and services to prevent avoidable pressure sores for 2 of 3 residents (#24 and #35) reviewed with pressure sores in stage 2 out of a sample of 29 residents by failing to: 1) Perform accurate body audits every week on residents at high risk for development of pressure ulcers (#24 and #35). 2) Measure a pressure sore when the pressure ulcer was discovered (#24 and #35). 3) Comprehensively assess an open area to resident's coccyx area on 3/12/11 that was not assessed until 3/13/11 (#24) and failed to comprehensively assess an open area to another resident's coccyx area discovered on 2/28/11 until 03/02/11 (#35). 4) Implement correct treatment in a timely manner once an open area was discovered on the coccyx of Resident #24 and the sacral area of Resident #35. 5) Update the care plan with new/additional approaches when the resident was assessed as high risk for pressure sores (#24) Resident #24 experienced an actual harm when a weekly body audit was documented for 3/11/11 and on 3/12/11 an opened area with eschar was discovered on a resident's coccyx area by a registered nurse. On 3/15/11 the physician assessed the pressure ulcer as a stage III pressure ulcer with sloughing. Resident #35 experienced an actual harm when an opened area on his sacral area was discovered on 02/28/11 by a licensed practical nurse. The appropriate treatment was not initiated until 03/02/11 when the physician assessed the pressure ulcer as a Stage III. Prior to the discovery of the pressure ulcer on 02/28/11, a weekly body audit was not performed on 02/27/11 as ordered. Findings: Review of the facility's Skin Care Policy and Procedure revealed in part: Skin problems will be minimized to the greatest extent possible through an aggressive approach consisting of four components. These are : 1. Prevention, Evaluation, and Screening 2. Ongoing Surveillance 3. Treatment Orders 4. Treatment Regimen... 4. The Skin at Risk Assessment is done on admission, and reevaluated every three months, and at significant change. If the evaluation show the resident to be "at risk" or prone to skin breakdown, the assessment will be sent to the Dietary Manager and the following measure will be considered and, if implemented, placed in the care plan and on the nursing assistant assignment sheet: a. Use of an anti-pressure device in bed and chair, bed rail protectors, arm and legs protectors, etc. b. Positioning with support pillows and routine turn schedule. c. Skin care with lotions and/ or moisture barriers, etc. d. Evaluation of dietary needs and of fluid intake for the resident. Inform the Dietary Supervisor to include nutritional parameter. e. Evaluation of incontinency, toileting programs, or use of indwelling foley catheter. f. Nutritional and skin at risk meetings.... III. Treatment Orders A. After observation/evaluation of the affected skin area, notify physician of the treatment order as follows: 1. Name of cleanser 2. Treatment (medication, debridement, etc.) 3. Type of dressing 4. Number of treatment times. 5 Duration of treatment, i.e. x's (times)10 days, until healed, etc. B. Obtain orders for pain management.... D. After completion of each treatment, date and initial each dressing. Document on the TAR (Treatment Administration Record). IV. Treatment Regimen treatment for [REDACTED]. Resident and responsible family member will be notified of treatment regimen. A. Carefully document condition..... Weekly Body Audit Assessment - DON (Director of Nurses) will assign to nursing staff residents for weekly body audits. All licensed nursing staff should be involved in scheduled weekly body audits and physically assess residents for pressure ulcers/skin problem. Weekly body audits will be documented on the M.A.R. (Medication Administration Record). New problems not identified from last body audit will indicated by a "Y". No new problem will be indicated by an "N". When "Y" is noted there must be follow-up documentation in the nurses' notes and follow-up care according to applicable policies and procedures. Resident #24 Resident #24 was a [AGE] year old female admitted to the facility 1/12/09 with [DIAGNOSES REDACTED]. An observation/interview was conducted with Resident #24 on 3/30/11 at 2:30 p.m. She stated that the pressure ulcer had been discovered by S26RN Supervisor. She stated that the area was not hurting that bad and she did not know where it came from. Review of the Skin At Risk assessment dated [DATE] revealed a total Risk Score of 14-Score above 12 should be considered High Risk. Pressure Ulcer present: No Review of the interventions/approaches done in conjunction with the assessment necessary to prevent skin breakdown included the following: Assistance with repositioning Nutritional Support Skin care measures Special mattresses or cushions to reduce pressure Daily skin checks Weekly body audit Review of the Comprehensive Care Plan dated 11/11/10 revealed the following: Problem: Potential for Impaired Skin Integrity related to bowel incontinence and impaired physical mobility Goal: Will remain free from skin breakdowns and rashes Approach: Incontinent briefs with perineal care at each change; then apply skin barrier Shampoo, Shower/Bath 3 x/wk (MWF) Manual w/c with cushion Weekly Skin Observation Monitor for red or opened areas on skin and report any significant findings to unit nurse The Care Plan did not have the interventions/approaches that were indicated on the 2/02/11 Skin At Risk Assessment until after development of the pressure sore on 3/13/11. Review of the weekly body audits as documented on the Medication Administration Record (MAR) revealed that Body Audits were done on 11-7 shift every Friday. Documentation indicated to document "N" No problem and "Y" new problems and document findings on body audit form. The MAR further revealed that body audits were done on 3/04/11 initialed with a "N" in the block; an audit was done 3/11/11-initialed with a "N" in the block; another audit was done 3/13/11 with "Y" in the block. There was no documented body audit form filled out for this resident for the month of March 2011. The body audit done on 3/11/11 as documented on the MAR revealed no broken areas. Review of the Nursing Progress Note dated 3/12/11 at 9:00 a.m. revealed the following: "Opened area noted to coccyx area, denies pain to touch. Applied Bordeaux's Butt Paste, chart flagged for MD to evaluate, RN Supervisor notified." Review of the Nursing Progress Note dated 3/13/11 at 9:25 a.m. revealed the following: "Stage-unstageable-3 cm diameter with eschar/black coccyx area. Denies pain, state burns". The RN Supervisor failed to assess and/or document the open area to the resident's coccyx area the day it was discovered and it was 24 hours later before the area was assessed and the doctor called. Review of the physician progress notes [REDACTED]. Patient has small sacral decubitus- stage 3, already on treatment, some slough in wound. Review of the facility's staging form for the week of 3/18/11 revealed the following: Acquired in facility-Yes admitted with-No Eschar--Yes Size cm (centimeter) --3.0 x 3.0 Depth--unable to determine Odor/Drain-- None/None Site--Coccyx Treatment--Iodosorb gel q d (every day) Prevention Equipment--Mattress, Positioning Pillows, Other Review of the facility's staging form for the week of 3/25/11 revealed the following: Stage--III Site (L/W)--2.1 x 1.8 Depth--0.2 cm Odor/Drainage--N/N Site--coccyx Iodosorb QD Wound Bed--100% Review of the Wound/Skin Management Documentation Record revealed the following; Date--3/13/11 Pressure Ulcer Stage--Unstageable Length/Width (cm)--3 x 3 cm Depth (cm)--? Undermine--? Wound Bed---Eschar Drainage--None Surround Skin--Pink Odor--None Treatment/Frequency--Iodosorb Gel qd (every day) Pain Scale (1-10)--O Date--3/25/11 Pressure Ulcer Stage--III Length/Width--2.1 x 1.8 Depth--0.2 cm Undermine--None Wound Bed--Pink Drainage--None Surround Skin--Pink Odor--None Treatment/Frequency-Iodosorb Gel qd Pain scale (1-10)--1 An interview was conducted with S4RN Unit Supervisor on 3/31/11 at 9:43 a.m. She reviewed the Skin At Risk assessment dated [DATE] and verified that the approaches/interventions were not updated on the care plan after the resident was noted to be high risk for skin breakdown. She said that she was the person who should have updated the care plan with the interventions. She further stated that the nurse discovered the pressure ulcer, but it could not be staged because the resident had eschar to the wound. She stated that when the resident has eschar, the nurse has to wait for the MD to stage the wound. An interview was conducted with S15CNA Supervisor (2-10) and S16CNA Supervisor (2-10) on 3/31/11 at 2:15 p.m. S15CNA Supervisor stated that they accompany Resident #24 to the shower room on Tuesdays, Thursdays, and Saturdays. She stated that the resident sits on a shower chair, her back was washed and assistance was provided as needed. She stated that the resident washed her buttocks herself and because they did not wash that area, they were unable to see a skin break. S16CNA Supervisor stated the resident never wore adult diapers before she got the pressure ulcer. She stated that she wore her own underwear prior to the pressure ulcer. An interview was conducted with S25RN Manager on 3/31/11 at 11:10 a.m. She verified that she was the person who first assessed the pressure ulcer after she was informed that Resident #24 had it. She further stated that when she observed the wound, the wound had black eschar and was unstageable. An interview was conducted with S26RN Manager on 4/01/11 at 8:15 a.m. She stated she discovered the pressure ulcer on 3/13/11 and it was black in the middle. An interview was conducted with S27LPN on 4/01/11 at 8:50 a.m. She verified that she did work with Resident #24 on the morning of 3/12/11 and saw the open reddened area on her coccyx. She stated that it was red and open, but not deep and she said she put the Bordeaux's Butt Paste on the wound so it would not be left with nothing on it. She stated that she did report it to the RN Manager on duty that day. An interview was conducted with S2DON on 4/1/11 at 9:15 a.m. He stated that when the nurse discovered the pressure ulcer, an incident report should have been written and that was the only way the Risk Manager can track the incidents such as that. He verified that a Stage III pressure ulcer was discovered on the resident and the pressure ulcer was facility acquired. Resident #35 Resident #35 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the Skin at Risk assessment dated [DATE] revealed a score of 12, on the 01/14/11 skin assessment revealed a score of 14, and the skin assessment on 2/1/11 revealed a score of 14. Review of the Skin at Risk Assessment revealed in part, "The higher the score, the greater the potential for developing pressure ulcer. A score above 12 should be considered High Risk....For residents at "high risk", complete and implement plan of prevention for "High Risk". Review of the Potential Pressure ulcer protocol revealed residents assessed as High Risk must have areas 1-6 addressed. Areas 1-6 are: 1. Assistance with repositioning 2. Range of motion 3. Nutritional Support 4. Skin care measures (lotion, massage, whirlpool) 5. Special mattresses or cushions to reduce pressure 6. Daily Skin Checks Review of the resident's Doctor's Order Sheet dated 2/18/11 revealed in part, "D/C (discontinue) Skilled Services....May use routine standing orders. Clean buttock and genitalia daily and apply BBP (Boudreaux's Butt Paste)..." Review of the Nursing Progress Notes dated 2/28/11 and time 2100 revealed, "Vet (veteran) has pressure ulcer 5 cm (centimeters) X (by) 5 cm at least a Stage 2 on coccyx. RWC (routine wound care) done. NO ( new order) noted. MAR (Medication Administration Record) adjusted. Copy sent to MR (medical records), pharm (pharmacy) and RN Supervisor. MD communication log noted. Supervisor notified." Review of the Routine Standing Orders revealed in part "....8. Routine Wound Care- Superficial wound- Notify MD (Medical Doctor) if not healed in 5 days. Apply triple antibiotic ointment to affected area daily X 5 days..." Review of the MAR for 01/01/11 to 01/31/11 revealed an order date of 1/04/11 for Weekly Body Audits 7-3 shift. Document "N" no problem "Y" document findings on body audit (form #438). There was no documentation of a body audit done from 1/17/11 to 1/29/11. Review of the MAR for 02/01/11 to 02/28/11 revealed an order date of 2/18/11 for Weekly Body Audits 7-3 shift. Document "N" no problem "Y" document findings on body audit (form #438). Documented on the MAR was a body audit done on 2/20/11 with no problems found. The next body audit was due on 02/27/11. There was no documentation of a body audit done on this date. Review of the Skin Audit Schedule for Resident #35's room revealed his skin audit assessment was due to be assessed every Sunday on the 7:00 a.m. to 3:30 p.m. shift. Review of the Wound/Skin Management Documentation Record revealed on 3/02/11 a Stage III sacral pressure ulcer measuring 2.8 cm X 2.4 cm with a depth of 0.1 cm with red bloody drainage. On 3/10/11 the Stage III pressure ulcer was measured 7.0 cm X 5.5 cm, on 3/19/11 the ulcer measurements were 6.0 cm X 4.5 cm and on 3/24/11 the measurements were 6.8 cm X 4.5 cm. Review of the Nursing Progress Notes dated 3/2/11 and timed 1320 revealed, "Dr. _____ made rounds to assess sacral decubitus measuring 2.8 X 2.4 X 0.1 cm with surrounding tissue red but still blanchable. Wound bed is red and bleeding. No c/o (complaint of) pain noted or reported. V/S (vital signs) 115/78, 97.6, 91, 18. Called Mrs. ______ to advise her of the above information. Care plan reviewed and revised for impaired skin integrity. New orders received for wound care orders. Will continue to monitor wound progress." An interview was conducted on 3/31/11 at 10 a.m. with S9LPN. He stated body audits are done weekly based on the resident's room number. Body audit documentations are documented on the MAR. S9LPN verified the body audit was missing for Resident #35 on 2/27/11. He also said there was no documentation in the body audit book for the sacral decubitus found on 2/28/11. He further stated S12LPN discovered the wound and documented in the nursing notes on 2/28/11. He went on to state S12LPN no longer worked at the facility. S12LPN staged the wound at a Stage II. S9LPN stated that LPNs cannot stage pressure ulcers. He stated the family should had been notified when the wound was found on 2/28/11. On 3/31/11 at 10:30 a.m. an interview was conducted with S4RN Unit Supervisor. She stated the sacral pressure ulcer for Resident #35 was acquired in the facility and discovered at a Stage III. She confirmed the resident on 2/01/11 was assessed as High Risk for pressure ulcers. She further stated the nurse notified the RN Supervisor when he discovered the pressure ulcer, the RN Supervisor should have notified the physician for more than routine wound care orders and notified the family of the development of the pressure ulcer. She went on to state an assessment by the RN Supervisor should had been done when the RN Supervisor was notified. LPNs and RNs do not stage pressure ulcers in the facility, only the physician stages pressure ulcers. An interview was conducted on 3/31/11 at 11:45 a.m. with S13RN Supervisor. She stated when the RN Supervisor was notified of the pressure ulcer, the pressure ulcer should have been assessed at that time. An interview was conducted with S3ADON on 3/31/11 at 1 p.m. He stated the RN Supervisor should had assessed the pressure ulcer when notified and per the facility's policy after the observation/evaluation of the affected skin area, notify physician for treatment orders as follows: 1. Name of cleanser 2. Treatment 3. Type of dressing 4. Number of treatment times 5. Duration of treatments Review of the Physician's Telephone Orders revealed the first order for the Stage III pressure ulcer other than Routine Wound Care was dated 3/2/11. The order revealed, "Apply Iodasorb to Stage 3 sacral decubitus after cleansing with NS (normal saline) and cover with bordered dressing daily." An interview was conducted with S2DON at 2:20 p.m. at 3/31/11. He stated as soon as the pressure ulcer was reported to the RN Supervisor, an assessment and measurement of the pressure ulcer should have been done. He further stated routine wound care (RWC) was not an appropriate treatment for [REDACTED]. S2DON confirmed a body audit should have been done on 2/27/11 and there was a missed body audit in January 2011 according to the January MAR. An interview was conducted on S11RN Supervisor at 3/31/11 at 3 p.m. She stated she worked on the evening of 2/28/11. She stated she didn't remember being notified of the pressure ulcer S12LPN discovered on 2/28/11. She further stated if she was notified she would have assessed and measured the pressure ulcer and documented her findings. She said she wouldn't have staged the pressure ulcer because only the physician stages pressure ulcers according to the facility's policy. She said if she had been notified, she would have told the LPN to call the doctor for orders other than routine wound care orders because routine wound care orders, were only for wounds such as skin tears. She said the family should had been notified immediately.

I. Based on observation, clinical record review, the facility's Skin Care Policy and Procedure, and interviews the facility failed to conduct a comprehensive assessment on two residents with Stage III facility acquired pressure ulcers for 2 out 3 residents reviewed for pressure ulcers out of a Stage II sample of 29 residents (Resident #24 and #35). An actual harm occurred to Resident #35 when a facility acquired Stage III pressure ulcer was discovered on a resident on 02/28/11 by a licensed practical nurse and was not assessed and the appropriate treatment was not initiated until 03/02/11 when a physician and regisitered nurse assessed the pressure ulcer. An actual harm occurred to Resident #24 when a facility acquired Stage III pressure ulcer was discovered on 03/11/11 and was not assessed and the appropriate treatment was not initiated until 03/12/11. Findings: Review of the facility's Skin Care Policy and Procedure revealed in part, " Skin problems will be minimized to the greatest extent possible through an aggressive approach consisting of four components. These are: 1. Prevention, Evaluation, and Screening 2. Ongoing Surveillance 3. Treatment Orders 4. Treatment Regimen... 4. The Skin at Risk Assessment is done on admission, and reevaluated every three months, and at significant change. If the evaluation show the resident to be "at risk" or prone to skin breakdown, the assessment will be sent to the Dietary Manager and the following measure will be considered and, if implemented, placed in the care plan and on the nursing assistant assignment sheet: a. Use of an anti-pressure device in bed and chair, bed rail protectors, arm and legs protectors, etc. b. Positioning with support pillows and routine turn schedule. c. Skin care with lotions and/or moisture barriers, etc. d. Evaluation of dietary needs and of fluid intake for the resident. Inform the Dietary Supervisor to include nutritional parameter. e. Evaluation of incontinency, toileting programs, or use of indwelling foley catheter. f. Nutritional and skin at risk meetings.... III. Treatment Orders A. After observation/evaluation of the affected skin area, notify physician of the treatment order as follows: 1. Name of cleanser 2. Treatment (medication, debridement, etc.) 3. Type of dressing 4. Number of treatment times. 5 Duration of treatment, i.e. x's 10 days, until healed, etc. B. Obtain orders for pain management.... D. After completion of each treatment, date and initial each dressing. Document on the TAR (Treatment Administration Record). IV. Treatment Regimen treatment for [REDACTED]. Resident and responsible family member will be notified of treatment regimen. A. Carefully document condition..... Weekly Body Audit Assessment -DON (Director of Nurses) will assign to nursing staff residents for weekly body audits. All licensed nursing staff should be involved in scheduled weekly body audits and physically assess residents for pressure ulcers/skin problem. Weekly body audits will be documented on the M.A.R. (Medication Administration Record). New problems not identified from last body audit will indicated by a "Y". No new problem will be indicated by an "N". When "Y" is noted there must be follow-up documentation in the nurses' notes and follow-up care according to applicable policies and procedures. Resident #35 Resident #35 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the Skin at Risk assessment dated [DATE] revealed a score of 14. Review of the Skin at Risk Assessment revealed in part, "The higher the score, the greater the potential for developing pressure ulcer. A score above 12 should be considered High Risk....For residents at "high risk", complete and implement plan of prevention for "High Risk". Review of the Potential Pressure ulcer protocol revealed residents assessed as High risk must have areas 1-6 addressed. Areas 1-6 are: 1. Assistance with repositioning 2. Range of motion 3. Nutritional Support 4. Skin care measures (lotion, massage, whirlpool) 5. Special mattresses or cushions to reduce pressure 6. Daily Skin Checks Review of the resident's Doctor's Order Sheet dated 2/18/11 revealed in part, "D/C (discontinued) Skilled Services....May use routine standing orders. Clean buttock and genitalia daily and apply BBP (Boudreaux's Butt Paste)..." Review of the Nursing Progress Notes dated 2/28/11 and timed 2100 revealed, "Vet has pressure ulcer 5 cm X 5 cm at least a Stage 2 on coccyx. RWC (routine wound care) done. NO ( new order) noted. MAR (Medication Administration Record) adjusted. Copy sent to MR (medical records), pharm (pharmacy) and RN Supervisor. MD communication log noted. Supervisor noted." Review of the Routine Standing Orders revealed in part "....8. Routine Wound Care- Superficial wound- Notify MD (Medical Doctor) if not healed in 5 days. Apply triple antibiotic ointment to affected area daily X 5 days..." Review of the MAR for 01/01/11 to 01/31/11 revealed an order date of 1/04/11 for Weekly Body Audits 7-3 shift. Document "N" no problem "Y" document findings on body audit (form #438). There was no documentation of a body audit done from 1/17/11 to 1/29/11. Review of the MAR for 02/01/11 to 02/28/11 revealed an order date of 2/18/11 for Weekly Body Audits 7-3 shift. Document "N" no problem "Y" document findings on body audit (form #438). Documented on the February MAR was a body audit done on 2/20/11 with no problems found. The next body audit was due on 02/27/11. There was no documentation of a body audit done on this date. Review of the Skin Audit Schedule for Resident #35's room revealed his skin audit assessment was scheduled to be done every Sunday on the 7:00 a.m. to 3:30 p.m. shift. Review of the Wound/Skin Management Documentation Record revealed on 03/02/11 a Stage III sacral pressure ulcer measuring 2.8 cm (centimeters) X 2.4 cm with a depth of 0.1 cm with red bloody drainage. On 3/10/11 the Stage III pressure ulcer was measured 7.0 cm X 5.5 cm, on 3/19/11 the ulcer measurements were 6.0 cm X 4.5 cm and on 3/24/11 the measurements were 6.8 cm X 4.5 cm. Review of the Nursing Progress Notes dated 3/02/11 and timed 1320 revealed, "Dr. _____ made rounds to assess sacral decubitus measuring 2.8 X 2.4 X 0.1 cm with surrounding tissue red but still blanchable. Wound bed is red and bleeding. No c/o (complaint of) pain noted or reported. V/S (vital signs) 115/78, 97.6, 91, 18. Called Mrs. ______ to advise her of the above information. Care plan reviewed and revised for impaired skin integrity. New orders received for wound care orders. Will continue to monitor wound progress." An interview was conducted on 3/31/11 at 10 a.m. with S9LPN. He stated body audits are done weekly based on the resident's room number. Body audit assessments are documented on the MAR. S9LPN verified the body audit was missing for Resident #35 on 2/27/11. He also stated there was no documentation in the body audit book for the sacral decubitus found on 2/28/11. He further stated S12LPN discovered the wound and documented the wound in the nursing notes on 2/28/11. He went on to state S12LPN no longer worked at the facility. S12LPN staged the wound at a Stage II. S9LPN stated that LPNs cannot stage pressure ulcers. He stated the family should had been notified when the wound was found on 02/28/11. On 3/31/11 at 10:30 a.m. an interview was conducted with S4RN Unit Supervisor. She stated the sacral pressure ulcer for Resident #35 was acquired in the facility and discovered as a Stage III. She confirmed the resident was assessed as High Risk for pressure ulcers on 2/01/11. She further stated when the nurse notified the RN Supervisor when he discovered the pressure ulcer, the RN Supervisor should have notified the physician for more than routine wound care orders and should have notified the family of the development of the pressure ulcer. She went on to state an assessment by the RN Supervisor should have been done when she was notified. A LPN and RN cannot stage pressure ulcers in the facility, only the physician stages pressure ulcers. An interview was conducted on 3/31/11 at 11:45 a.m. with S13RN Supervisor. She stated when the RN Supervisor was notified of the pressure ulcer, the pressure ulcer should have been assessed at that time. An interview was conducted with S3ADON on 3/31/11 at 1 p.m. He stated the RN Supervisor should have assessed the pressure ulcer when she was notified. Per the facility's policy after the observation/evaluation of the affected skin area, notify physician for treatment orders as follows: 1. Name of cleanser 2. Treatment 3. Type of dressing 4. Number of treatment times 5. Duration of treatments Review of the Physician's Telephone Orders revealed the first order for the Stage III pressure ulcer, other than Routine Wound Care, was dated 3/2/11. The order revealed, " Apply Iodasorb to Stage 3 sacral decubitus after cleansing with NS(normal saline) and cover with bordered dressing daily." An interview was conducted with S2DON at 2:20 p.m. at 3/31/11. He stated as soon as the pressure ulcer was reported to the RN Supervisor, an assessment and measurement of the pressure ulcer should have been done. He further stated routine wound care (RWC) was not an appropriate treatment for [REDACTED]. S2DON confirmed a body audit should have been done on 2/27/11 and there was a missed body audit in January 2011 according to the January MAR. An interview was conducted on S11RN Manager at 3/31/11 at 3 p.m. She stated she worked on the evening of 2/28/11. She stated she didn't remember being notified of the pressure ulcer S12LPN discovered on 2/28/11. She further stated if she was notified she would have assessed and measured the pressure ulcer and documented her findings.She said she wouldn't have staged the pressure ulcer because only the physician stages pressure ulcers according to the facility's policy. Also if she had been notified she would have told the LPN to call the doctor for orders, other than routine wound care orders. She stated routine wound care orders were only for wounds such as skin tears. She also stated the family should have been notified immediately. Resident #24 Resident #24 was a [AGE] year old female admitted to the facility 1/12/09 with [DIAGNOSES REDACTED]. An observation/interview was conducted with Resident #24 on 3/30/11 at 2:30 p.m. She stated that the pressure ulcer had been discovered by S26RN Supervisor. She stated that the area was not hurting that bad and she did not know where it came from. Review of the Skin At Risk assessment dated [DATE] revealed a total Risk Score of 14-Score above 12 should be considered High Risk. Pressure Ulcer present: No Review of the interventions/approaches done in conjunction with the assessment necessary to prevent skin breakdown included the following: Assistance with repositioning Nutritional Support Skin care measures Special mattresses or cushions to reduce pressure Daily skin checks Weekly body audit Review of the Comprehensive Care Plan dated 11/11/10 revealed the following: Problem: Potential for Impaired Skin Integrity related to bowel incontinence and impaired physical mobility Goal: Will remain free from skin breakdowns and rashes Approach: Incontinent briefs with perineal care at each change; then apply skin barrier Shampoo, Shower/Bath 3 x/wk (MWF) Manual w/c with cushion Weekly Skin Observation Monitor for red or opened areas on skin and report any significant findings to unit nurse The Care Plan did not have the interventions/approaches that were indicated on the 2/02/11 Skin At Risk Assessment until after development of the pressure sore on 3/13/11. Review of the weekly body audits as documented on the Medication Administration Record (MAR) revealed that Body Audits were done on 11-7 shift every Friday. Documentation indicated to document "N" No problem and "Y" new problems and document findings on body audit form. The MAR further revealed that body audits were done on 3/04/11 initialed with a "N" in the block. The next audit was done 3/11/11-initialed with a "N" in the block. Another audit was done 3/13/11 with "Y" in the block. There was no documented body audit sheet filled out for this resident for the month of March 2011. The body audit dated on 3/11/11 as documented on the MAR revealed no broken areas. The facility failed to do a comprehensive assessment as documented on the plan of care. Review of the Nursing Progress Note, dated 3/12/11 at 9:00 a.m., revealed the following: "Opened area noted to coccyx area, denies pain to touch. Applied Bordeaux's Butt Paste, chart flagged for MD to evaluate, RN Supervisor notified." Review of the Nursing Progress Note dated 3/13/11 at 9:25 a.m. revealed the following: "Stage-unstageable-3 cm diameter with eschar/black coccyx area. Denies pain, state burns". The RN Supervisor failed to assess and/or document the open area to the resident's coccyx area the day it was discovered and it was 24 hours later before the area was assessed and the doctor called. Review of the physician progress notes [REDACTED]. Patient has small sacral decubitus- stage 3, already on treatment, some slough in wound. Review of the facility's staging form for the week of 3/18/11 revealed the following: Acquired in facility-Yes admitted with-No Eschar--Yes Size (cm) --3.0 x 3.0 Depth--unable to determine Odor/Drain-- None/None Site--Coccyx Treatment--Iodosorb gel qd (every day) Prevention Equipment--Mattress, Positioning Pillows, Other Review of the facility's staging form for the week of 3/25/11 revealed the following: Stage--III Site (L/W)--2.1 x 1.8 Depth--0.2 cm Odor/Drainage--N/N Site--coccyx Iodosorb QD Wound Bed--100% Review of the Wound/Skin Management Documentation Record revealed the following; Date--3/13/11 Pressure Ulcer Stage--Unstageable Length/Width (cm)--3 x 3 cm Depth (cm)--? Undermine--? Wound Bed---Eschar Drainage--None Surround Skin--Pink Odor--None Treatment/Frequency--Iodosorb Gel qd (every day) Pain Scale (1-10)--O Date--3/25/11 Pressure Ulcer Stage--III Length/Width--2.1 x 1.8 Depth--0.2 cm Undermine--None Wound Bed--Pink Drainage--None Surround Skin--Pink Odor--None Treatment/Frequency-Iodosorb Gel qd Pain scale (1-10)--1 An interview was conducted with S4RN Manager on 3/31/11 at 9:43 a.m. She reviewed the Skin At Risk Assessment, dated 2/2/11, and verified that the approaches/interventions were not updated on the care plan after the resident was noted to be high risk for skin breakdown. She said she was the person who should have updated the care plan with the interventions. She further stated that the nurse discovered the pressure ulcer, but it could not be staged because the resident had eschar to the wound. She stated when the resident has eschar, the nurse has to wait for the MD to stage the wound. An interview was conducted with S25RN Manager on 3/31/11 at 11:10 a.m. She verified that she was the person who first assessed the pressure ulcer after she was informed that Resident #24 had it. She further stated that when she observed the wound, the wound had black eschar and was unstageable. An interview was conducted with S26RN Supervisor on 4/01/11 at 8:15 a.m. She stated she discovered the pressure ulcer on 3/13/11 and it was black in the middle. An interview was conducted with S27LPN on 4/01/11 at 8:50 a.m. She verified that she did work with Resident #24 on the morning of 3/12/11 and saw the open reddened area on her coccyx. She stated that it was red and open, but not deep and she said that's why she put the Bordeaux's Butt Paste on the wound so that it would not be left with nothing on it. She stated that she did report it to the RN Manager on duty that day.

Based on record review, interviews, and review of the facility's policy, the facility failed to develop, review and revise the comprehensive plan of care for 2 of 29 sampled residents reviewed for care planning (#29, #37). The facility failed to develop a plan of care for a resident that experienced suicidal thoughts and behaviors with self inflicted injuries, coping with a terminal illness and the loss of a son (#37). The facility failed to a plan of care for a resident receiving hospice services (#29). Findings: Resident #37 Resident #37 was a [AGE] year old army veteran that was admitted to the facility on [DATE]. The resident was admitted to the facility with [DIAGNOSES REDACTED]. While at the facility the resident underwent [REDACTED]. Further review of the clinical record revealed that in [DATE], the resident's son passed away [MEDICAL CONDITION]. Review of the admission MDS (Minimum Data Set) dated [DATE] revealed the resident was coded as having a [DIAGNOSES REDACTED]. The resident was not coded to have any hallucinations or [MEDICAL CONDITION]. Review of the "State Home Program Application For Veteran Care" form revealed documentation made by the Physician on [DATE]. The documentation included the resident's history as a [AGE] year old male with [MEDICAL CONDITION] that had [MEDICAL CONDITION] but developed brain metastasis. He had two surgeries for metastasis of the brain. Further review of the form revealed section, "Social Work Assessment (To be completed by Social Worker)". This section was dated [DATE] and completed by S23Counselor. The section included that the resident was "having difficulty settling in". Review of the Nursing Progress Notes revealed the following: [DATE] at 4:00 a.m. - resident was crying, stating that no one had visited him. At 5:45 a.m. the resident was "requesting to see a lawyer". The resident stated, "I have my rights and I want my family to come see me now." Review of form entitled, "Information Sheet" dated [DATE] and timed for 7:00 a.m. revealed documentation completed by S18CNA (Certified Nursing Assistant). The documentation within the form revealed that when S18CNA responded to resident #37's call light, "he had it against his neck pressed down saying he wanted to hang himself.". S18CNA further documented that she left the resident's room and the resident "hit the light again". When S18CNA responded to the resident's call light, the resident was demonstrating the same behavior, and S18CNA documented that again the resident was told "not to do that". The resident asked S18CNA "to do it (hang him) for him". S18CNA documented that she removed the cord, put it on the side of the bed and notified S6CNA Supervisor and S10LPN (Licensed Practical Nurse). Review of an Incident Report dated [DATE] and timed for 9:50 a.m. that was completed by S10LPN revealed the description of the incident as, "Veteran lying in bed, calling for assistance to get up. Upon entering the room, observed right arm bleeding. Skin tears noted on arm near wrist. Veteran stated he pulled the bandaid off arm". Review of the Social Services Admission Assessment, completed by S23Counselor and dated [DATE] (not timed), revealed documentation that the resident had no previous mental health treatment and "appears upset and disoriented upon assessment". Review of a Social Services Progress Note dated [DATE] included that the resident was admitted from the hospital and appeared alert and verbal but disoriented. Further documented was the following: "Calls out frequently - confused. Family states he is depressed due to state of health. Will see needs are met." S23Counselor made no reference to either incident involving the resident on [DATE] (call light to resident's neck or skin tears found to resident's right wrist). Review of the Nursing Progress Notes revealed the following: [DATE] at 10:20 a.m., S17LPN documented that the CNA reported the resident had skin tear to left hand. Upon assessing the resident, was asked what happened to his arm. He stated "I tried to cut my wrist, I wanna die. I wish I had a gun." Was asked by the nurse, "are you telling me you're trying to harm yourself." He stated, "no I'm trying to kill myself do you have a gun." The nurse reported this to the DON (Director of Nursing). Upon returning to the room, the nurse observed a broken piece of tile with dried blood on it. The resident stated "my kids gave up on me and my wife is gone marry a black man". At 11:30 a.m., the resident was assessed for suicidal gestures, and a 2 inch superficial cut was noted to the resident's left wrist. The resident was observed to be pulling the sutures from his scalp. He complained of "severe pain" to his back and legs with movement. The physician was present and ordered the resident to be transferred to the hospital due to him being a danger to self. At 2:30 p.m., the resident was transferred to the hospital. Review of the Incident Report dated [DATE] and timed for 10:20 a.m. revealed a description of the incident as: Veteran has skin tear to left wrist, stated "I tried to cut my wrist, I want to die." Two inch superficial skin tear noted to left wrist. Veteran also attempted to pull suture from scalp. Review of the Social Services Progress Notes dated [DATE] (no documented time) revealed documentation made by S19LSW. The documentation included the following: "Went into vet's (veteran) room and MD (Medical Doctor), nursing staff in room with him. After staff left spoke with vet regarding cutting of his wrists. He stated he wanted 'to kill them all'. When asked by this writer who he was referring to he said 'my wife and kids'. When asked why, he stated 'my wife is having an affair with a black man and wants to marry him'. When asked about his children he stated, 'they want my money'. Vet appears to feel abandoned, angry and hopeless. He also stated he was tired of being in pain (headache and backache). He had trouble changing positions in bed due to pain. He also discussed the loss of his son (youngest) due [MEDICAL CONDITION] and how that made his wife 'go crazy'. Vet is grieving but trying to understand his wife's current behavior. He is in need of a thorough mental health assmt (assessment) as well as family tx (treatment) and pain mgmt (management) at this time. Inpt (Inpatient) hosp (hospital) recommended." Review of the Physician's Telephone Orders revealed an order dated for [DATE] to transfer the resident to the psychiatric hospital per ambulance. Review of the Physician Emergency Certificate (PEC) dated [DATE] and timed for 11:30 a.m. revealed documentation made by the physician that the resident was "suicidal" and that the resident had [MEDICAL CONDITION] with metastasis-has pain to pelvic area with movement-made attempt to cut wrists-has depression. Review of the physician progress notes [REDACTED]. The Physician referenced that the resident had [MEDICAL CONDITION] with metastasis. The Physician further documented that the resident would be transferred to psych unit for "evaluation of his depression and suggestion for better control". Review of the hospital records revealed the following: *History and Physical dated [DATE] revealed that the resident was alert and oriented x 3. That he had a history of [REDACTED]. The resident presented to the hospital for a suicide attempt at nursing home. The resident tried to cut the vein of his hands and said that he felt that there was "no sense to continue to live". *Psychiatric Evaluation dated [DATE] that was completed by the hospital's physician revealed: General Appearance and Behavior: Both wrists bandaged. Chief Complaint: When asked why he cut his wrists he states: "for fun...I had nothing else to do...I was bored". History of Psychiatric: He cut both wrists with piece of formica *physician progress notes [REDACTED]. effects of [MEDICAL CONDITION] for the last 5 years. Pt (patient) has been saying that he would kill himself b/c (because) he did not want to live like this." *Psychosocial assessment dated [DATE] that was completed by the hospital's social worker included following: Presenting Problem: Pt admitted on PEC for treatment of [REDACTED]. Other/Comments: Says he is tired of the pain and wants to get rid of it. Previous Attempts: Has had suicidal thoughts in the past but did not act on them - per daughter. Homicidal Ideations: Voiced homicidal thoughts to the doctor concerning his wife whom he thought was having an affair. Appetite Problems: Poor appetite. Family/Significant Other input relating to Present Problem: Daughter feels recent incident was impulsive and says Pt is upset with family. Feeling they do not visit him enough. Daughter says they try to visit daily. Family Origin: Married, has children (3 living and 1 deceased ), 1 brother living. Developmental History: Daughter reported Pt has been [MEDICAL CONDITION] for last 5 years. Cancer started in the lungs and is now also in the brain. Severe Grief/Loss Issues relating to: Pt's son died [DATE] (6 weeks after being diagnosed with [REDACTED]. Recommendations for Treatment and Services for Family: 1:1 as needed. Further review of the hospital records revealed the resident was discharged back to the facility on [DATE]. Review of the hospital's discharge summary revealed that the resident was "actively hallucinating". Review of the nursing Documentation Record dated [DATE] included that the resident was receiving routine wound care (RWC) to three skin tears on his left arm, one to his right hand, and a laceration to his right forearm. Review of the Comprehensive Care Plan revealed the following: Problem: Lack of participation r/t refuses to attend, dependent on staff, lack of interest, inability to perform, new admission, daytime napping, new limiting disability, inappropriate social behavior, bedfast. Problem Date: [DATE]. A hand written "Redefined SW [DATE]" noted beneath Problem. Problem: History of Depression. Resident is on [MEDICATION NAME]. Problem Date: [DATE]. There was no documentation of the resident's terminal illness, [MEDICAL CONDITION]/behaviors, self inflicted wounds or interventions for the problems. Review of the facility's policy entitled, "Care Planning", revealed in part: "Each resident will have a comprehensive care plan that is current, individualized, and consistent with the medical regimen. Care plans are to be reviewed and updated at least quarterly, annually and any time there is a significant change in the resident's condition. As the resident's needs change between the scheduled care plan conferences, the care plan will be re-addressed and revised as needed.... F. Between care plan conferences, each discipline will add interventions to the care plan when initiated and discontinue interventions when resolved." On [DATE] at 11:40 a.m., an interview was held with S5RN-MDS/Care Plan. She verified she had completed resident #37's Care Plan. She reviewed the Care Plan and verified there was no documentation to indicate the resident had suicidal behaviors or had been transferred to the hospital for suicide attempts. An interview was held with S4RN Unit Supervisor on [DATE] at 12:00 p.m. She reviewed the resident's Comprehensive Care Plan and verified the Care Plan did not reflect the resident's mental status or interventions for his behaviors. She stated that social services were responsible for the planning of care for a residents' behaviors. An interview was held with S19LSW on [DATE] at 1:30 p.m. S19LCW recalled resident #37. She stated the resident had behaviors of [MEDICAL CONDITION]. She recalled the resident having "paranoid" thoughts regarding his wife and another man. She verified the resident self inflicted a wound to his left wrist on [DATE] and was sent to the hospital. She verified that prior to the hospitalization and after the resident returned to the hospital on [DATE], there were no interventions put into place for the resident. She stated the social service department was responsible for developing and revising a resident's plan of care that involved behaviors. S19LSW reviewed the resident's Comprehensive Care Plans and verified the Care Plan did not identify the resident's actual problems that included, [MEDICAL CONDITION], self inflicted injury, terminal illness and adjustment to the facility. She verified that without the problems identified within the Care Plan, that interventions were not established. Further review of the Social Services Progress Notes revealed the following dates/documentation: [DATE]: Resident returned from the hospital on [DATE] with [DIAGNOSES REDACTED]. [DATE]: "Stated to RN that he wanted to die." S22Counselor documented that she spoke with the resident and asked him about depression and thoughts of dying, but the resident denied the feelings with a response of "no, I just go with the flow". S22Counselor documented that she suggested and IOP visit to the RN. [DATE]: S22Counselor documented that she met with the resident's daughter as the daughter read over a book from hospice. The resident's daughter informed S22Counselor that "they recently lost a brother [MEDICAL CONDITION] and did not think their mother (resident's spouse) could handle another death at home at this time. Another interview was held with S19LSW on [DATE] at 2:30 p.m. She said that the staff and other counselors would refer residents to her when needed. She further stated that she was not made aware of the incidents that occurred on [DATE] involving the resident's behavior of placing call cord around neck or of the staff finding skin tears to the resident's right wrists on [DATE]. She reviewed the resident's clinical record and verified that upon admission, S23Counselor documented the resident was "having difficulty settling in". She verified the resident had a terminal illness upon admission and had recently lost one of his children [MEDICAL CONDITION]. As S19LCW further reviewed the social notes, she verified that there was documentation indicating the resident had underwent a craniectomy which resulted in loss of vision in his right eye while residing in the facility. S19LCW verified that these problems were not included in the resident's Care Plan either. Resident #29 Resident #29 was an [AGE] year old male resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admit assessment for hospice reveals the resident was admitted to hospice care on [DATE]. Further review of the assessment revealed the resident had been a resident of the nursing home for 2.5 year with the loss of communicative ability. It revealed the resident was totally dependent on others for Activities of Daily Living skills and he was totally incontinent of both bowel and bladder. Review of the Hospice agency's Plan of Care dated [DATE] revealed the following: Nursing 1 time per week HHA 3 times per week Chaplain 1 time per month Social Worker 1 time per month Review of the facility's Comprehensive Care Plan for Resident #29 did not include any Hospice approaches/interventions. There was no indication on the care plan that the resident was receiving hospice care. An interview was conducted with S25RN Manager on [DATE] at 10:00 a.m. She reviewed the care plan and verified that there was no Hospice included on the facility's care plan. She stated she has never put the hospice information on the facility's care plan. She stated Hospice should have their own care plan. An interview was conducted with S7LPN/MDS Nurse on [DATE] at 1:15 p.m. She stated that she was not sure if the Hospice staff ever attended a care planning meeting. She verified that Hospice was not a part of the facility's care plan and stated that Hospice does their own care plan. An interview was conducted with S3ADON on [DATE] at 1:30 p.m. He reviewed the care plan and verified that the Hospice care was not a part of the care plan. There was no indication of coordination of care between the Hospice staff and the facility staff.

Based on observations and interviews, the facility failed to maintain a safe and sanitary environment for the prevention and transmission of disease and infection by failing to: 1) Transport clean linen to the nursing unit properly covered. 2) Control and prevent contamination of the residents indwelling catheter device by allowing the device to lie/drag on the floor for 3 of 7 residents in the facility with foley catheters (#29, #31, and #32). Findings: 1) During an observation on 3/30/11 at 9:30 a.m., S30Housekeeping was delivering linen-sheets, blankets, towels and draw sheets-to hall "A". The linen was stacked high on a metal cart with no covering. An interview was conducted with S30Housekeeper on 3/30/11 at 9:35 a.m. When asked if that was the way he always transported linen-he stated no. He stated that the linen should have been covered to transport, but he was just trying to hurry and get it to the CNAs on the unit and they would put on the cart with a cover. An interview was conducted with S31Housekeeping Supervisor on 4/01/11 at 9:00 a.m. She stated the proper way to transport linen from the linen truck was to obtain a cart from the nursing unit, fill it with linen, and cover it with a sheet to transport the linen to the unit. She verified the linen should never be brought down the hallway uncovered. 2) During the initial tour on 3/28/11 at 12:30 p.m., an observation was made of Resident #29 laying in bed on his left side. He had a foley catheter that was in a privacy cover, but the bag was lying on the floor. An interview was conducted with S9LPN on 3/28/11 at 12:40 p.m. He verified the foley bag was lying on the floor and should not have been. He stated the bag should have been placed on the side of the bed. During the medication pass on 3/30/11 at 11:30 a.m. an observation was made of Resident #31 wheeling himself in the hallway on the way to the cafeteria. The resident's foley catheter tubing was dragging on the floor under the wheelchair. An interview was conducted with S29LPN on 3/30/11 at 11:35 a.m. He verified the foley tubing was on the floor and should not have been. He stated the tubing should have been clipped to the wheelchair. Resident #32 Resident # 32 was readmitted to the facility on [DATE] and his latest MDS (Minimum Data Set) was dated 03/12/11 and revealed his [DIAGNOSES REDACTED]. Review of his clinical record revealed the following positive urine cultures dated: 10/13/10, 10/28/10, 12/24/10, 1/25/11, and 03/07/11. . An observation was conducted on 03/30/11 at 1:10 p.m. Resident # 32 was sitting on his low bed with his catheter bag still attached to his wheelchair, which was located next to his bed. S8CNA placed the foley collection bag on the floor and questioned the resident about if he got in his bed without assistance of a staff member. S8CNA proceeded to place the foley catheter collection bag on the floor and scooted the foley collection bag across the floor with her foot until it was next to the resident's bed and then she attached the collection bag to the resident's bed. Part of the catheter tubing was observed on the floor also. S17LPN was in the room and verified the observation. An observation was performed on 4/01/11 at 9:15 a.m. in Dining Room "c". Resident #32 was sitting at a table in his wheelchair and part of his foley catheter tubing was resting on the floor. The observation was confirmed by S6CNA Supervisor.