Every finding on record at Park Village Health Care Center Inc

Based on observation, interview with staff, and review of the recommendations of the US Department of Agriculture, the facility failed to store and serve food in a manner to prevent foodborne illness. This had the potential to affect 75 of 76 residents who received meals from the facility kitchen. The facility census was 76.Findings include: Observation and interview on 04/19/26 between 9:05 A.M. and 9:24 A.M. during the initial kitchen tour revealed four full loaves and one half loaf of [NAME] sandwich bread with use by date of 04/14/26 on the bread rack used for meal service on 04/19/26. This was verified at the time of observation by Dietary [NAME] (DC) #513 who removed the bread and discarded it in the trash. Observation on 04/21/26 at 11:20 A.M. of food and drink temperature checks for the lunch meal revealed drinks cups containing water, juices, and white and chocolate milk lined up on the counter for lunch meal services. The cups did not have any lids or coverings. There was no ice bath or device/means to keep the fluids cold. Further observation revealed the temperature check of the milk from two different cups was 47 degrees Fahrenheit (F) and 50 degrees F. Temperature check of the apple juice revealed a temperature reading of 44 degrees F. These observations were verified at the time of observation by Dietary Manager (DM) #408.Observation on 04/21/26 at 12:25 P.M. of the tray line for the lunch meal revealed a dietary staff member carrying three cups containing juice, milk, and water to place on a tray for lunch service. The dietary staff member was carrying all three cups by the top rims, and her fingers were inside of the rim of two of the cups. This was verified by DM #408 who immediately directed the dietary staff member to throw the drinks out and get new ones. Review of the United States Department of Agriculture (USDA) website for recommendations for safe handling, Danger Zone (40 F - 140 F) | Food Safety and Inspection Service, revealed cold foods should be kept at or below 40 degrees Fahrenheit, and place food on ice. Further review revealed the danger zone of foods left at temperatures between 40-140 degrees Fahrenheit for as little as 20 minutes can lead to doubling of bacterial growth leading to food borne illness.

Based on medical record review, policy review, and staff interview, the facility failed to ensure the Pre-admission Screening and Resident Review (PASARR) document reflected accurate medical diagnoses. This affected two (Resident #9 and #69) of two residents reviewed for PASARR documents. The facility census was 76.Findings include: Medical record review revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, dementia, anxiety, delusional disorders, and depression.Review of Resident #9's most recent PASARR document, dated 05/14/25, revealed Section E: Indications of Serious Mental Illness did not indicate the diagnoses of and was not revised/updated to include diagnoses of hallucinations, delusions, depression, and anxiety.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 02/25/26, revealed the resident had a severe cognitive impairment.Interview on 04/21/26 at 9:36 A.M. with Social Service Director (SSD) #404 confirmed Resident #9's PASARR, dated 05/14/25, did not include the diagnoses of hallucinations, delusions, depression, and anxiety.2. Medical record review revealed Resident #69 was admitted to the facility on [DATE] with diagnoses including severe dementia, delusional disorder, anxiety disorder, major depressive disorder, and heart failure.Review of Resident #69's most recent PASARR document, dated 02/19/26, revealed Section D did not indicate the diagnosis of dementia; and Section E did not indicate the diagnosis of delusional disorder.Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 03/04/26, revealed the resident had a moderate cognitive impairment.Interview on 04/21/26 at 9:40 A.M. with SSD #404 confirmed Resident #69's PASARR, dated 02/19/26, did not accurately reflect the resident's diagnoses of dementia and delusional disorder. Review of the facility policy titled PASARR Policy dated 03/24/25 revealed a PASARR will be completed by the social service designee for all residents prior to admission to the facility, with the exception of residents with a hospital exemption. Any resident who requires a level two screen will be considered part of the PASARR population. A new resident review will be completed following a significant change of condition for the resident. Any resident who has a clean level one screen will be considered part of the non-PASARR population. A new resident review will be completed following admission to psychiatric hospital or upon the addition of a new psychiatric diagnosis and/or medication.

Based on closed record review, hospice record review, interview, review of a contract between the facility and an outside hospice agency, and facility policy review, the facility failed to effectively communicate with Resident #83's hospice agency as per the written agreement to ensure the resident's need for medication administration was met. This affected one resident (#83) of four residents reviewed for hospice care. The facility census was 76.Findings include: Review of the closed medical record for Resident #83 revealed an admission date of 03/03/25. Diagnoses included muscle weakness, anxiety disorder, major depressive disorder, hypertension, and vascular dementia, unspecified. Resident #83 passed away at the facility on 05/29/25. Review of a care plan for Resident #83, updated on 05/28/25, revealed the resident was admitted to hospice care. Interventions included administering medications as ordered by hospice and maintaining resident's safety and comfort.Review of Resident #83's physician orders revealed Hospice Medical Director (HMD) #900 provided orders dated 05/29/25 for the resident to receive Ativan (a controlled anti-anxiety medication) 0.5 milligrams (mg) two tablets (totaling 1 mg) by mouth every three hours scheduled on a routine basis. The order began on 05/29/25 at 3:00 A.M. Resident #83 additionally had an order dated 05/29/25 for Dilaudid (a narcotic analgesic) 4 mg every two hours for pain scheduled on a routine basis to begin on 05/29/25 at 2:00 A.M.Review of Resident #83's Medication Administration Record (MAR) for May 2025 revealed the resident's Ativan was recorded as administered as ordered on 05/29/25 at 3:00 A.M., 6:00 A.M., and 9:00 A.M. The 12:00 P.M. dose and the 3:00 P.M. doses of Ativan were not recorded as administered. Continued review of the MAR revealed the resident's Dilaudid was recorded as administered as ordered on 05/29/25 at 2:00 A.M., 4:00 A.M., 6:00 A.M., and 8:00 A.M. The 10:00 A.M. and 12:00 P.M. doses of Dilaudid were not recorded as administered, despite the MAR referencing the resident had a recorded pain level of one at 10:00 A.M. and a pain level of two at 12:00 P.M. Continued review of Resident #83's medical record revealed no evidence of communication between Registered Nurse (RN) #442 and the resident's hospice agency to indicate the reason for holding the medication. An interview on 04/22/26 with Licensed Practical Nurse (LPN) #452 confirmed Resident #83's medical record contained no indication or rationale as to why the resident's Avitan and Dilaudid doses were held on 05/29/25. Review of Resident #83's hospice records dated 05/29/25 revealed no communication between or with the facility of any reported change in condition or to collaborate on Resident #83's medication regimen.The record failed to reveal communication between RN #442 and the hospice agency to indicate the reason for holding the ordered medication. This was confirmed by interview on 04/22/26 with Licensed Practical Nurse (LPN) #452. Review of the hospice record for Resident #83 also failed to reveal any communication with the facility with report of a change in condition requiring a change in the ordered doses or frequency of medications.Continued review of the hospice medical record revealed a note dated 05/29/25 authored by Hospice LPN #901 which revealed she arrived at the facility on 05/29/25 for a visit related to Resident #83 experiencing periods of apnea (temporary cessation or pausing of breathing, lasting from a few seconds to minutes). Hospice LPN #901 noted the resident was unresponsive to verbal and tactile stimuli and was receiving scheduled Ativan and Dilaudid. The note referenced RN #442 had held doses (of the Ativan and Dilaudid) due to her judgement of not feeling the resident needed the medications. Per hospice staff that have been present at the bedside, Resident #83 had been very restless and agitated throughout the night and would not leave his gown on. Hospice LPN #901 discussed with the resident's daughter about medication administration and whether she wanted staff to hold medications or if she preferred the medications be administered as scheduled. The daughter reported to the nurse she preferred to do what hospice staff felt was best and she wanted the resident kept comfortable. Hospice LPN #901 recommended administering the resident the scheduled medications as ordered, rather than risking medications wearing off and the resident beginning to show signs of discomfort again to which the daughter agreed. Hospice LPN #901 discussed with RN #442 the family's wishes for medication and RN #442 was very upset as she felt the resident did not need the medications and, per her judgement, she would not give. RN #442 informed and discussed with the facility's Director of Nursing (DON). Hospice LPN #901 discussed Resident #83's medications with the DON who voiced understanding to the family's request for medication administration. The DON informed Hospice LPN #901 that she, the DON, would plan to administer the resident's ordered medication as RN #442 still did not feel comfortable administering medications as ordered and as the family wished. Further review of Resident #83's MAR revealed at 1:52 P.M., Resident #83 was administered his scheduled Dilaudid (due at 2:00 P.M.) by the DON.On 04/21/26 at 9:32 A.M. an interview with the Administrator revealed communication with hospice was based on Interdisciplinary Team (IDT) recommendations. If a facility nurse had a concern about medication or order, there would be a discussion with [Director of Nursing (DON)] and she would advise what further steps should be taken. He agreed calling the physician would be necessary to determine a medication concern or discrepancy, not the DON. Interview with LPN #452 on 04/22/26 at 4:55 P.M. revealed if there were concerns regarding a hospice resident, a change in condition, a family concern, or a concern with medications, it must be relayed to the hospice nurse for further orders. She confirmed a nurse from the facility should never administer a different dose than ordered without first talking to hospice for further orders or directions.Review of a policy titled Nursing Services Policy and General Guidelines revised 03/25, revealed all medications were to be administered by the method, time, and dosage as prescribed by the attending physician. Review of a document titled 2026 Quality Assurance Performance Improvement Plan for Park Village Dover revealed the facility provided supervision and collaborated with the medical and nursing team at Park Village by reviewing, dispensing, and monitoring medication effectiveness to ensure therapeutic goals were maintained for each and every resident. Review of a facility contract with Resident #83's hospice agency, dated 04/25/23, revealed each party was responsible for documenting communications in the clinical record to ensure the needs of Hospice patients were met 24 hours a day. The facility would not make any modifications to the plan of care without first consulting with hospice. Hospice retained the sole authority for determining the appropriate level of hospice care provided to each patient. The facility should immediately inform hospice of any change in condition of the patient. Further, if there were physician orders that were inconsistent with the plan of care or Hospice protocols, a RN with the facility should notify hospice. An authorized representative of Hospice would resolve the differences directly with the physician and secure the necessary orders.This deficiency represents non-compliance investigated under Complaint Number 1394812 (OH00166707).

Based on observation, interview, review of Centers for Disease Control (CDC) guidelines, and facility policy review, the facility failed to provide routine cleaning and disinfection of resident care equipment including equipment shared among residents (blood pressure cuff and pulse oximeters). This affected two residents (#7 and #67) of seven residents observed for infection control during medication administration. Further, the facility failed to ensure staff demonstrated the proper use of gloves with hand hygiene during incontinence care. This affected one resident (#71) of three residents reviewed for incontinence care. The facility identified 63 incontinent residents. The facility census was 76.Findings include:1.Observation on 04/20/26 at 8:19 A.M., during medication pass, revealed Registered Nurse (RN) #442 take the blood pressure (BP) of Resident #67 with a wrist BP cuff prior to administering medications. After obtaining the BP reading, the RN placed the BP cuff back onto the medication cart and did not sanitize it before using the cuff on another resident. This was confirmed by RN #442 during an interview on 04/20/26 at 9:26 A.M.Continued observation on 04/20/26 at 9:05 A.M., during medication pass, observed RN #442 check the heart rate of Resident #7 with a pulse oximeter (device used to check oxygen level and heart rate) prior to administering medication. RN #442 did not disinfect the pulse oximeter prior to or after use. The device was placed back into a basket holding several other pulse oximeters on the medication cart. This was confirmed by RN #442 during an interview on 04/20/26 at 9:26 A.M.On 04/20/26 at 9:26 A.M., an interview with RN #442 confirmed she had not disinfected manual BP cuff or pulse oximeter prior to or after use on residents. She indicated she did not disinfect equipment as a general practice and would welcome recommendations on how to disinfect the equipment between resident usages.The facility failed to provide a policy for disinfecting resident care equipment shared between residents.Review of Center for Disease Control (CDC) guidelines revealed it was required to disinfect shared noncritical resident equipment (stethoscopes, blood pressure cuffs, etc.) with an EPA (Environmental Protection Agency) registered hospital disinfectant after each use. 2. On 04/22/26 at 2:00 P.M., an observation of Certified Nursing Assistant (CNA) #478 and CNA #501 performing incontinence care on Resident #71 was completed. During the observation, the aides sanitized their hands and donned gloves prior to beginning care. The aides removed the resident's soiled brief, cleaned the resident's perineal area, applied a new brief, replaced her bed clothes, straightened the room, and took out the trash. The two CNAs did not wash their hands or change their gloves at any point during care. Once care and room tidying was completed, the aides removed their gloves and washed their hands. This was confirmed by CNAs #478 and #501 immediately following the observation. On 04/22/26 at 2:30 P.M., an interview with the Director of Nursing revealed the expectation would be to follow the facility policy. The policy indicated hand washing and glove changes should take place prior to care, after removing soiled clothing and briefs, and after completing resident care. She provided the facility policy.Review of a facility policy titled incontinence care policy, revised 08/24/22, revealed the policy was to prevent skin breakdown from moisture and fecal waste on the skin due to incontinence and to promote resident dignity. The procedure stated staff were to put on gloves, remove wet or soiled undergarment, cleanse the perineal area and place soiled linens in appropriate receptacles. The staff should then remove gloves, wash hands with either water or antibacterial hand sanitizer, and dry hands. The staff would then apply clean gloves, assist with applying a clean brief, and adjusting clothing. The staff should then remove gloves, sanitize hands, and settle the resident into bed or chair. Soiled linens and trash would then be taken to the appropriate receptacle, and hands would again be sanitized.

Based on observation, interview and policy review, the facility failed to properly store food in the refrigerators. This had the potential to affect 73 of 74 residents in the facility who receive meals from the kitchen. The facility identified Resident #1 to receive alternate nutrition. The facility census was 74. Findings included: Observation on [DATE] at 9:39 A.M. of the meat refrigerator revealed a large pan of chicken on the bottom shelf which had thawed and leaked onto the bottom of the refrigerator, and rusty shelving. Observation on [DATE] at 9:43 A.M. revealed one gallon of milk expired on [DATE] and a gallon Ziploc bag of peanut butter and jelly sandwiches were not dated. Interview on [DATE] at 9:49 A.M. with Dietary Manager #102 confirmed findings. Review of a policy titled Date Marking and Disposal of Ready to Eat Potentially Hazardous Foods revised on [DATE] revealed dated marking is a tool to help ensure food safety and helps staff to know how old the food item is. Refrigerated, ready to eat, potentially hazardous food prepared and held for more than 24 hours must be marked with the date of preparation. A food packaged by a food processing plant must be consumed or discarded within seven calendar days after the original package is opened.

Based on record review and interview, the facility failed to ensure Resident #57 had a Pre-Admission Assessment Screening (PASRR) in place after the expiration of a Hospital Exemption. This affected one (Resident #57) of one resident reviewed for PASRR. The facility census was 74. Findings included: Record review revealed Resident #57 admitted to the facility on [DATE] with diagnoses including cerebral atherosclerosis, dementia with psychotic disturbance, congestive heart failure, anxiety disorder, delusional disorders, hallucinations, neurocognitive disorder with lewy bodies, and major depressive disorder. Review of a significant change minimum data set (MDS) dated [DATE] revealed Resident #57 did not have a level two PASRR (ensures the appropriate placement of persons with mental illness or intellectual disability and determines if an individual requires specialized rehabilitative services). Review of a Hospital Exemption dated 02/27/23 revealed an expiration date of 03/29/23. There was no other evidence of a PASRR being completed prior to admission or the expiration of the 30 Day Hospital Exemption. Interview on 04/02/24 at 1:11 PM with Social Services Director (SSD) revealed new PASRR's are done when residents come from the hospital within the first 30 days. SSD stated she did not see where a PASRR was completed for Resident #57, but did see a hospital exemption was in place. Review of a PASRR policy dated 03/24/20 revealed PASRRs should be completed by the designee for all residents prior to admission to the facility, with the exception of residents with a hospital exemption. In this situation, the PASRR will be completed by the 29 th day after admission, and all PASRR will be reviewed and signed by the Director of Nursing. Any resident who requires a level II screen will be considered part of the PASRR population, a new resident review will be completed following a significant change of condition for the resident. Any resident who has a clean level I PASRR will be considered part of the non PAS population. A new resident review will be completed following admission to psychiatric hospital or upon the addition of a new psychiatric diagnosis and/or medication.

Based on medical record review, policy review and staff interview the facility to ensure residents had an appropriate indication for antibiotic use. This affected one (Resident #54) of five residents reviewed for medication use. The facility census was 74. Findings include: Review of Resident #54's medical record revealed an admitted [DATE] with diagnoses that included congestive heart failure, cerebrovascular accident and dementia. Further review of Resident #54's medical record including advanced practitioner's orders revealed on 03/21/24 the resident was prescribed amoxicillin-potassium clavulanate (antibiotic) 875 milligrams (mg) every 12 hours for seven days for aspiration pneumonia. On 03/23/24 the medication was discontinued due to a chest x-ray completed that was negative for pneumonia. Review of Resident #54's Medication Administration Record (MAR) revealed the resident was administered the medication as ordered from 03/21/24 evening to 03/23/24 morning for a total of four doses administered. An antibiotic assessment completed on 03/23/24 indicated the chest x-ray was negative and therefore did not meet criteria for antibiotic use. Review of the chest x-ray completed on 03/23/24 revealed no evidence of pneumonia. Interview with Registered Nurse (RN) #101 on 04/04/24 at 9:05 A.M. verified an antibiotic was started for Resident #54 prior to obtaining a chest x-ray and was then discontinued after a negative chest x-ray. Resident #54 also received four doses of antibiotic without an appropriate indication for use. Review of the facility policy titled Antibiotic Surveillance Policy and Procedure with a review date of October 2023 revealed the nurse is to initiate a McGeer's assessment when a resident starts to show signs and symptoms of an infection. If the resident meets criteria, then the physician is to be notified. If an antibiotic is ordered an assessment has not been completed, the nurse must notify the practitioner for the reasoning behind the antibiotic usage. A McGeer's assessment should then be initiated and if criteria are not met than the practitioner must be notified that criteria is not met.

Based on interview, record review and policy review revealed the facility failed to provide Resident #72 written bed hold notice upon admission to the hospital. This affected one (Resident #72) of two residents reviewed for hospitalization s. The facility identified 41 residents who do not have Medicaid as their payer source. The facility census was 74. Findings include: Review of the medical record for Resident #72 revealed an admitted [DATE]. Diagnoses included hyponatremia, altered mental status, and paroxysmal atrial fibrillation. The record indicated the resident was sent from the facility to the hospital on 01/31/24. The resident did not return to the facility. Continued review of the record revealed she was not provided a written bed hold notice. Interview on 04/03/24 at 3:00 P.M. with the Director of Nursing confirmed the facility did not send a written bed hold notice to the resident or her representative. Further interview revealed the facility only provides written bed hold notices to residents who received Medicaid as their payer source. Review of the undated facility policy, Discharge/Transfer revealed the policy does not indicate how the resident or their responsible party will be notified of or given the bed hold notice once transferred to the hospital.

Based on record review, interview, and facility policy review the facility failed to ensure proper infection control practices and procedures were in place to prevent the spread of Respiratory Syncytial Virus (RSV). This had the potential to affect all 70 residents who resided in the facility. Findings Include: Resident #76 was admitted to the facility on [DATE] and expired [DATE]. Diagnoses included diabetes mellitus, persistent mood affect disorder, major depressive disorder, and anxiety disorder. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated [DATE], revealed Resident #76 had severely impaired cognition and required substantial assistance for walking and had behaviors of wandering one to three days during the seven-day look back period. Review of the order note dated [DATE] at 4:57 P.M. revealed that the son of Resident #76 was notified of Resident #76 tested positive for RSV and would be in isolation for at least eight days. Interview on [DATE] at 11:56 A.M. with the Director of Nursing (DON) revealed Resident #76 would sit in her wheelchair in the common area because she was a fall risk, so we put her where we could watch her. We tried to keep Resident #76's mask on, but she would take it off. Interview on [DATE] at 2:23 P.M. with Activity Director #105 revealed that Resident #76 was not isolated because the resident had behaviors of yelling, she would want to get up and look for her family. Resident #76 would wander around in her wheelchair. Interview on [DATE] at 2:33 P.M. with State tested Nursing Assistant (STNA) #106 revealed Resident #76 had RSV and should have been quarantined. She was out in the common area because she was a fall risk. STNA #106 stated that Resident #76 had to be checked on every two hours. Interview on [DATE] at 2:54 P.M. with the Administrator revealed Resident #76 was out in the common area because she was a fall risk. Resident #76 would not keep a mask on. He did not call the local or state health department for guidance, and no meeting was held with the medical director. Review of the facility policy titled, RSV Infection Control Prevention Measures, dated ,d+[DATE], revealed that residents who test positive for RSV will immediately be put in contact plus droplet precautions. Residents that are at high fall risk will be put in isolation and every effort will be made to keep the resident safe. If the resident must be out of their room, staff will make every effort to put the resident in an area away from other residents, encourage the resident to wear a mask, encourage the resident to sanitize their hands. Staff will make every effort to prevent the spread of infection. This deficiency represents noncompliance investigated under Complaint Number OH00150718.

Based on medical record review, review of hospital records, interviews, and facility policy review, the facility failed to provide timely and necessary care and treatment to prevent complications following a fall with injury and changes in resident condition. This resulted in Immediate Jeopardy and serious life-threatening harm on [DATE] when Resident #2 sustained a fall with his left arm assessed to have an area that was raised, red, and warm to touch between his ulna and humerus bone without evidence of additional medical treatment. Between [DATE] and [DATE] Resident #2 continued to exhibit changes in condition including his arm being red, edematous, warm, and tender to touch, Resident #2 was lethargic and experienced episodes of decreased appetite, elevated body temperatures, and decreased oxygen saturation levels. The facility failed to seek medical treatment for Resident #2 until [DATE] (five days later), when Resident #2 was transported to the emergency room (ER). Resident #2 was admitted to the intensive care unit (ICU) with diagnoses of cellulitis and related septic shock. Resident #2 required Levophed (a potent vasoconstrictor used to treat hypotension) intravenous (IV) and IV antibiotics. Resident #2 was hospitalized for four days, returning to the facility on [DATE]. The Immediate Jeopardy and actual harm continued on [DATE] at 1:50 A.M. when Resident #2 was found to be foaming at the mouth with a decreased level of consciousness, and was cold and clammy, lethargic, and difficult to arouse, with a decreased oxygen saturation of 71% on room air, an elevated respiratory rate of 28 and a decreased blood glucose level of 23 milligrams per deciliter (mg/dl) (per the Centers for Disease Control, a blood glucose level below 70 mg/dl is considered hypoglycemia). Glucagon was administered via intramuscular (IM) injection. After 15 minutes, Resident #2's blood glucose level was 66. On [DATE] at 4:05 A.M., Resident #2's blood glucose level was 47 and a second dose of Glucagon IM was administered. After 15 minutes, his blood glucose level was 38 and a third dose of Glucagon was administered. Resident #2 was then administered half packet of oral glucose gel and given orange juice, which resulted in a glucose level of 68. Resident #2 was transferred to the ER by Emergency Medical Services (EMS) at 6:15 A.M. (over four hours after the change in condition was first identified). Resident #2 was admitted to the intensive care unit (ICU) with diagnoses of worsening (left upper extremity [LUE]) cellulitis and severe sepsis. Resident #2 did not return to the facility and expired on [DATE]. Additionally, a concern that did not rise to an Immediate Jeopardy occurred when facility staff failed to adequately monitor and report (to the physician) episodes of hyperglycemia for Resident #1 to properly manage the resident's diagnosis of diabetes mellitus. This affected two residents (#1 and #2) of three residents reviewed for change in condition. The facility census was 77. On [DATE] at 5:20 P.M., the Administrator and the Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] when facility staff failed to timely identify and obtain medical treatment for Resident #2 following an acute change in condition. The facility failed to seek adequate and necessary treatment until [DATE] when Resident #2 was transferred to the emergency room and admitted with cellulitis and related septic shock. Following Resident #2's return to the facility, on [DATE] at 1:50 A.M. the resident exhibited an acute change in condition but was not transferred to the emergency room until 6:15 A.M. (over four hours later) where he was admitted with worsening (LUE) cellulitis and severe sepsis. Resident #2 did not return to the facility and expired on [DATE]. The Immediate Jeopardy was removed on [DATE] when the facility completed the following corrective actions: On [DATE] the facility initiated a Performance Improvement Plan (PIP)/Quality Assurance Performance Improvement (QAPI) for skin prevention. On [DATE], the DON and Interdisciplinary Team (IDT) reviewed the skin care policy and no changes were made. On [DATE], the DON conducted an investigation concerning physician response during Resident #2's change of condition on [DATE]. On [DATE], the DON spoke with Resident #2's physician and voiced concern the on-call practitioner did not respond during a change of status for Resident #2. The practitioner stated that he would look into why no one responded. On [DATE], the DON then contacted the [NAME] President of Nursing for the facility and the facility Medical Director via a conference call. On [DATE], the DON devised a plan of correction (POC) for physician notification with a change of condition. On [DATE], the staff nurse involved in the hypoglycemia incident was educated by the DON on the incident and facility POC. On [DATE], the rolodex on each nurse's unit was updated by the DON with the medical director's name and phone number. On [DATE], a secure conversation was sent out to all nurses' regarding physician notification by the DON, after the message was read, each nurse had to respond through PointClickCare (PCC) to the DON that the message was received and read. On [DATE], the DON and wound nurse completed small huddles with nurses and State-tested Nursing Assistant (STNA) staff regarding importance of preventable skin measures. On [DATE], the facility wound nurse began tracking all skin issues such as, skin tears, abrasions, rashes, etc. The wound nurse would notify the practitioner of new wounds and change in wounds, weekly and as needed. She also would notify the resident power of attorney (POA) weekly of wound status and any changes, unless the POA did not want weekly updates, then it would be documented how often POA would like to be notified. On [DATE] to [DATE], the DON reviewed one-on-one with all professional nurses, the facility skin care policy. On [DATE] and [DATE] the DON conducted official meetings with all nurses addressing physician notification during resident change of status, skin integrity/wounds, falls/injuries, assessments and documentation. The meeting was mandatory with all nurses present on either [DATE] or [DATE]. On [DATE], the IDT met for the first monthly meeting to discuss skin issues and concerns, as well as compare if skin issues improved or worsened for one year. On [DATE] and [DATE], skin sweeps for all residents with the wound nurse and wound practitioner were conducted. Findings were documented in the resident's medical record. If any open areas or concerns, treatments were initiated and POA's were notified. On [DATE], a plan for weekly skin sweeps to be completed by the staff nurse on duty for the shift and day the skin sweep was scheduled. On [DATE], the facility performance improvement plan (PIP) was evaluated by the IDT and facility continued with the current interventions put in place. It was discussed that the IDT would review with the Medical Director compliance and barriers regarding skin assessments during quarterly Quality Assurance (QA) meetings, discussing standards in practice and utilizing any guidance. The facility wound nurse would present findings and initiate any PlP's according to QA discussion. On [DATE], the DON developed a tracking tool to review resident charts to ensure physicians were being notified promptly and resident change of condition was being addressed promptly. On [DATE], the facility implemented a plan for the DON and /or assigned designee to review the 24-hour report in PCC daily to review documentation for any change of status and ensure physician notification was being completed in a timely manner. On [DATE], the facility implemented a plan for the DON and/or designee to address any concerns promptly with the staff, should a concern arise. The IDT will review with the Medical Director compliance and barriers regarding change of condition and physician notification during quarterly QA meetings, discussing standards in practice and utilizing any guidance. The DON would present findings and initiate any PIP's according to QA discussion. On [DATE], a facility Quality Assessment Performance Improvement (QAPI) plan was developed. On [DATE], a tracking log was developed to track blood sugars (BS) of all diabetics to ensure that a practitioner had been properly notified (based on physician orders or facility policy parameters). On [DATE], the facility implemented a plan for the DON and/or designee to audit BS results daily for one year then as needed to ensure physician was notified and policy and procedure followed. If any concerns were observed during the auditing process they would be addressed promptly by the DON and/or designee, as well as education to involved staff. The IDT will review with the Medical Director compliance and barriers regarding Blood Sugar Policy and Procedure during quarterly QA meetings, discussing standards in practice and utilizing any guidance. The DON will present findings and initiate any PIP's according to QA discussion. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1. Review of the closed medical record for Resident #2 revealed an initial admitted [DATE] with diagnoses including mild cognitive impairment, diabetes mellitus, chronic kidney disease, atherosclerotic heart disease, anxiety disorder, and muscle weakness. Review of the medical record revealed Resident #2's physician was Physician #400. Review of Resident #2's care plan, dated [DATE], revealed the resident had diabetes mellitus with interventions including to administer insulin per physician orders, monitor/document/report as needed any side effects and/or effectiveness; and to check all body for breaks in skin and treat promptly as ordered by the physician. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated [DATE], revealed Resident #2 had moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of nine. The assessment revealed Resident #2 required limited, one-person assistance from one staff for bed mobility, transfer, walking corridor, toileting, and personal hygiene. The assessment further indicated the resident sustained one fall since admission/re-entry or prior assessment with no major injury. The resident had no pressure ulcers or other ulcers, wounds, or skin problems. The resident was continent of bowel and bladder. Review of the nursing progress note, dated [DATE] at 9:30 P.M., revealed Resident #2 was found sitting on the floor with his back against his bathroom door. Vital signs were not within normal limits (WNL) with an oxygen (O2) saturation bouncing around in the 70's, blood pressure (BP) ,d+[DATE] (hypotensive), and temperature 98.9 degrees F. The resident's left arm was observed to be raised, red, and warm to touch between his ulna and humerus bone. The resident was noted to be incontinent of bowel movement (BM) at the time of the fall. The physician was notified, and an x-ray was ordered for the left arm. The physician instructed the nurse to continue to monitor the resident closely. Review of the nursing progress note, dated [DATE] at 12:32 P.M., revealed Resident #2 was very lethargic during the shift. His O2 saturation was 86% on room air and oxygen was applied at 2 liters (L) per nasal cannula. The resident was very non-compliant with leaving the nasal cannula on. The resident complained of pain to the LUE and Tylenol was administered. There was no documented evidence that the resident's physician was notified of the low oxygen saturation and complaint of LUE pain. Review of the Medication Administration Record (MAR), dated [DATE], revealed Tylenol 650 milligram (mg) suppository was administered on [DATE] at 1:14 A.M. for a temperature of 100.6 degrees F. Review of the post-fall 72 Hour Neurological assessment dated [DATE] at 1:00 A.M. revealed Resident #2 was hypotensive with a blood pressure (BP) of ,d+[DATE]. At 5:00 A.M. the resident's BP was ,d+[DATE] (hypotensive). There was no documented evidence the resident's physician was notified of the resident's hypotension or that the resident was transferred to the emergency room for evaluation/treatment. Review of the nursing progress note, dated [DATE] at 10:29 A.M., revealed Resident #2's left forearm was red, warm, swollen, and painful to the touch. The nurse's note revealed the resident's physician was updated at that time. A physician's order, dated [DATE], revealed an order for the antibiotic, Clindamycin HCL 300 milligrams (mg) one capsule, three times per day, for cellulitis of the left arm. The physician also provided an order, on [DATE] to cleanse left wrist laceration with normal saline and apply a Vaseline gauze and foam patch each day shift. Review of the Treatment Administration Record (TAR), dated [DATE], revealed the order (obtained [DATE]) to cleanse left wrist laceration with normal saline and apply a Vaseline gauze and foam patch was not initiated until [DATE]. Review of the nursing progress notes revealed Resident #2 sustained two additional falls without injury on [DATE] and [DATE]. Review of the Medication Administration Record, dated [DATE], revealed on [DATE] at 5:00 P.M., Resident #2's blood glucose was 315 and on [DATE] at 8:00 A.M., the blood glucose was 361. There was no documented evidence of the physician being notified of the resident's blood glucose levels greater than 300 per the facility's policy (for hyperglycemia). Review of the nursing progress note, dated [DATE] at 12:54 P.M., revealed Resident #2's left arm remained edematous, red, and warm to touch. The resident required two-person assistance with activities of daily living (ADL) and was incontinent of bowel and bladder. There was no documented evidence that the resident's physician was notified of the continued edema, redness, and warmth of the left arm, continued bowel incontinence, or of the resident's decline in ADL status. There was no evidence the resident was transferred to the emergency room for evaluation/treatment at this time. Review of the nursing progress note, dated [DATE] at 6:10 P.M., revealed Resident #2's left arm continued to be edematous and tight, red, and warm to touch. Inside elbow skin is sloughed off and red, moist skin under. The resident was lethargic. There was no documented evidence that the resident's physician was notified of the continued edema, tightness, redness, warmth, and skin sloughing of the left arm or that the resident was transferred to the emergency room for evaluation/treatment at this time. Review of the nursing progress note, dated [DATE] at 10:07 A.M., revealed Resident #2 refused breakfast and his left arm remained red, warm, edematous, and tender to touch. The dressing was changed to the left wrist wound. There was no documented evidence that the resident's physician was notified of the continued edema, redness, and warmth of the left arm or that the resident was transferred to the emergency room for evaluation/treatment at this time. Review of the nursing progress note, dated [DATE] at 7:28 P.M., revealed Resident #2 was lethargic and difficult to arouse. Cellulitis to the left arm was worsening and he was unable to take oral medication. Resident #2's BP was ,d+[DATE] (hypotensive), pulse 62, respirations 24, temperature 99.9 F, and O2 saturation was 65% (low). The resident's fingers were cold with poor circulation noted. At 4:00 P.M., the resident's blood glucose level was elevated at 232 and his insulin held because the resident had not eaten anything all day and drank very little. The physician was notified at that time and the note indicated the nurse was awaiting a return call. Review of the nursing progress note, dated [DATE] at 7:47 P.M., revealed Resident #2 was transported to the ER by EMS. Review of hospital records, dated [DATE], revealed Resident #2 presented with hypotension and a swollen left arm and forearm and was diagnosed with cellulitis and septic shock. IV fluids and antibiotics per sepsis protocol were initiated in the emergency department (ED). The resident required Levophed IV, a potent vasoconstrictor used to treat hypotension and was admitted to the intensive care unit (ICU) until [DATE]. Review of the nursing progress note, dated [DATE] at 4:30 P.M., revealed Resident #2 returned from the hospital and was readmitted to the skilled nursing facility. Review of the physician order, dated [DATE], revealed the order for the antibiotic, Augmentin oral tablet ,d+[DATE] mg, one tablet every 12 hours for seven days, for cellulitis. Review of a nursing progress note, dated [DATE] at 7:42 P.M., revealed Resident #2 refused his antibiotic Augmentin. There was no documented evidence of the physician being notified of the resident's medication refusal. Review of the Medication Administration Record, dated [DATE], revealed on [DATE] at 5:00 P.M. the resident's blood glucose was 332. There was no documented evidence of the physician being notified of the resident's blood glucose levels greater than 300 per the facility's policy. Review of a nursing progress note, dated [DATE] at 1:50 A.M., revealed Resident #2 was found to be foaming at the mouth with a decreased level of consciousness, and was cold and clammy, lethargic, and hard to arouse. His O2 saturation was 71% on room air and his respiratory rate was 28. An attempt to notify the physician was unsuccessful. Resident #2's blood glucose level was 23 mg/dl (per the Centers for Disease Control, a blood glucose level below 70 mg/dl is considered hypoglycemia) and Glucagon was administered via IM injection. After 15 minutes, at 2:10 A.M. the resident's blood glucose level was 66. At 2:45 A.M., the blood glucose level was 68. Review of a nursing progress note, dated [DATE] at 4:05 A.M., revealed Resident #2's blood glucose level was 47 and a second dose of Glucagon IM was administered. After 15 minutes, his blood glucose level was 38 and a third dose of Glucagon was administered. The resident was then administered half packet of oral glucose gel and given orange juice, which resulted in a glucose level of 68. Further attempts to notify the physician were unsuccessful. The POA was called at 6:15 A.M. and Resident #2 was transferred to the ED by EMS at 6:30 A.M. Review of the hospital history and physical, dated [DATE], revealed Resident #2's chief complaint was worsening shortness of breath and low blood sugar. The resident's white blood cell count was 13.9 (elevated). The LUE had cellulitis from the distal forearm to the proximal humerus with ulcerations noted in the area. The assessment revealed LUE cellulitis, dementia, septic shock, and bilateral pneumonia. The resident did not return to the facility following this hospitalization and expired on [DATE]. Interview on [DATE] at 2:40 P.M., with Registered Nurse (RN) #124 confirmed she authored the nursing progress note, dated [DATE] at 11:46 A.M., which revealed Resident #2 had a left wrist laceration with thick, yellow drainage in the wound bed and redness and warmth was noted in the peri-wound. RN #124 confirmed she did not obtain wound measurements or notify the physician of the thick, yellow drainage to obtain adequate and necessary medical treatment. Interview on [DATE] at 11:15 A.M. with the DON confirmed a thorough skin/wound assessment, including wound measurements, was not completed for Resident #2's left, open wrist wound, nor was there a comprehensive assessment of the LUE cellulitis. The DON confirmed the physician should have been updated regarding any changes of condition or worsening of Resident #2's cellulitis. The DON further confirmed the facility had identified an issue related to Resident #2's incidents of hypoglycemia on [DATE] and the lack of physician response when notification was attempted. The DON stated the nurse should have contacted the resident's POA and sent Resident #2 to the hospital sooner for evaluation when she could not reach the physician. Interview on [DATE] at 12:39 P.M. with Physician #400 revealed he was not notified of Resident #2's continued LUE redness, swelling, edema, and pain following the initiation of the antibiotic Clindamycin. Physician #400 stated that without proper skin assessments, the nursing staff would have been unable to determine if the infection was spreading despite the treatment plan. Physician #400 further stated while he was not sure if anything additional could of have been done in the outpatient setting, he would have sent the resident to the hospital (sooner) and properly adjusted the treatment plan. Physician #400 stated the resident's cellulitis contributed to septic shock because the antibiotic Clindamycin was not strong enough and the patient was not responding and needed IV antibiotics and IV fluids to get out of harm's way. Review of the facility policy titled, Non-Pressure Related Skin Assessment Policy and Procedure, dated [DATE], revealed document any non-pressure skin impairments, notify the physician, initiate treatment and document on the Treatment Administration Record (TAR), notify the family, and evaluate the treatment and effectiveness of treatment, update the physician as needed. Review of the facility policy titled, Blood Sugar Policy, revision date [DATE], revealed the following protocol would be followed concerning blood sugar results by an outside lab, assisted living, or nursing home monitoring system. Hypoglycemia: Administer 15 grams of carbohydrates for a blood sugar below 60 mg/ml and the resident is still alert. Recheck the blood sugar. If hypoglycemic symptoms continue, treat again with carbohydrates. If the hypoglycemia episode was unresolved within one hour, notify the attending or on-call physician. If the resident was unresponsive due to hypoglycemia, administer Glucagon one mg IM per standing order. If hypoglycemia episode was unresolved within one hour, notify the attending or on-call physician. Hyperglycemia: Notify the attending or on-call physician for a blood sugar reading of 300 mg/ml or higher unless physician has given specific blood sugar parameters. Examples of 15 grams of carbohydrates: four ounces of a sugar free supplement, four ounces of orange juice, or one dose of Glutose 45 (a fast-acting glucose gel). 2. Review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia, Alzheimer's disease, diabetes mellitus, anxiety, dysphagia, and chronic kidney disease. Review of the annual Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 99 which indicated the resident could not be interviewed. The assessment revealed Resident #1 was dependent on staff with assistance for eating, toileting, and personal hygiene. The assessment further revealed the resident was always incontinent of bowel and bladder. Review of Resident #1's care plan, dated [DATE], revealed an intervention for fingerstick blood glucose monitoring per physician order/facility policy and as needed and to notify the physician of blood sugar reading below or above specified physician order/facility policy values. Review of the Medication Administration Record, dated [DATE] and [DATE], revealed on [DATE] at 5:00 P.M., Resident #1's blood glucose was 341, on [DATE] at 5:00 P.M., Resident #2's blood glucose was 355, on [DATE] at 5:00 P.M., the blood glucose was 385, on [DATE] at 5:00 P.M., the blood glucose was 305, on [DATE] at 5:00 P.M. the blood glucose was 312, and on [DATE] at 5:00 P.M. at the blood glucose was 420. There was no documented evidence of the physician being notified of Resident #1's blood glucose levels greater than 300 per the facility's policy. Interview on [DATE] at 3:40 P.M. with the Director of Nursing (DON) confirmed Resident #1's physician was not notified of blood glucose levels greater than 300 on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] as indicated in the facility's policy resulting in the resident's diabetes mellitus not being properly managed and monitored. Review of the facility policy titled, Blood Sugar Policy, revision date [DATE], revealed the following protocol would be followed concerning blood sugar results by an outside lab, assisted living, or nursing home monitoring system. Hypoglycemia: Administer 15 grams of carbohydrates for a blood sugar below 60 mg/ml and the resident is still alert. Recheck the blood sugar. If hypoglycemic symptoms continue, treat again with carbohydrates. If the hypoglycemia episode was unresolved within one hour, notify the attending or on-call physician. If the resident was unresponsive due to hypoglycemia, administer Glucagon one mg IM per standing order. If hypoglycemia episode was unresolved within one hour, notify the attending or on-call physician. Hyperglycemia: Notify the attending or on-call physician for a blood sugar reading of 300 mg/ml or higher unless physician has given specific blood sugar parameters. Examples of 15 grams of carbohydrates: four ounces of a sugar free supplement, four ounces of orange juice, or one dose of Glutose 45. This deficiency represents non-compliance investigated under Complaint Number OH00148970.

Based on record review and interview the facility failed to implement an effective plan/policy to prevent recurrence of a system failure that resulted in harm for Resident #5. This affected one resident (#5) and had the potential to affect all 83 residents residing in the facility. Findings included: Review of staff education dated 05/08/23 and 05/12/23 revealed when a resident has a change of condition you would need to notify the physician or the practitioner on call. Physician #501 had a communication book at each nurse station with instructions on how to contact a practitioner. If you were unable to reach a practitioner, then you have to contact the Medical Director and his phone number would be in the rolodex at each nurse's station. If you were unable to get hold of any of the above, contact the family and send them to the emergency department. Notify the nursing if the practitioner did not respond. Review of the undated communication book/form for Physician #501 (Resident #5's physician) revealed please contact the Advance Practice Registered Nurse (APRN) between 3-4:00 P.M. with all issues and as needed for emergent issues only from 6:00 A.M. to 8:00 P.M. Please see the guidelines for provider notification in the communication book. Monday through Friday 8:00 P.M. to 6:00 A.M. and Saturday, Sundays and Holidays call the office answering services (number listed) for the on-call APRN. Do not call or fax the office unless directed to do so (numbers were listed). An additional form in the communication book dated 06/2023 titled After Hours Provider Notification Protocol(8:00 P.M. to 6:00 A.M. weekday, all day on holidays and weekends) revealed the objective was to provide timely, efficient, safe, appropriate patient care by ensuring a thorough situation evaluation before contacting after-hours, on call providers. Purpose: The on-call provider's coverage is to be used for urgent issues that cannot wait until the next day a provider is in the facility or for a daytime call to the managing Advanced Practice Nurse. Information from the facility included the federal regulation regarding Notification of Changes (F517) speaks to the immediate notification which included any significant change any significant change in physical or mental status from baseline. This document was meant to use as a guide and not to replace the need for appropriate discernment to call either 911 or to contact the on-call team in the event the situation was unclear, and the patient was unstable. Included in the communication book was a checklist titled Guideline for Provider Notification dated 06/2023 revealed immediate notification would be a change in condition/mental status, fall with injury requiring further evaluation and treatment and abnormal x-ray (symptomatic and requiring treatment). Review of the facility audits and tracking log for change of condition, as part of the facility Immediate Jeopardy removal plan, dated 12/20/23 to 01/29/24 revealed the tracking form included resident name, change of condition, name of practitioner notified, POA notified, documented, and signature of DON or designee. Record review revealed no evidence a fall with injury, for Resident #5 that occurred on 12/27/23 was noted on the log. Review of a facility Performance Improvement Project (PIP) dated 01/11/24 to 01/23/24 revealed the facility goal was to provide timely and necessary treatment to all residents and timely physician notification. The facility developed a tracking form for the floor nurses to list residents that have had a change in condition. The final measured data was completed on 01/23/24 and all physician notifications were documented to have taken place timely and no concerns with physician response time were identified. Review of facility Quality Assessment Performance Improvement (QAPI) minutes dated 01/22/24, 01/25/24, and 01/29/24 related to the F684 IJ citation revealed the QAPI team reviewed residents, notification, and the 24-hour reports and had no issues noted at this time/or met standards. Interview on 01/30/24 at 12:02 P.M., with Registered Nurse (RN) #163 and the Director of Nursing (DON) verified Resident #5 had fallen on 01/27/24 around 12:30 A.M. They indicated the resident had no visible signs of injuries, however the resident verbalized pain and had facial grimacing with movement. RN #163 attempted to call the on-call provider a few times but had to leave a message with on-call answering services. The on-call APRN did not return his call until around 6:30 A.M. The RN reported he did not know how to handle the situation because he was an emergency nurse, and this was new to him. He did not know who the medical director was until this date and he did not have his number to call him. The RN also reported he did not reach out to the DON or nursing supervisor when he was not able to reach a provider for guidance. The RN confirmed the fall was not documented in the resident's electronic medical record. The interview was reviewed with the RN and DON to confirm accuracy of the interview. The RN confirmed the accuracy of the interview. Interview on 01/30/24 at 12:03 P.M. and 1:02 P.M., with the DON revealed RN #163 should have called herself or the medical director when the on-call provider did not return his call timely. The DON reported the medical director's number was in the rolodex and staff had been educated on notification as part of the plan of correction for the surveyor that was completed on 12/27/23. The DON confirmed the change of condition log, which was part of the facility plan of correction, included falls, skin, etc. did not include Resident #5's fall because it did not trigger the 24-hour report due to the nurse not documenting the fall in the resident's medical record. The interview was reviewed with the DON to confirm accuracy of the interview. The DON confirmed accuracy of the interview. Interview on 01/30/24 at 2:07 P.M., with the DON revealed the facility uses an on-call provider system after hours. Medical Director #500 and Physician #501 were a part of the on-call system. As part of the facility plan of correction for the Immediate Jeopardy that the facility received on 12/27/23 if there was urgent issue the nurse was to ensure the provider would respond in 20 minutes and if was a non-urgent issue the staff were to keep trying to call. The resident (Resident #5) who had a suspected fracture and needed an x-ray would have been an urgent issue. The interview was reviewed with the DON to confirm accuracy of the interview. The DON confirmed accuracy of the interview. Interview on 01/30/24 at 3:11 P.M. with the Administrator revealed the on-call system was a group of providers who cover for one another. Some of the providers did not provide services to the residents except for answering the on-calls that come in. Sometimes the providers would answer calls and sometimes it would go to an answering service, and the answering service would contact the one call provider. The facility expected the provider to call back within 20 minutes if there was an adverse effect. The Administrator verified Resident #5's fall with possible fracture suspected would be an example of an adverse event. The nurse should notify the family or send the resident to the emergency room if an adverse event occurs, and the provider doesn't return a call. The interview was reviewed with the Administrator to confirm accuracy of the interview. The Administrator confirmed the accuracy of the interview. Review of the facility undated policy titled QAPI Policy and Procedure revealed the PIPs data source included survey findings. The committee would consider and prioritize both external and internal elements affecting the long-term care industry and facility when selecting priorities of focus for the coming year. Once the PIP had been approved, the QAPI Committee would establish a QAPI charter, timeline, and to allocate staff and resources prior to the launch of the PIP. The PIP team members would be selected based on scope of the work, considering such factors as time commitment and expertise. Whenever possible, the facility should consider a resident/family advisor to be appointed to the team. Meeting minutes would be recorded and shared with the QAPI Steering Committee, Executive Leadership, and staff. The facility would use data from every QAPI Steering Committee to ensure performance measures are meeting QAPI Goals. PSDA cycles would be utilized to improve existing processes. Data specific to the PDSA intervention would be collected and monitored to the end of each cycle. Since PDSA cycles were dynamic and current, data collected during these intervention periods would be analyzed on a frequency designated by the PIP team and/or QAPI Committee that would be useful for making mid-cycle adjustments. The PDSA cycle outcomes would be reported to the QAPI Committee at least quarterly; however, more frequent monitoring may be required for rapid cycle PDSA cycles of change to capture the impact of the change once the intervention was spread across the facility.

Based on record review and interview the facility failed to implement an effective plan/policy to prevent recurrence of a system failure that resulted in harm for Resident #5. This affected one resident (#5) and had the potential to affect all 83 residents residing in the facility. Findings included: Review of staff education dated 05/08/23 and 05/12/23 revealed when a resident has a change of condition you would need to notify the physician or the practitioner on call. Physician #501 had a communication book at each nurse station with instructions on how to contact a practitioner. If you were unable to reach a practitioner, then you have to contact the Medical Director and his phone number would be in the rolodex at each nurse's station. If you were unable to get hold of any of the above, contact the family and send them to the emergency department. Notify the nursing if the practitioner did not respond. Review of the undated communication book/form for Physician #501 (Resident #5's physician) revealed please contact the Advance Practice Registered Nurse (APRN) between 3-4:00 P.M. with all issues and as needed for emergent issues only from 6:00 A.M. to 8:00 P.M. Please see the guidelines for provider notification in the communication book. Monday through Friday 8:00 P.M. to 6:00 A.M. and Saturday, Sundays and Holidays call the office answering services (number listed) for the on-call APRN. Do not call or fax the office unless directed to do so (numbers were listed). An additional form in the communication book dated 06/2023 titled After Hours Provider Notification Protocol(8:00 P.M. to 6:00 A.M. weekday, all day on holidays and weekends) revealed the objective was to provide timely, efficient, safe, appropriate patient care by ensuring a thorough situation evaluation before contacting after-hours, on call providers. Purpose: The on-call provider's coverage is to be used for urgent issues that cannot wait until the next day a provider is in the facility or for a daytime call to the managing Advanced Practice Nurse. Information from the facility included the federal regulation regarding Notification of Changes (F517) speaks to the immediate notification which included any significant change any significant change in physical or mental status from baseline. This document was meant to use as a guide and not to replace the need for appropriate discernment to call either 911 or to contact the on-call team in the event the situation was unclear, and the patient was unstable. Included in the communication book was a checklist titled Guideline for Provider Notification dated 06/2023 revealed immediate notification would be a change in condition/mental status, fall with injury requiring further evaluation and treatment and abnormal x-ray (symptomatic and requiring treatment). Review of the facility audits and tracking log for change of condition, as part of the facility Immediate Jeopardy removal plan, dated 12/20/23 to 01/29/24 revealed the tracking form included resident name, change of condition, name of practitioner notified, POA notified, documented, and signature of DON or designee. Record review revealed no evidence a fall with injury, for Resident #5 that occurred on 12/27/23 was noted on the log. Review of a facility Performance Improvement Project (PIP) dated 01/11/24 to 01/23/24 revealed the facility goal was to provide timely and necessary treatment to all residents and timely physician notification. The facility developed a tracking form for the floor nurses to list residents that have had a change in condition. The final measured data was completed on 01/23/24 and all physician notifications were documented to have taken place timely and no concerns with physician response time were identified. Review of facility Quality Assessment Performance Improvement (QAPI) minutes dated 01/22/24, 01/25/24, and 01/29/24 related to the F684 IJ citation revealed the QAPI team reviewed residents, notification, and the 24-hour reports and had no issues noted at this time/or met standards. Interview on 01/30/24 at 12:02 P.M., with Registered Nurse (RN) #163 and the Director of Nursing (DON) verified Resident #5 had fallen on 01/27/24 around 12:30 A.M. They indicated the resident had no visible signs of injuries, however the resident verbalized pain and had facial grimacing with movement. RN #163 attempted to call the on-call provider a few times but had to leave a message with on-call answering services. The on-call APRN did not return his call until around 6:30 A.M. The RN reported he did not know how to handle the situation because he was an emergency nurse, and this was new to him. He did not know who the medical director was until this date and he did not have his number to call him. The RN also reported he did not reach out to the DON or nursing supervisor when he was not able to reach a provider for guidance. The RN confirmed the fall was not documented in the resident's electronic medical record. The interview was reviewed with the RN and DON to confirm accuracy of the interview. The RN confirmed the accuracy of the interview. Interview on 01/30/24 at 12:03 P.M. and 1:02 P.M., with the DON revealed RN #163 should have called herself or the medical director when the on-call provider did not return his call timely. The DON reported the medical director's number was in the rolodex and staff had been educated on notification as part of the plan of correction for the surveyor that was completed on 12/27/23. The DON confirmed the change of condition log, which was part of the facility plan of correction, included falls, skin, etc. did not include Resident #5's fall because it did not trigger the 24-hour report due to the nurse not documenting the fall in the resident's medical record. The interview was reviewed with the DON to confirm accuracy of the interview. The DON confirmed accuracy of the interview. Interview on 01/30/24 at 2:07 P.M., with the DON revealed the facility uses an on-call provider system after hours. Medical Director #500 and Physician #501 were a part of the on-call system. As part of the facility plan of correction for the Immediate Jeopardy that the facility received on 12/27/23 if there was urgent issue the nurse was to ensure the provider would respond in 20 minutes and if was a non-urgent issue the staff were to keep trying to call. The resident (Resident #5) who had a suspected fracture and needed an x-ray would have been an urgent issue. The interview was reviewed with the DON to confirm accuracy of the interview. The DON confirmed accuracy of the interview. Interview on 01/30/24 at 3:11 P.M. with the Administrator revealed the on-call system was a group of providers who cover for one another. Some of the providers did not provide services to the residents except for answering the on-calls that come in. Sometimes the providers would answer calls and sometimes it would go to an answering service, and the answering service would contact the one call provider. The facility expected the provider to call back within 20 minutes if there was an adverse effect. The Administrator verified Resident #5's fall with possible fracture suspected would be an example of an adverse event. The nurse should notify the family or send the resident to the emergency room if an adverse event occurs, and the provider doesn't return a call. The interview was reviewed with the Administrator to confirm accuracy of the interview. The Administrator confirmed the accuracy of the interview. Review of the facility undated policy titled QAPI Policy and Procedure revealed the PIPs data source included survey findings. The committee would consider and prioritize both external and internal elements affecting the long-term care industry and facility when selecting priorities of focus for the coming year. Once the PIP had been approved, the QAPI Committee would establish a QAPI charter, timeline, and to allocate staff and resources prior to the launch of the PIP. The PIP team members would be selected based on scope of the work, considering such factors as time commitment and expertise. Whenever possible, the facility should consider a resident/family advisor to be appointed to the team. Meeting minutes would be recorded and shared with the QAPI Steering Committee, Executive Leadership, and staff. The facility would use data from every QAPI Steering Committee to ensure performance measures are meeting QAPI Goals. PSDA cycles would be utilized to improve existing processes. Data specific to the PDSA intervention would be collected and monitored to the end of each cycle. Since PDSA cycles were dynamic and current, data collected during these intervention periods would be analyzed on a frequency designated by the PIP team and/or QAPI Committee that would be useful for making mid-cycle adjustments. The PDSA cycle outcomes would be reported to the QAPI Committee at least quarterly; however, more frequent monitoring may be required for rapid cycle PDSA cycles of change to capture the impact of the change once the intervention was spread across the facility.

Based on record review, review of physician's communication book, review of staff education, interviews, and policy review the facility to ensure the resident physician was notified timely of fall with suspected injury. This affected one resident (#5) of three residents reviewed for change of condition. Findings included: Record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including dementia, Alzheimer's, chronic pain, polyosteoathritis, generalized anxiety, age related osteoporosis without current pathological fracture, and repeated falls. There was no evidence the diagnoses list was updated to reflect the acute left hip fracture and left superior pubic ramus fracture that occurred on 01/27/24. Review of Resident #5's risk management report form (not part of the resident's medical record) dated 01/27/24 at 12:30 A.M. authored by Registered Nurse (RN) #163 revealed this RN was called to the resident room by State Tested Nurse's Aide (STNA). The resident was sitting on the floor next to the bed. Resident vitals were taken at this time (temperature was 97.7, respirations were 18, oxygen saturation was 94% room air, heart rate 89, and blood pressure was 174/87). Resident was alert to self. Pupils equal, round, reactive, light, and Accommodation (PERRLA). No visible injury was noted at this time. Resident complains of left hip pain. Resident stated that she was trying to get to the bathroom. The resident denied hitting her head. Reminded resident not to attempt to get out of bed without assistance. Pain level was a 10 and she was alert and oriented to the person only. Unable to determine the injury type but the location was in the left gluteal fold. The resident was noted to be wheelchair bound. There were no environmental factors noted. The predisposing physiological factors included the resident was confused, incontinent, and had gait imbalance. The predisposing factors indicating the resident ambulated without assist. The on-call service was notified at 12:40 A.M. and the POA at 12:41 A.M. At the bottom of the fall investigation report form it indicated the report was privileged and confidential - not part of the medical record- do not copy. Review of Resident #5's electronic medical record dated 01/22/24 to 01/30/24 revealed no evidence of details of the fall including notification, time of fall, assessment, etc. regarding the resident's fall on 01/27/24. Review of the hospital/transfer form dated 01/27/24 at 2:11 P.M., revealed the resident was going to be transferred to the hospital emergency room. The resident was alert and confused. There was a change in confusion compared to the baseline. The resident had a fall. There was an additional note that indicated the resident had fallen around 1:00 A.M. and a bedside x-ray was obtained of the left hip for complaints of pain. The x-ray results showed an acute left hip fracture. The on-called Certified Nurse Practitioner (CNP) #502 was updated on results and order given to send to the emergency room for evaluation. The Power of Attorney (POA) was updated on and agreeable with decision. Regional emergency management services (EMS) were notified. Interview on 01/30/24 at 12:02 P.M., with RN #163 and the Director of Nursing (DON) revealed the resident had fallen around 12:30 A.M. The resident had no visible signs of injuries, however the resident verbalized pain and had facial grimacing with movement. He attempted to call the on-call provider a few times but had to leave a message with on-call answering services. The on-call APRN did not return his call until around 6:30 A.M. The RN reported he did not know how to handle the situation because he was an emergency nurse, and this was new to him. He did not know who the medical director was until today and he did not have his number to call him. The RN also reported he did not reach out to the DON or nursing supervisor when he was not able to reach a provider for guidance. The RN confirmed the fall was not documented in the resident's electronic medical record. The interview was reviewed with the RN and DON to confirm accuracy of the interview. The RN confirmed the accuracy of the interview. Interview on 01/30/24 at 12:03 P.M. and 1:02 P.M., with the DON revealed RN #163 should have called herself or the medical director when the on-call provider did not return his call timely. The DON reported the medical director's number was in the rolodex and staff had been educated on notification as part of the plan of correction for the surveyor that was completed on 12/27/23. The DON confirmed the change of condition log, which was part of the facilities plan of correction, included falls, skin, etc. did not include Resident #5's fall due it did not trigger the 24 hour report due the nurse not documenting the fall in the residents medical record. The interview was reviewed with the DON to confirm accuracy of the interview. The DON confirmed accuracy of the interview. Interview on 01/30/24 at 2:07 P.M., with the DON revealed the facility uses an on-call provider system after hours. The Medical Director #500 and Physician #501 were a part of the on-call system. As part of the plan of correction for the Immediate Jeopardy that the facility received on 12/27/23 was if there was urgent issue the nurse was to ensure the provider would respond in 20 minutes and if was a non-urgent issue the staff were to keep trying to call. The resident (Resident #5) that had a suspected fracture and needing an x-ray would have been an urgent issue. The interview was reviewed with the DON to confirm accuracy of the interview. The DON confirmed accuracy of the interview. Interview on 01/30/24 at 3:11 P.M. with the Administrator revealed the on-call system was a group of providers that cover for one another. Some of the provider due not provided services to the residents except for answering the on-calls that come in. Sometimes the providers will answer calls and sometimes it will go to an answering service, and the answering service would contact the one call provider. The facility except the provider to call back within 20 minutes if there was an adverse effect. Resident #5's fall with possible fracture suspected would be an example of an adverse event. The nurse should notify the family or send the resident to the emergency room if an adverse event occurs and the provider doesn't return a call. The interview was reviewed with the Administrator to confirm accuracy of the interview. The Administrator confirmed accuracy of the interview. Review of the facility policy for falls management (dated 10/2023) revealed the nurse must notify the physician promptly by telephone. The nurse must notify the physician if any injury is obtained. Review of staff education (dated 05/08/23 and 05/12/23) revealed when a resident has a change of condition you would need to notify the physician or the practitioner on call. Physician #501 had a communication book at each nurse station with instructions on how to contact a practitioner. If you are unable to reach a practitioner, then you have to contact the Medical Director and his phone number will be in the rolodex at each nurse's station. If you were unable to get hold of any of the above, contact the family and send them to the emergency department. Notify the nursing if the practitioner did not respond. Review of the communication book/form for Physician #501 (Resident #5's physician) (undated) revealed please contact the Advance Practice Registered Nurse (APRN) between 3-4:00 P.M. with all issues and as needed for emergent issues only from 6:00 A.M. to 8:00 P.M. Please see the guidelines for provider notification in the communication book. Monday through Friday 8:00 P.M. to 6:00 A.M. and Saturday, Sundays and Holidays call the office answering services (number listed) for the on call APRN. Do not call or fax the office unless directed to do so (numbers were listed). Additional form in the communication book dated 06/2023 titled After Hours Provider Notification Protocol(8:00 P.M. to 6:00 A.M. weekday, all day on holidays and weekends) revealed the objective was to provide timely, efficient, safe, appropriate patient care by ensuring a thorough situation evaluation before contacting after-hours, on call providers. Purpose: The on-call provider's coverage is to be used for urgent issues that cannot wait until the next day a provider is in the facility or for a daytime call to the managing Advanced Practice Nurse. The federal regulation regarding Notification of Changes (F517) speaks to the immediate notification which included any significant change any significant change in physical or mental status from baseline. This document was meant to use as a guide and not to replace the need for appropriate discernment to call either 911 or to contact the on-call team in the event the situation was unclear, and the patient was unstable. Included in the communication book was a checklist titled Guideline for Provider Notification dated 06/2023 revealed immediate notification would be a change in condition/mental status, fall with injury requiring further evaluation and treatment and abnormal x-ray (symptomatic and requiring treatment). Review of the facility audits and tracking log for change of condition (part of the Immediate Jeopardy removal plan) dated 12/20/23 to 01/29/24 revealed no evidence of Resident #5's fall with major injury was noted on the log. The tracking form included resident name, change of condition, name of practitioner notified, POA notified, documented, and signature of DON or designee.

Based on record review, review of physician's communication book, review of staff education, interviews, and policy review the facility to ensure the resident physician was notified timely of fall with suspected injury. This affected one resident (#5) of three residents reviewed for change of condition. Findings included: Record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including dementia, Alzheimer's, chronic pain, polyosteoathritis, generalized anxiety, age related osteoporosis without current pathological fracture, and repeated falls. There was no evidence the diagnoses list was updated to reflect the acute left hip fracture and left superior pubic ramus fracture that occurred on 01/27/24. Review of Resident #5's risk management report form (not part of the resident's medical record) dated 01/27/24 at 12:30 A.M. authored by Registered Nurse (RN) #163 revealed this RN was called to the resident room by State tested Nurse's Aide (STNA). The resident was sitting on the floor next to the bed. Resident vitals were taken at this time (temperature was 97.7, respirations were 18, oxygen saturation was 94% room air, heart rate 89, and blood pressure was 174/87). Resident was alert to self. Pupils equal, round, reactive, light, and Accommodation (PERRLA). No visible injury was noted at this time. Resident complains of left hip pain. Resident stated that she was trying to get to the bathroom. The resident denied hitting her head. Reminded resident not to attempt to get out of bed without assistance. Pain level was a 10 and she was alert and oriented to the person only. Unable to determine the injury type but the location was in the left gluteal fold. The resident was noted to be wheelchair bound. There were no environmental factors noted. The predisposing physiological factors included the resident was confused, incontinent, and had gait imbalance. The predisposing factors indicating the resident ambulated without assist. The on-call service was notified at 12:40 A.M. and the POA at 12:41 A.M. At the bottom of the fall investigation report form it indicated the report was privileged and confidential - not part of the medical record- do not copy. Review of Resident #5's electronic medical record dated 01/22/24 to 01/30/24 revealed no evidence of details of the fall including notification, time of fall, assessment, etc. regarding the resident's fall on 01/27/24. Review of the hospital/transfer form dated 01/27/24 at 2:11 P.M., revealed the resident was going to be transferred to the hospital emergency room . The resident was alert and confused. There was a change in confusion compared to the baseline. The resident had a fall. There was an additional note that indicated the resident had fallen around 1:00 A.M. and a bedside x-ray was obtained of the left hip for complaints of pain. The x-ray results showed an acute left hip fracture. The on-called Certified Nurse Practitioner (CNP) #502 was updated on results and order given to send to the emergency room for evaluation. The Power of Attorney (POA) was updated on and agreeable with decision. Regional emergency management services (EMS) were notified. Interview on 01/30/24 at 12:02 P.M., with RN #163 and the Director of Nursing (DON) revealed the resident had fallen around 12:30 A.M. The resident had no visible signs of injuries, however the resident verbalized pain and had facial grimacing with movement. He attempted to call the on-call provider a few times but had to leave a message with on-call answering services. The on-call APRN did not return his call until around 6:30 A.M. The RN reported he did not know how to handle the situation because he was an emergency nurse, and this was new to him. He did not know who the medical director was until today and he did not have his number to call him. The RN also reported he did not reach out to the DON or nursing supervisor when he was not able to reach a provider for guidance. The RN confirmed the fall was not documented in the resident's electronic medical record. The interview was reviewed with the RN and DON to confirm accuracy of the interview. The RN confirmed the accuracy of the interview. Interview on 01/30/24 at 12:03 P.M. and 1:02 P.M., with the DON revealed RN #163 should have called herself or the medical director when the on-call provider did not return his call timely. The DON reported the medical director's number was in the rolodex and staff had been educated on notification as part of the plan of correction for the surveyor that was completed on 12/27/23. The DON confirmed the change of condition log, which was part of the facilities plan of correction, included falls, skin, etc. did not include Resident #5's fall due it did not trigger the 24 hour report due the nurse not documenting the fall in the residents medical record. The interview was reviewed with the DON to confirm accuracy of the interview. The DON confirmed accuracy of the interview. Interview on 01/30/24 at 2:07 P.M., with the DON revealed the facility uses an on-call provider system after hours. The Medical Director #500 and Physician #501 were a part of the on-call system. As part of the plan of correction for the Immediate Jeopardy that the facility received on 12/27/23 was if there was urgent issue the nurse was to ensure the provider would respond in 20 minutes and if was a non-urgent issue the staff were to keep trying to call. The resident (Resident #5) that had a suspected fracture and needing an x-ray would have been an urgent issue. The interview was reviewed with the DON to confirm accuracy of the interview. The DON confirmed accuracy of the interview. Interview on 01/30/24 at 3:11 P.M. with the Administrator revealed the on-call system was a group of providers that cover for one another. Some of the provider due not provided services to the residents except for answering the on-calls that come in. Sometimes the providers will answer calls and sometimes it will go to an answering service, and the answering service would contact the one call provider. The facility except the provider to call back within 20 minutes if there was an adverse effect. Resident #5's fall with possible fracture suspected would be an example of an adverse event. The nurse should notify the family or send the resident to the emergency room if an adverse event occurs and the provider doesn't return a call. The interview was reviewed with the Administrator to confirm accuracy of the interview. The Administrator confirmed accuracy of the interview. Review of the facility policy for falls management (dated 10/2023) revealed the nurse must notify the physician promptly by telephone. The nurse must notify the physician if any injury is obtained. Review of staff education (dated 05/08/23 and 05/12/23) revealed when a resident has a change of condition you would need to notify the physician or the practitioner on call. Physician #501 had a communication book at each nurse station with instructions on how to contact a practitioner. If you are unable to reach a practitioner, then you have to contact the Medical Director and his phone number will be in the rolodex at each nurse's station. If you were unable to get hold of any of the above, contact the family and send them to the emergency department. Notify the nursing if the practitioner did not respond. Review of the communication book/form for Physician #501 (Resident #5's physician) (undated) revealed please contact the Advance Practice Registered Nurse (APRN) between 3-4:00 P.M. with all issues and as needed for emergent issues only from 6:00 A.M. to 8:00 P.M. Please see the guidelines for provider notification in the communication book. Monday through Friday 8:00 P.M. to 6:00 A.M. and Saturday, Sundays and Holidays call the office answering services (number listed) for the on call APRN. Do not call or fax the office unless directed to do so (numbers were listed). Additional form in the communication book dated 06/2023 titled After Hours Provider Notification Protocol(8:00 P.M. to 6:00 A.M. weekday, all day on holidays and weekends) revealed the objective was to provide timely, efficient, safe, appropriate patient care by ensuring a thorough situation evaluation before contacting after-hours, on call providers. Purpose: The on-call provider's coverage is to be used for urgent issues that cannot wait until the next day a provider is in the facility or for a daytime call to the managing Advanced Practice Nurse. The federal regulation regarding Notification of Changes (F517) speaks to the immediate notification which included any significant change any significant change in physical or mental status from baseline. This document was meant to use as a guide and not to replace the need for appropriate discernment to call either 911 or to contact the on-call team in the event the situation was unclear, and the patient was unstable. Included in the communication book was a checklist titled Guideline for Provider Notification dated 06/2023 revealed immediate notification would be a change in condition/mental status, fall with injury requiring further evaluation and treatment and abnormal x-ray (symptomatic and requiring treatment). Review of the facility audits and tracking log for change of condition (part of the Immediate Jeopardy removal plan) dated 12/20/23 to 01/29/24 revealed no evidence of Resident #5's fall with major injury was noted on the log. The tracking form included resident name, change of condition, name of practitioner notified, POA notified, documented, and signature of DON or designee.

Based on record review and interview, the facility failed to ensure Resident #2 had a physician order and care plan for oxygen therapy. This affected one (Resident #2) of three residents reviewed for respiratory care. The facility census was 77. Findings include: Review of the closed medical record for Resident #2 revealed an initial admitted [DATE] with diagnoses including mild cognitive impairment, diabetes mellitus, chronic kidney disease, atherosclerotic heart disease, anxiety disorder, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 03/09/23, revealed Resident #2 had moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of nine. The assessment revealed Resident #2 required limited, one-person assistance from one staff for bed mobility, transfer, walking corridor, toileting, and personal hygiene. Review of Resident #2's physician orders prior to 04/14/23 revealed no orders for the administration of oxygen therapy. An order for oxygen was given on 04/14/23 and indicated oxygen at 2 liters per minute as needed (prn) for shortness of breath for three days. Review of the care plan, dated 04/14/23, revealed Resident #2 had shortness of breath related to low oxygen with the intervention for oxygen at 2 liters/minute per nasal cannula. Further review of Resident #2's care plans prior to 04/14/23 revealed no interventions for oxygen therapy. Review of the nursing progress note, dated 04/04/23 at 9:30 P.M., revealed Resident #2 was found sitting on the floor with his back against his bathroom door. Vital signs were not within normal limits (WNL) with an oxygen (O2) saturation bouncing around in the 70's, blood pressure (BP) 80/62, and temperature 98.9 degrees Fahrenheit (F). O2 at five liters (L) infused per nasal cannula (NC). Review of the nursing progress note, dated 04/05/23 at 12:32 P.M., revealed Resident #2's O2 saturation was 86% and oxygen was infusing at 2 L per NC. Review of the nursing progress note, dated 04/09/23 at 7:28 P.M., revealed Resident #2's O2 saturation was 65% and oxygen was infusing at 2 L per NC. Interview on 12/18/23 at 11:15 A.M. with the Director of Nursing (DON) confirmed Resident #2 received oxygen therapy on 04/04/23, 04/05/23, and 04/09/23 without a physician's order. This deficiency represents non-compliance investigated under Complaint Number OH00148970.

Based on record review, review of risk management report, review of hospital records, interview, and policy review the facility failed to implement an effective pain management program for one resident (Resident #5) after sustaining a fall with fracture. This affected one (#5) of three residents reviewed for change of condition. Findings included: Record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including dementia, Alzheimer's, chronic pain, polyosteoathritis, generalized anxiety, age-related osteoporosis without current pathological fracture, and repeated falls. There was no evidence the diagnoses list was updated to include the acute left hip fracture and left superior pubic ramus fracture that occurred on 01/27/24. Review of Resident #5's quarterly Minimum Data Set (MDS) 3.0 dated 10/21/23 revealed the resident's speech was unclear and had minimal difficulty hearing. She could sometimes make herself understood and sometimes understood others. She had impaired vision and no corrective lenses. The resident's brief interview for mental status (BIMS) score was three, which indicated she had severe cognition impairment. The resident had inattention and disorganized thinking behaviors that fluctuated (comes and goes, changes in severity). The resident was dependent on staff for all activities of daily living except when she required substantial/maximal assistance with eating. The resident was always incontinent of urine and bowel. The resident was on a scheduled pain manage regimen; however, a pain assessment interview was not conducted due to the resident being rarely/never understood. The staff pain assessment was not completed as well due to there being no signs or symptoms of pain observed or documented. Resident #5 had two falls with no injuries since the last admission/entry. The resident was marked to be on high-risk drug classes of antianxiety and antidepressants. The resident used a manual wheelchair. Review of Resident #5 chronic pain plan of care initiated on 07/15/20 and revised on 11/23/22 related to fibromyalgia and polyosteoathritis revealed to plan heavy care when pain was controlled, administer Biofreeze, Gabapentin, Tylenol, and Percocet per physician orders and monitor/document/report as needed for any side effects and or effectiveness (revised on 01/30/24), consult pain management, monitor/report/record to nurse any sign or symptoms of non-verbal pain (changes in breathing, vocalization, mood/behavior, eyes, face, body), offer rest periods as indicated. Review of Resident #5's risk management report form (not part of the medical record) dated 01/27/24 at 12:30 A.M. authored by Registered Nurse (RN) #163 revealed this RN was called to the resident room by State tested Nurse's Aide (STNA). The resident was sitting on the floor next to the bed. Resident vitals were taken at this time (temperature was 97.7, respirations were 18, oxygen saturation was 94% room air, heart rate 89, and blood pressure was 174/87). Resident was alert to self. Pupils equal, round, reactive, light, and Accommodation (PERRLA). No visible injury was noted at this time. Resident complains of left hip pain. Resident stated that she was trying to get to the bathroom. The resident denied hitting her head. Reminded resident not to attempt to get out of bed without assistance. Pain level was a 10 and she was alert and oriented to the person only. Unable to determine the injury type but the location was in the left gluteal fold. The resident was noted to be wheelchair bound. There were no environmental factors noted. The predisposing physiological factors included the resident was confused, incontinent, and had gait imbalance. The predisposing factors indicated the resident ambulated without assist. The on-call service was notified at 12:40 A.M. and the power of attorney (POA) at 12:41 A.M. At the bottom of the fall investigation report form it indicated the report was privileged and confidential - not part of the medical record- do not copy. Review of Resident #5's electronic medical record dated 01/22/24 to 01/30/24 revealed no evidence of details of the fall including provider notification, time of fall, assessment, orders, etc. regarding the resident's fall on 01/27/24. Review of Resident #5's x-ray results dated 01/27/24 at 1:37 P.M., revealed a nondisplaced fracture of the left intertrochanteric region was noted. A mildly displaced left superior pubic ramus fracture was noted. Diffuse osteopenia was noted. Impression acute left hip fractures of the left superior pubic ramus fracture. Review of Resident #5's hospital notes dated 01/27/24 revealed the x-ray showed acute moderately displaced left intertrochanteric proximal femur fracture and acute moderately displaced fracture of the left superior and inferior pubic rami. The resident's face pain assessment for the left hip was 10 out of 10 at 3:12 P.M and 3:50 P.M. The resident was given intravenous Fentanyl and Zofran for pain. The left leg was shortened and rotated. The resident had lumbar pain and neck pain and c-collar was applied. The discharge instruction was to call Physician #501 in one day for palliative care due to the resident being a surgical candidate. The final diagnoses was closed traumatic displaced intertrochanteric fracture of left femur and closed fracture of multiple rami of left pubic. Review of Resident #5's current orders dated 01/2024 revealed on 01/27/24 the resident was ordered Percocet 5/235 milligrams (mg) every six hours as needed for pain. On 11/23/20 she was ordered Tylenol Extra Strength 500 mg and by mouth twice daily for pain and two every 8 hours as needed for pain. Also, on 11/23/20 was an order for Gabapentin 100 mg one capsule twice a day and two at bedtime for pain. Review of Resident #5's medication administration records (MAR) dated 01/27/24 to 01/31/24 revealed the resident had received one dose of Percocet 5-325 mg on 01/27/24 at 9:52 P.M. for a pain level of 3 out of 10, three doses on 01/28/24 (3:52 A.M. pain level two out of 10, noon for pain level of eight out of 10, 6:06 P.M. for pain level four out of 10), three doses on 01/29/24 (6:16 A.M. for pain level one out of 10, 12:20 P.M. for pain level eight out of 10, and 9:40 for pain five out of 10) and three doses on 01/30/24 (4:55 A.M. for pain level of eight out 10, 11:05 A.M. for pain level of seven out of 10, and 10:30 P.M. for a pain level of four out of 10). All Percocet administration doses indicated the medication was effective. There was no pain number listed for the effectiveness. There was no evidence the as needed Tylenol was administered after the resident returned from the hospital or parameters for when to administer the Tylenol versus the Percocet for pain. Review of Resident #5's administration/progress notes dated 01/27/24 to 01/31/24 revealed the nurse called Certified Nurse Practitioner (CNP) #502 to obtain order for Percocet after the resident returned from the hospital due to she was restless. On 01/27/24 at 9:52 P.M. Resident #5 received Percocet for a pain level of 3 out of 10. At 12:20 A.M. the follow up pain was four out of 10 (which was higher than prior to administration) and the nurse documented the pain medication was effective. Further review of progress note dated 01/31/24 at 3:00 A.M. revealed the resident was noted to be yelling out and upon entering the room the resident was noted to be grimacing and squeezing the STNA hands. Resident #5 was not able to voice needs due to her severe dementia. The on-call provider was called and received a one time order to administer an additional Percocet 5/235 mg. Currently, working on obtaining authorization to pull from mediwise due to the resident was out of Percocet. (There was no evidence the as needed Tylenol was utilized). There was no documented evidence on the MAR or progress note indicating non-pharmacological interventions were attempted prior to administering pain medications. Review of the facility policy titled Pain Management Policy (dated 10/2023) revealed the purpose was to provide resident comfort with care. The procedure included: the resident would be assessed for complaints and/or signs and symptoms of pain upon admission and as indicated. Pain assessment will be completed five days after admission and quarterly. The interdisciplinary care plan team will initiate and implement a pain management plan of care. Pain interventions will be monitored for effectiveness by Nursing. The physician will be notified as indicated. Interview and review of Resident #5's MAR on 01/31/24 at 10:27 A.M., with LPN #165 and the DON confirmed there should be parameters when to administer the Tylenol versus the Percocet and they would call the provider to get clarification.

Based on record review, review of risk management report, review of hospital records, interview, and policy review the facility failed to implement an effective pain management program for one resident (Resident #5) after sustaining a fall with fracture. This affected one (#5) of three residents reviewed for change of condition. Findings included: Record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including dementia, Alzheimer's, chronic pain, polyosteoathritis, generalized anxiety, age-related osteoporosis without current pathological fracture, and repeated falls. There was no evidence the diagnoses list was updated to include the acute left hip fracture and left superior pubic ramus fracture that occurred on 01/27/24. Review of Resident #5's quarterly Minimum Data Set (MDS) 3.0 dated 10/21/23 revealed the resident's speech was unclear and had minimal difficulty hearing. She could sometimes make herself understood and sometimes understood others. She had impaired vision and no corrective lenses. The resident's brief interview for mental status (BIMS) score was three, which indicated she had severe cognition impairment. The resident had inattention and disorganized thinking behaviors that fluctuated (comes and goes, changes in severity). The resident was dependent on staff for all activities of daily living except when she required substantial/maximal assistance with eating. The resident was always incontinent of urine and bowel. The resident was on a scheduled pain manage regimen; however, a pain assessment interview was not conducted due to the resident being rarely/never understood. The staff pain assessment was not completed as well due to there being no signs or symptoms of pain observed or documented. Resident #5 had two falls with no injuries since the last admission/entry. The resident was marked to be on high-risk drug classes of antianxiety and antidepressants. The resident used a manual wheelchair. Review of Resident #5 chronic pain plan of care initiated on 07/15/20 and revised on 11/23/22 related to fibromyalgia and polyosteoathritis revealed to plan heavy care when pain was controlled, administer Biofreeze, Gabapentin, Tylenol, and Percocet per physician orders and monitor/document/report as needed for any side effects and or effectiveness (revised on 01/30/24), consult pain management, monitor/report/record to nurse any sign or symptoms of non-verbal pain (changes in breathing, vocalization, mood/behavior, eyes, face, body), offer rest periods as indicated. Review of Resident #5's risk management report form (not part of the medical record) dated 01/27/24 at 12:30 A.M. authored by Registered Nurse (RN) #163 revealed this RN was called to the resident room by State Tested Nurse's Aide (STNA). The resident was sitting on the floor next to the bed. Resident vitals were taken at this time (temperature was 97.7, respirations were 18, oxygen saturation was 94% room air, heart rate 89, and blood pressure was 174/87). Resident was alert to self. Pupils equal, round, reactive, light, and Accommodation (PERRLA). No visible injury was noted at this time. Resident complains of left hip pain. Resident stated that she was trying to get to the bathroom. The resident denied hitting her head. Reminded resident not to attempt to get out of bed without assistance. Pain level was a 10 and she was alert and oriented to the person only. Unable to determine the injury type but the location was in the left gluteal fold. The resident was noted to be wheelchair bound. There were no environmental factors noted. The predisposing physiological factors included the resident was confused, incontinent, and had gait imbalance. The predisposing factors indicated the resident ambulated without assist. The on-call service was notified at 12:40 A.M. and the power of attorney (POA) at 12:41 A.M. At the bottom of the fall investigation report form it indicated the report was privileged and confidential - not part of the medical record- do not copy. Review of Resident #5's electronic medical record dated 01/22/24 to 01/30/24 revealed no evidence of details of the fall including provider notification, time of fall, assessment, orders, etc. regarding the resident's fall on 01/27/24. Review of Resident #5's x-ray results dated 01/27/24 at 1:37 P.M., revealed a nondisplaced fracture of the left intertrochanteric region was noted. A mildly displaced left superior pubic ramus fracture was noted. Diffuse osteopenia was noted. Impression acute left hip fractures of the left superior pubic ramus fracture. Review of Resident #5's hospital notes dated 01/27/24 revealed the x-ray showed acute moderately displaced left intertrochanteric proximal femur fracture and acute moderately displaced fracture of the left superior and inferior pubic rami. The resident's face pain assessment for the left hip was 10 out of 10 at 3:12 P.M and 3:50 P.M. The resident was given intravenous Fentanyl and Zofran for pain. The left leg was shortened and rotated. The resident had lumbar pain and neck pain and c-collar was applied. The discharge instruction was to call Physician #501 in one day for palliative care due to the resident being a surgical candidate. The final diagnoses was closed traumatic displaced intertrochanteric fracture of left femur and closed fracture of multiple rami of left pubic. Review of Resident #5's current orders dated 01/2024 revealed on 01/27/24 the resident was ordered Percocet 5/235 milligrams (mg) every six hours as needed for pain. On 11/23/20 she was ordered Tylenol Extra Strength 500 mg and by mouth twice daily for pain and two every 8 hours as needed for pain. Also, on 11/23/20 was an order for Gabapentin 100 mg one capsule twice a day and two at bedtime for pain. Review of Resident #5's medication administration records (MAR) dated 01/27/24 to 01/31/24 revealed the resident had received one dose of Percocet 5-325 mg on 01/27/24 at 9:52 P.M. for a pain level of 3 out of 10, three doses on 01/28/24 (3:52 A.M. pain level two out of 10, noon for pain level of eight out of 10, 6:06 P.M. for pain level four out of 10), three doses on 01/29/24 (6:16 A.M. for pain level one out of 10, 12:20 P.M. for pain level eight out of 10, and 9:40 for pain five out of 10) and three doses on 01/30/24 (4:55 A.M. for pain level of eight out 10, 11:05 A.M. for pain level of seven out of 10, and 10:30 P.M. for a pain level of four out of 10). All Percocet administration doses indicated the medication was effective. There was no pain number listed for the effectiveness. There was no evidence the as needed Tylenol was administered after the resident returned from the hospital or parameters for when to administer the Tylenol versus the Percocet for pain. Review of Resident #5's administration/progress notes dated 01/27/24 to 01/31/24 revealed the nurse called Certified Nurse Practitioner (CNP) #502 to obtain order for Percocet after the resident returned from the hospital due to she was restless. On 01/27/24 at 9:52 P.M. Resident #5 received Percocet for a pain level of 3 out of 10. At 12:20 A.M. the follow up pain was four out of 10 (which was higher than prior to administration) and the nurse documented the pain medication was effective. Further review of progress note dated 01/31/24 at 3:00 A.M. revealed the resident was noted to be yelling out and upon entering the room the resident was noted to be grimacing and squeezing the STNA hands. Resident #5 was not able to voice needs due to her severe dementia. The on-call provider was called and received a one time order to administer an additional Percocet 5/235 mg. Currently, working on obtaining authorization to pull from mediwise due to the resident was out of Percocet. (There was no evidence the as needed Tylenol was utilized). There was no documented evidence on the MAR or progress note indicating non-pharmacological interventions were attempted prior to administering pain medications. Review of the facility policy titled Pain Management Policy (dated 10/2023) revealed the purpose was to provide resident comfort with care. The procedure included: the resident would be assessed for complaints and/or signs and symptoms of pain upon admission and as indicated. Pain assessment will be completed five days after admission and quarterly. The interdisciplinary care plan team will initiate and implement a pain management plan of care. Pain interventions will be monitored for effectiveness by Nursing. The physician will be notified as indicated. Interview and review of Resident #5's MAR on 01/31/24 at 10:27 A.M., with LPN #165 and the DON confirmed there should be parameters when to administer the Tylenol versus the Percocet and they would call the provider to get clarification.

Based on record review, review of risk management report, review of hospital records, review of tracking logs, interviews, and policy review the facility failed to ensure a complete and accurate medical record. This affected one resident (#5) of three residents reviewed for falls. Findings included: Record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including dementia, Alzheimer's, chronic pain, polyosteoathritis, generalized anxiety, age-related osteoporosis without current pathological fracture, and repeated falls. There was no evidence the diagnoses list was updated to include the acute left hip fracture and left superior pubic ramus fracture that occurred on 01/27/24. Review of the Resident #5's risk management report (which indicated at the bottom of the report that it was not part of the medical record) dated 01/22/24 at 1:42 A.M. revealed Registered Nurse (RN) #163 was called to room by a State tested Nurse's Aide (STNA). Resident was sitting on the floor at this time. No visible injuries were noted at this time. Resident mental status as per normal. Vitals taken at this time (97.7 Fahrenheit temperature, 18 respirations, 94% on room air, 89 heart rate, and BP 174/87). The resident was not able to give a description of the event. Assisted resident to wheelchair at this time. Moved resident to common area for observation. The resident was alert and wheelchair bound. She was oriented to person only and had no pain. Her predisposing physiological factors included confusion, gait imbalance, and impaired memory. The resident was ambulating without assistance. There was no witness. The physician was notified at 1:49 A.M. and power of attorney (POA) at 1:52 A.M. Review of Resident #5's medical record revealed on 01/23/24 at 10:39 A.M., there was a late entry authored by the Director of Nursing (DON) for 01/22/24 at 1:42 A.M. that indicated this Registered Nurse (RN) was called to the room by a State tested Nurse's Aide (STNA). The resident was sitting on the floor at this time. No visible injuries were noted at this time. Resident mental status as per normal. Vitals taken at this time. The temperature was 97.7, respirations were 18 respirations, 94% room air, 89 heart rate, and blood pressure was 174/87. Residents are unable to give any description of the event. Assisted resident to wheelchair at this time. Moved resident to common area for observation. The resident's physician and POA was notified. A correction note was entered at 10:41 A.M. indicating RN #163 was the nurse who found the resident regarding the fall. Review of Resident #5's risk management report form dated 01/27/24 at 12:30 A.M. authored by Registered Nurse (RN) #163 revealed this RN was called to the resident room by State tested Nurse's Aide (STNA). The resident was sitting on the floor next to the bed. Resident vitals were taken at this time (temperature was 97.7, respirations were 18, oxygen saturation was 94% room air, heart rate 89, and blood pressure was 174/87). Resident was alert to self. Pupils equal, round, reactive, light, and Accommodation (PERRLA). No visible injury was noted at this time. Resident complains of left hip pain. Resident stated that she was trying to get to the bathroom. The resident denied hitting her head. Reminded resident not to attempt to get out of bed without assistance. Pain level was a 10 and she was alert and oriented to the person only. Unable to determine the injury type but the location was in the left gluteal fold. The resident was noted to be wheelchair bound. There were no environmental factors noted. The predisposing physiological factors included the resident was confused, incontinent, and had gait imbalance. The predisposing factors indicating the resident ambulated without assist. The on-call service was notified at 12:40 A.M. and the POA at 12:41 A.M. At the bottom of the fall investigation report form it indicated the report was privileged and confidential - not part of the medical record- do not copy. Review of Resident #5's medical record revealed no evidence of incident note or progress note regarding Resident #5's fall that occurred on 01/27/24 at 12:30 A.M. Review of Resident #5's hospital notes dated 01/27/24 revealed the x-ray showed acute moderately displaced left intertrochanteric proximal femur fracture and acute moderately displaced fracture of the left superior and inferior pubic rami. The discharge instruction was to call Physician #501 in one day for palliative care and the final diagnoses was closed traumatic displaced intertrochanteric fracture of left femur and closed fracture of multiple rami of left pubic. Interview on 01/30/24 at 10:38 A.M., with LPN #168 revealed Resident #5's fall that occurred on 01/27/24 was still being investigated and she had not interviewed any other staff at this time regarding the incidents due to the fall happened over the weekend. She was aware RN #163 had not documented the fall on 01/27/24 and had reached out to the nurse.The interview was reviewed with LPN #168 to confirm accuracy of the interview. The LPN confirmed the accuracy of the interview. Interview on 01/30/24 at 9:49 A.M., 12:03 P.M., and 1:02 P.M., with the DON confirmed she had documented the fall that occurred on 01/22/24 in Resident #5's medical record on 01/23/24 on the behalf of RN #163. The DON reported staff were instructed to type all fall information into risk management and then copy the information into the resident's medical record. RN #163 did not do that for the falls that occurred on 01/22/24 and 01/27/24. The interview was reviewed with the DON to confirm accuracy of the interview. The DON confirmed accuracy of the interview. Interview on 01/30/24 at 12:02 PM with RN#163 (and the DON) verified RN#163 was Resident #5's nurse on 01/22/24 and 01/27/24 and he did not document the falls that occurred on those dates in the medical record. RN#163 reported he thought he had documented the two falls in the medical record, and he didn't know what he had done wrong for them not to show up in the medical record. RN #163 verified he was not provided additional education regarding not documenting falls in the medical record. The interview was reviewed with RN #163 and the DON to confirm accuracy of the interview. RN #163 confirmed accuracy of the interview. Review of the facility policy titled Fall Management Policy dated 10/2023 revealed fall intervention would be posted on the Kardex and plan of care. The nurse must document in the resident's chart in the risk management and the incident progress note.

Based on record review, review of risk management report, review of hospital records, review of tracking logs, interviews, and policy review the facility failed to ensure a complete and accurate medical record. This affected one resident (#5) of three residents reviewed for falls. Findings included: Record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including dementia, Alzheimer's, chronic pain, polyosteoathritis, generalized anxiety, age-related osteoporosis without current pathological fracture, and repeated falls. There was no evidence the diagnoses list was updated to include the acute left hip fracture and left superior pubic ramus fracture that occurred on 01/27/24. Review of the Resident #5's risk management report (which indicated at the bottom of the report that it was not part of the medical record) dated 01/22/24 at 1:42 A.M. revealed Registered Nurse (RN) #163 was called to room by a State Tested Nurse's Aide (STNA). Resident was sitting on the floor at this time. No visible injuries were noted at this time. Resident mental status as per normal. Vitals taken at this time (97.7 Fahrenheit temperature, 18 respirations, 94% on room air, 89 heart rate, and BP 174/87). The resident was not able to give a description of the event. Assisted resident to wheelchair at this time. Moved resident to common area for observation. The resident was alert and wheelchair bound. She was oriented to person only and had no pain. Her predisposing physiological factors included confusion, gait imbalance, and impaired memory. The resident was ambulating without assistance. There was no witness. The physician was notified at 1:49 A.M. and power of attorney (POA) at 1:52 A.M. Review of Resident #5's medical record revealed on 01/23/24 at 10:39 A.M., there was a late entry authored by the Director of Nursing (DON) for 01/22/24 at 1:42 A.M. that indicated this Registered Nurse (RN) was called to the room by a State Tested Nurse's Aide (STNA). The resident was sitting on the floor at this time. No visible injuries were noted at this time. Resident mental status as per normal. Vitals taken at this time. The temperature was 97.7, respirations were 18 respirations, 94% room air, 89 heart rate, and blood pressure was 174/87. Residents are unable to give any description of the event. Assisted resident to wheelchair at this time. Moved resident to common area for observation. The resident's physician and POA was notified. A correction note was entered at 10:41 A.M. indicating RN #163 was the nurse who found the resident regarding the fall. Review of Resident #5's risk management report form dated 01/27/24 at 12:30 A.M. authored by Registered Nurse (RN) #163 revealed this RN was called to the resident room by State Tested Nurse's Aide (STNA). The resident was sitting on the floor next to the bed. Resident vitals were taken at this time (temperature was 97.7, respirations were 18, oxygen saturation was 94% room air, heart rate 89, and blood pressure was 174/87). Resident was alert to self. Pupils equal, round, reactive, light, and Accommodation (PERRLA). No visible injury was noted at this time. Resident complains of left hip pain. Resident stated that she was trying to get to the bathroom. The resident denied hitting her head. Reminded resident not to attempt to get out of bed without assistance. Pain level was a 10 and she was alert and oriented to the person only. Unable to determine the injury type but the location was in the left gluteal fold. The resident was noted to be wheelchair bound. There were no environmental factors noted. The predisposing physiological factors included the resident was confused, incontinent, and had gait imbalance. The predisposing factors indicating the resident ambulated without assist. The on-call service was notified at 12:40 A.M. and the POA at 12:41 A.M. At the bottom of the fall investigation report form it indicated the report was privileged and confidential - not part of the medical record- do not copy. Review of Resident #5's medical record revealed no evidence of incident note or progress note regarding Resident #5's fall that occurred on 01/27/24 at 12:30 A.M. Review of Resident #5's hospital notes dated 01/27/24 revealed the x-ray showed acute moderately displaced left intertrochanteric proximal femur fracture and acute moderately displaced fracture of the left superior and inferior pubic rami. The discharge instruction was to call Physician #501 in one day for palliative care and the final diagnoses was closed traumatic displaced intertrochanteric fracture of left femur and closed fracture of multiple rami of left pubic. Interview on 01/30/24 at 10:38 A.M., with LPN #168 revealed Resident #5's fall that occurred on 01/27/24 was still being investigated and she had not interviewed any other staff at this time regarding the incidents due to the fall happened over the weekend. She was aware RN #163 had not documented the fall on 01/27/24 and had reached out to the nurse.The interview was reviewed with LPN #168 to confirm accuracy of the interview. The LPN confirmed the accuracy of the interview. Interview on 01/30/24 at 9:49 A.M., 12:03 P.M., and 1:02 P.M., with the DON confirmed she had documented the fall that occurred on 01/22/24 in Resident #5's medical record on 01/23/24 on the behalf of RN #163. The DON reported staff were instructed to type all fall information into risk management and then copy the information into the resident's medical record. RN #163 did not do that for the falls that occurred on 01/22/24 and 01/27/24. The interview was reviewed with the DON to confirm accuracy of the interview. The DON confirmed accuracy of the interview. Interview on 01/30/24 at 12:02 PM with RN#163 (and the DON) verified RN#163 was Resident #5's nurse on 01/22/24 and 01/27/24 and he did not document the falls that occurred on those dates in the medical record. RN#163 reported he thought he had documented the two falls in the medical record, and he didn't know what he had done wrong for them not to show up in the medical record. RN #163 verified he was not provided additional education regarding not documenting falls in the medical record. The interview was reviewed with RN #163 and the DON to confirm accuracy of the interview. RN #163 confirmed accuracy of the interview. Review of the facility policy titled Fall Management Policy dated 10/2023 revealed fall intervention would be posted on the [NAME] and plan of care. The nurse must document in the resident's chart in the risk management and the incident progress note.

Based on interview and record review, the facility failed to ensure a second generation antipsychotic medication was not ordered and administered for a diagnosis of dementia with behaviors. This affected one resident (#77) of three residents reviewed for unnecessary medications. The facility census was 77. Findings included: Review of Resident #77's medical record revealed an admitted [DATE] with diagnoses including displaced subtrochanteric fracture of the left femur, atherosclerotic heart disease, type two diabetes mellitus, morbid obesity, essential hypertension, generalized weakness, major depressive disorder and dementia in other diseases classified elsewhere. Review of Resident #77's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/26/23, revealed the resident was severely cognitively impaired. Further review revealed she had a non-Alzheimer dementia diagnosis and did not have a diagnosis of psychosis or bipolar. During Resident #77's look back period she had taken an antipsychotic for seven days. Review of Resident #77's physician order, dated 03/23/23, indicated she was to receive quetiapine fumarate (Seroquel - a second generation antipsychotic medication) 12.5 milligrams by mouth at bedtime for dementia with behaviors. Review of Resident #77's medication administration records (MARs), dated May 2023, June 2023 and July 2023, revealed she received the quetiapine fumarate tablet 12.5 mg at bedtime for dementia with behaviors. Review of Resident #77's plan of care, dated 11/04/21, revealed she had a behavior problem with a diagnosis of dementia with behavioral disturbances. An intervention, dated 10/10/22, was administer quetiapine fumarate per physician order, monitor/document/report as needed any side effects and or effectiveness. Interview on 07/27/23 at 3:58 P.M. with Registered Nurse (RN) #101 verified Resident #77 did not have an appropriate diagnosis to be receiving the quetiapine fumarate. RN #101 reviewed Resident #77's medical record and verified there was no diagnosis regarding psychosis or bipolar disorder for the use of the quetiapine fumarate. This deficiency is cited as an incidental finding to Complaint Number OH00144685.

Based on review of medical records, review of the facility's Advance Directives/Right to Choose and Code Status policies, hospital staff, physician, facility staff, and hospice staff interviews, the facility failed to initiate Cardio [MEDICAL CONDITION] Resuscitation (CPR) or contact emergency medical services (EMS) timely for one resident (Resident #128) who was a full code and was found unresponsive without vital signs. Life threatening harm and death occurred when Resident #128 did not receive CPR or emergency medical services and expired at the facility. This resulted in Immediate Jeopardy for one of three residents reviewed for an emergent change in condition and death. The facility identified nine residents residing in the facility designated with full code status. The facility census was 75. The Administrator, Director of Nursing (DON) #1, and DON #2 (the DON of a sister facility) were notified on [DATE] at 1:06 P.M. Immediate Jeopardy began on [DATE] at 5:22 P.M. when Resident #128 was found unresponsive and without vital signs by Licensed Practical Nurse (LPN) #18 who failed to initiate CPR or emergency medical services. Resident #128 expired at the facility. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: · On [DATE] the facility developed and implemented a new policy titled Code Status Policy and Procedure that identified all residents would be considered a full Code unless there was a physician signed and verified DNRCC (Do Not Resuscitate Comfort Care) or DNRCC/A (Do Not Resuscitate Comfort Care -Arrest) form in the resident's medical record. The social services director or designee will discuss and verify the resident's code status during the admission interview process, and as indicated. The code status will be placed in the Advanced Directives tab of the resident's chart and will be placed in the computer on the resident's dashboard. All new personnel that are licensed nurses will be educated on the code status policy during orientation and sign verification they have been educated on the policy. · On [DATE] the Administrator and DON #1 began in-service training on the new Code Status Policy and Procedure to 29 licensed nurses and the licensed social worker. · On [DATE] twenty-nine of 29 nurses had been in-serviced by the Administrator and DON #1 on the new Code Status Policy and Procedure. Two (2) nurses who had not been in-serviced will be in-serviced by DON #1 prior to returning to work in the facility. · On [DATE] the Administrator implemented an initiative that all new licensed nursing personnel will be educated by the Director of Human Resources on the Code Status Policy and Procedure during new employee orientation. Each newly hired licensed nurse will sign a receipt of acknowledgement they received the in-service training on the Code Status Policy and Procedure. · On [DATE] DON#1 began auditing the acknowledgement of receipt of the training on the Code Status Policy and Procedure for newly hired licensed nurses. · On [DATE], the Administrator implemented an initiative that the social service director or designee will discuss and verify the resident's code status during the admission interview process. · On [DATE] the Administrator began auditing the code status documentation of each newly admitted resident. · On [DATE] the Administrator and DON #1 completed medical record audits to ensure correct code status was identified for all 75 residents residing in the facility. No discrepancies were identified. · On [DATE] DON #1 identified nine (9) residents requested to be full code status and their code status was correctly identified in their medical record. · Beginning [DATE] the Administrator identified the facility compliance plan will be reviewed at the quarterly Quality Assurance meetings for one (1) year. · On [DATE], review of four (4) resident medical records identified accurate documentation for the resident's code status. · On [DATE], interview with four (4) licensed nursing staff verified the staff had received in-service training on the facility's new Code Status Policy and Procedure and the staff was knowledgeable of their responsibilities in regard to resident code status. Although the Immediate Jeopardy was removed on [DATE] the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility continues to complete audits to validate accurate documentation of code status in the medical record. Findings include: Review of Resident #128's closed medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the admission nursing assessment dated [DATE] indicated Resident #128 was oriented to person, place, time and situation. The admission nursing assessment indicated Resident #128's cognition was intact. Review of an admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #128 was able to make herself understood and she understood others. A Brief Interview for Mental Status (BIMS) score was ten, indicating moderately impaired cognition for decision making. Review of a Health Care Power of Attorney document signed [DATE] revealed the power of attorney only took effect when Resident #128 could not make health care decisions for herself. A social service note by Licensed Social Worker (LSW) #14 dated [DATE] at 2:42 P.M. indicated the social worker met with Resident #128 and her power of attorney (POA) and Resident #128 requested full code status. Review of a social service history dated [DATE] indicated Resident #128's code status was full code. Review of a hospice visit coordination note indicated on [DATE] at 11:30 A.M. the hospice nurse met with Resident #128's family to discuss hospice service. It was a referral only. No orders for hospice were received at the time but the family was in agreement with hospice or palliative services if appropriate. A nursing note by LPN #18 dated [DATE] at 10:01 P.M. revealed the note was a late entry for [DATE] at 5:00 P.M. The note indicated an unidentified state tested nursing assistant (STNA) alerted the nurse (LPN #18) that Resident #128 was unresponsive. LPN #18 found Resident #128 in a recliner chair with very shallow respirations and a faint heart rate was auscultated. According to this nursing note, a blood pressure was not able to be obtained. Many attempts to arouse Resident #128 were unsuccessful. The supervisor, Registered Nurse (RN) #19, was contacted to assess Resident #128. It was decided to move Resident #128 to the bed to provide further comfort. LPN #18 documented upon moving Resident #128, RN #19 stated another set of vital signs were warranted as it appeared Resident #128 had expired. The next nursing note entry by LPN #18 dated [DATE] at 10:04 P.M. indicated the note was a late entry for [DATE] at 5:22 P.M., Resident #128 had no palpable pulse, blood pressure or respirations. The family (did not designate which family member) was at the facility and made aware. On [DATE] at 11:36 P.M., RN #19 documented Resident #128's POA was notified at 5:18 P.M. of Resident #128's condition. The POA did not want Resident #128 sent to the hospital. The POA arrived at the facility at 5:25 P.M. Resident #128's sister was also at the bedside. At 5:35 P.M., a call was placed to the attending physician. At 5:47 P.M., the attending physician was notified. On [DATE] at 3:39 P.M., RN #19 was interviewed and stated Resident #128's sister was at the bedside when Resident #128 exhibited unresponsiveness on [DATE]. RN #19 stated Resident #128's sister stated she did not want Resident #128 to suffer any longer. RN #19 verified the sister was not the health care POA. RN #19 stated she called the grandson/POA as soon as she had assessed Resident #128 to see what he wanted done and he did not want anything done, stating he would go to the facility. RN #19 stated when she first attempted to contact the physician at 5:35 P.M, there was no response. RN #19 stated she contacted the physician at 5:45 P.M. RN #19 verified no CPR was initiated and there was no Do Not Resuscitate (DNR) order in the medical record. Resident #128 was a Full Code despite the discussion with the grandson indicating nothing should be done. On [DATE] at 4:03 P.M., Resident #128's POA was interviewed by phone. Resident #128's POA stated Resident #128 had been having excruciating pain. The day Resident #128 expired the POA had a meeting with hospice at the facility to see what alternatives were available for pain management and to discuss the possibility of taking Resident #128 home. Resident #128's POA stated Resident #128 was coherent when he visited her on [DATE] after the hospice meeting was finished. However, Resident #128 was having difficulty speaking that day and she was trying to tell him something but he could not understand. The POA stated he returned home after lunch and received a phone call later that afternoon. Resident #128's POA stated he was told Resident #128 was struggling and staff asked him what he wanted done. The POA stated Resident #128 always said she did not want her life prolonged with the use of extraordinary measures such as the use of ventilators. The facility's staff (could not identify who he spoke to) told him they did not have paper work on hand and they could not find a DNR on file. Resident #128's POA stated he did not participate in the admission process but he thought Resident #128 might have signed a DNR then. Resident #128's POA stated he was unaware Resident #128 had indicated to the facility she desired to be a full code. On [DATE] at 4:28 P.M., LPN #18 was interviewed and stated when she assessed Resident #128 on [DATE], the resident was not speaking or responding. LPN #18 stated she spoke to Resident #128's POA and he stated he just wanted Resident #128 kept comfortable. LPN #18's interview contained conflicting information regarding Resident #128's condition and when the POA arrived. LPN #18 stated it did not matter if a resident did not have a signed DNR. Staff honored the POA's wishes. On [DATE] at 8:32 A.M., LSW #14 was interviewed and stated she addressed code status with residents upon admission. LSW #14 stated Resident #128 indicated she wanted to be a full code. LSW #14 stated on [DATE] when Resident #128 signed the living will and power of attorney with the POA present, Resident #128 stated she wanted full code status. LSW #14 stated neither Resident #128 nor her POA ever approached her indicating a change in code status was desired. On [DATE] at 8:35 A.M., the Administrator was interviewed and stated she did not know the circumstances of what happened on [DATE] when Resident #128 expired. The Administrator stated she was not made aware of any issues so no action had been taken. If staff noticed a decline and a resident was a full code, staff were expected to speak with the family about their wishes. The Administrator provided a hospital emergency room (ER) report from [DATE] which indicated Resident #128 was a DNR/CC and it was confirmed with the grandson who was her POA. When the Administrator was asked if she could get a copy of the DNRCC, LSW #14, who was still present, stated there was none in hospital records because she checked. There was no indication the POA was in effect as Resident #128 was still alert and oriented in the emergency room . On [DATE] at 8:50 A.M., RN #19 was interviewed for further clarification. RN #19 stated Resident #128's overall condition had been deteriorating. When asked for clarification, RN #19 stated Resident #128 had been getting weaker and was not able to do as much for herself. RN #19 verified when she noticed the decline, she did not personally re-address code status with Resident #128. RN #19 stated on [DATE] when she was asked to assess Resident #128 she noticed Resident #128's color was bad and her vital signs were not good so she told staff to put Resident #128 to bed. When asked about LPN #18's documentation indicating RN #19 told LPN #18 she believed Resident #128 had expired, RN #19 stated she could not recall but at the point she called Resident #128's POA she believed Resident #128 still had vital signs. RN #19 was asked if a resident who had indicated they wanted to be full code and did not have a signed DNR had absence of vital signs, what the expectations were for initiation of CPR. RN #19 stated if the resident's condition was bad, she called the family to determine what their wishes were. RN #19 stated she did not know if any other nurses had spoken to Resident #128's POA regarding a change in code status but stated if code status had been changed to a DNR, documentation should have been available in the medical record. On [DATE] at 9:08 A.M., Hospice RN #20 was interviewed and stated Resident #128's POA phoned hospice on [DATE] to inquire about having Resident #128 admitted to the Hospice House. The meeting was for a referral only. Hospice RN #20 stated code status was not discussed and Resident #128 was not assessed by hospice staff. Hospice RN #20 stated Resident #128's physician was not available to provide an order for [REDACTED].>On [DATE] at 10:00 A.M., LSW #14 was interviewed and stated she called the hospital and spoke with the hospital's Director of Care Management #21 who stated once the physician documented Resident #128 was a DNRCC on the emergency room report and it was confirmed with her POA, that changed her code status to DNRCC. On [DATE] at 10:25 A.M., LSW #14 was interviewed and verified the healthcare POA did not take effect unless Resident #128 was unable to make health care decisions for herself. LSW #14 verified the emergency department report indicated Resident #128 was extremely hard of hearing but was able to answer questions appropriately and her mentation was at her baseline state. On [DATE] at 11:10 A.M., Hospital Director of Care Management #21 was interviewed by phone and stated she was unable to state why code status was discussed with Resident #128's POA instead of Resident #128 when the physician documented she was a DNRCC on the emergency room report dated [DATE]. On [DATE] at 10:26 A.M., RN #15 was interviewed and verified the facility had no copy of the ER report in the medical record indicating the resident was a DNRCC. On [DATE] at 2:12 P.M., ER Physician #22 was interviewed and stated he was not sure where he got the information about the DNRCC. He stated it would have had to have been from the previous hospital records or from information from the facility. ER Physician #22 stated he was reviewing the information from previous hospital records and could find nothing indicating Resident #128 was a DNRCC. ER Physician #22 stated he did not recall specific details regarding Resident #128 as he had probably seen 500 patients since Resident #128 was seen in theER on [DATE]. Review of the facility's policy, Advance Directives/Right to Choose Policy (not dated), indicated each resident and/or family member would be educated on advance directives and the right to choose. The social worker or facility designee were responsible for educating and providing written information to the resident/family member on what advance directives were and the right to refuse treatment. The resident or family member's choice would be documented in the social service note. The resident's advance directive was to be care planned in the resident's chart. The advance directive and right to choose was to be discussed with the resident or family member quarterly with care plan and as needed.