Every finding on record at Pavilion , The

Based on observation, interview, record review, and policy review, the facility failed for two Residents (#22 and #213), out of a total sample of 17 residents, to maintain and store respiratory equipment in a safe and sanitary manner. Specifically, the facility failed: 1. For Resident #22, to ensure oxygen (O2) equipment was maintained per physician's orders to ensure sanitary conditions to help decrease the risk of potential contamination and infection; and 2. For Resident #213, to store his/her continuous positive airway pressure (CPAP) respiratory tubing and nasal pillow mask in a sanitary way when not in use by the Resident to prevent potential contamination by germs and environmental debris. Findings include: Review of the facility's policy titled Equipment Change/Disinfection, undated, indicated but was not limited to the following: -Thoroughly clean all exterior surfaces of equipment. -All supplies while not in use in patient's room are to be stored in a treatment bag labeled with the patient's name, room number, date of change, and item. Oxygen Concentrators -Rinse and dry the external filter weekly and as needed when visibly dusty. Wipe down concentrator as needed when visibly dusty or soiled. 1. Resident #22 was admitted to the facility in July 2023 and had diagnoses including emphysema, acute and chronic respiratory failure with hypoxia (absence of enough oxygen in the tissues to sustain bodily functions), and dependence on supplemental Oxygen (O2). Review of the Minimum Data Set (MDS) assessment, dated 3/27/24, indicated Resident #22 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15 and required oxygen therapy. Review of current Physician's Orders indicated the following: -Clean concentrator filter every day shift every Wednesday, 7/5/23 -Clean concentrator filter as needed, 7/3/23 On 6/12/24 at 7:45 A.M. and 3:35 P.M., the surveyor observed Resident #22 lying in bed. An oxygen concentrator (takes air from your surroundings, extracts, and filters it into purified oxygen for you to breathe) was observed on the floor next to the bed delivering oxygen through the attached nasal cannula (NC- device that delivers extra oxygen through a tube and into your nostrils) tubing with the end of the tubing's prongs inserted into the Resident's nostrils. The O2 concentrator and external filter were laden with dust. On 6/13/24 at 7:43 A.M., the surveyor observed Resident #22 lying in bed. An oxygen concentrator was observed on the floor next to the bed delivering oxygen through the attached nasal cannula tubing with the end of the tubing's prongs inserted into the Resident's nostrils. The O2 concentrator and external filter were laden with dust. The external filter was not cleaned the day prior (Wednesday) per physician's orders and the concentrator was not wiped down as needed when visibly dusty per facility policy. During an observation with interview on 6/13/24 at 8:07 A.M., Nurse #3 entered the Resident's room with the surveyor and observed the O2 concentrator and external filter laden with dust. Nurse #3 said she changed the NC tubing the day before and documented that she cleaned the external filter but did not because the respiratory company went around and changed all the filters last Tuesday or Wednesday. Nurse #3 said the order is for nursing to clean the filter every Wednesday and as needed and she should have cleaned it but did not. She said there wasn't an order to wipe down the concentrator, but it should have been done if visibly dusty. During an interview on 6/13/24 at 11:11 A.M., the Director of Nursing (DON) said the respiratory company comes into the facility on ce a week to change out filters, but the order is for nursing to clean and rinse the filters once a week on Wednesdays. She said the expectation is to also clean the concentrator weekly on Wednesdays and as needed per professional standards. She said nursing should follow physician's orders for maintaining the oxygen equipment. 43935 2. Review of the Lippincott Nursing Procedure, eighth edition, indicated but was not limited to the following in regard to the use and storage of CPAP tubing: - When the CPAP therapy has been completed, follow these steps: remove the headgear and appliance from the patient; clean and disinfect the equipment using a facility-approved disinfectant according to the manufacturer's instructions, and store it properly. Resident #213 was admitted to the facility in June 2024 with diagnoses including: cerebral infarct (stroke), sleep apnea, and narcolepsy (chronic neurological disorder that affects the brain's ability to control sleep-wake cycles, resulting in excessive sleepiness during the day and/or falling asleep suddenly during an activity). Review of the Nursing admission evaluation indicated Resident #213 was alert and oriented to person, place, time and situation. During an observation with interview on 6/11/24 at 8:51 A.M., the surveyor observed Resident #213 in his/her room in bed with their CPAP head strap and nasal pillow hanging over the bedrail on the Resident's left side. The Resident said he/she wears the device each night and the staff remove it in the morning but he/she was not sure how the facility was protecting the tubing from germs or environmental debris and said he/she has not ever seen a storage container or bag for the tubing and headgear. Throughout the day on 6/11/24 the surveyor made further observations as follows: - 11:13 A.M., CPAP head strap and nasal pillow were hanging over the left side rail of the Resident's bed open to environmental debris and potential contamination of germs; the device was not in use by the Resident and not stored in a sanitary way. - 3:07 P.M., Resident was out of bed sitting in their room, the CPAP tubing, head strap, and nasal pillow were not in use, and were observed to be hanging over the bed rail open to air and not stored in a manner to protect them from potential germs or environmental debris. During an interview on 6/12/24 at 2:18 P.M., Unit Manager #2 said the best practice and expectation is that the CPAP tubing, headgear, and nasal pillows are to be stored in a respiratory equipment bag when not in use to protect them from potential contamination of germs in the environment. She said Resident #213 is not physically capable of placing the CPAP on or removing it related to their recent stroke and the staff would have to apply and remove the device and then clean and store it properly. She observed the manner in which the surveyor observed Resident #213's CPAP head strap, tubing, and nasal pillow throughout the day on 6/11/23 and said the tubing should never be stored in that manner and it needed to be stored in a way to protect it from potential germs. During an interview on 6/12/24 at 3:51 P.M., the DON said CPAP tubing and the Resident's nasal pillow should always be stored in a respiratory bag when not in use to protect it from potential contaminants. She said the manner in which the surveyor observed the tubing was not an appropriate way for the tubing to be stored and was not in line with the facility practice.

Based on interview, record review, and policy review, the facility failed to ensure monthly medication regimen reviews were maintained as part of the permanent medical record and failed to ensure recommendations made by the pharmacy consultant were addressed timely for one Resident (#9), out of a total sample of 17 residents. Findings include: Review of the facility's policy titled Medication Regimen Review (MRR), dated as last revised 6/1/24, indicated but was not limited to the following: - The consultant pharmacist will provide required recipients of residents' MRR on the MRR report to the Director of Nursing (DON) and/or the attending physician, and to the Medical Director. - Facility staff should ensure that the attending physician, medical director and director of nursing are provided with copies of the MRRs. - Facility should encourage physician/prescriber or other responsible parties receiving the MRR and the DON to act upon the recommendations contained in the MRR. - Facility should alert the medical director where MRRs are not addressed by the attending physician in a timely manner. - If an irregularity is not time sensitive but should be addressed before the consultant pharmacist's next MRR, the facility staff and the consultant pharmacist will confer on the timeliness of attending physician/prescriber responses to identified irregularities based on the specific resident's clinical condition. - The facility should maintain readily available copies of the consultant pharmacist's reports on file in the facility, and as a part of the resident's permanent health record. Resident #9 was admitted to the facility in January 2024 with diagnoses including but not limited to type II diabetes, anxiety, and depression. Review of the monthly reports from the Pharmacist Consultant indicated irregularities were noted on 2/14/24, 4/11/24, and 5/14/24. Review of the electronic and paper medical record failed to include the Consultation Report forms which identified the irregularities. During an observation with interview on 6/12/24 at 1:00 P.M., Unit Manager #1 and the surveyor reviewed the medical record for Resident #9. Unit Manager #1 said she was unable to locate the Consultation Report forms and would contact the Consultant Pharmacist. The surveyor requested copies of the February, April and May recommendations. During an interview on 6/12/24 at 3:25 P.M., Unit Manager #1 provided the surveyor with a copy of the Consultation Report form dated 5/14/24. The copy of the Consultation Report form was addressed by the attending physician but there was no date identifying when the response was completed. Unit Manager #1 said she had spoken to the Consultant Pharmacist who stated the May 2024 recommendation was a re-issued recommendation from February 2024 that was never addressed. Unit Manager #1 said she did not have a copy of the February 2024 Consultation Report form. Unit Manager #1 said she reached out to the Consultant Pharmacist to retrieve the records of the forms because she did not have a signed copy of the form at the facility. Unit Manager #1 said the Consultant Pharmacist was sending over a copy of the April 2024 recommendations that were addressed by the attending physician and they would be filed in the paper medical record. Unit Manager #1 said after a recommendation is reviewed by the Physician, the recommendation should be filed in the Resident's medical record and a copy faxed to the Consultant Pharmacist. During an interview on 6/13/24 at 8:41 A.M., the Director of Nursing (DON) said MRRs are completed by the Consultant Pharmacist monthly. The DON said the Consultant Pharmacist documents in the electronic medical record whether there are any irregularities. The DON said if irregularities are noted, the Consultation Report is sent to the facility for the Physician to review. The DON said unless there are immediate concerns, irregularities should be addressed prior to the next MRR completion. The DON said MRR Consultation Reports should be kept in the medical record.

Based on record review and interview, the facility failed to maintain accurate medical records in accordance with professional standards of practice for one Resident (#31), out of a total sample of 17 residents. Specifically, the facility failed to ensure the Resident's Massachusetts Medical Order for Life-Sustaining Treatment (MOLST- form that indicates a person's medical wishes regarding life sustaining treatments) was consistent with current physician's orders. Findings include: Review of the facility's policy titled Health Information Management Policy, undated, indicated but was not limited to the following: Purpose: -To ensure that health information, including but not limited to clinical records, is maintained in accordance with state, federal regulations, and professional practice standards, complete, accurately documented, readily accessible and systematically organized. Procedure: -A clinical record will be maintained for each resident and contain enough information to show that the facility knows the status of the individual, has adequate plans of care, and provides sufficient evidence of the effects of the care provided. -The medical record will contain complete and accurate documentation that clearly identified the resident, justifies the diagnoses, conditions, treatment, and care approaches, and response to the care provided. -Documentation should provide a picture of the resident's progress, including response to treatment, change in condition, and changes in treatment. Review of the facility's policy titled Advanced Directive Guideline, revised [DATE], indicated but was not limited to the following: -Advanced Directives will be respected and honored in accordance with State Law and resident/legal representative preferences. -Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advanced directive if he or she chooses to do so. -If the resident is incapacitated and unable to receive information about his or her right to formulate an advanced directive, the information may be provided to the resident's legal representative. -Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advanced directives. -The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advanced directive. -The resident's attending physician will clarify and present any relevant medical issues and decisions to the resident or legal representative as the resident's condition changes in an effort to clarify and adhere to the resident's wishes. -The Interdisciplinary Team (IDT) will review annually with the resident his or her advance directives to ensure that such directives are still the wishes of the resident. Such reviews will be made during the annual assessment process and recorded on the resident assessment (MDS). -The Director of Nursing Services or designee will notify the attending physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care. Resident #31 was admitted to the facility in [DATE] and had diagnoses including Alzheimer's disease, dementia, and age-related cognitive decline. Review of the Minimum Data Set (MDS) assessment, dated [DATE], indicated Resident #31 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 10 out of 15. Review of the admission Social Services progress note, dated [DATE], indicated the Resident's MOLST selections were as follows: attempt resuscitation, intubate and ventilate short term, use noninvasive ventilation short term, transfer to hospital, use dialysis, no artificial nutrition, hydrate. Review of current Physician's Orders indicated the following: -Attempt resuscitation, intubate and ventilate, use non-invasive ventilation, transfer to hospital, use dialysis, no artificial nutrition, use artificial hydration, [DATE] Review of the medical record indicated Resident #31 had a Decree and Order of Appointment of Guardian (someone who has received permission through a legal process to take care of and make decisions for a child or incapacitated adult) for an Incapacitated Person, dated [DATE]. Review of the MOLST, signed by the Resident and Nurse Practitioner (NP) #1 on [DATE], indicated the following: -Do not resuscitate -Do not intubate and ventilate -Do not use non-invasive ventilation (e.g. CPAP) -Transfer to hospital -No dialysis -Artificial nutrition, undecided -Artificial hydration, use artificial hydration, but short-term only Review of a Nurse's Note, dated [DATE], indicated the NP had been in to see the Resident that morning with a new order to honor the MOLST. Review of the medical record failed to indicate the NP's order (change in directive) was transcribed into the medical record. The Resident remained a full code. NP #1 was unavailable for interview. Review of a Social Services progress note, dated [DATE], indicated Resident #31's legal guardian was confirmed on [DATE]. Further review of the medical record did indicate Resident #31 had capacity at the time of signing the MOLST or that the legal guardian was granted the authority to make and communicate decisions concerning continuance or withdrawal of life-sustaining treatment. The MOLST form remained in Resident #31's chart to the current date even though it was determined, approximately 11 months ago, that it was not valid and was inconsistent with current physician's orders. During an interview on [DATE] at 3:54 P.M., Unit Manager (UM) #1 said the current MOLST should be in the Resident's chart and match the physician's electronic order, but Resident #31's did not. During an interview on [DATE] at 10:58 A.M., the Director of Social Services said when the Resident was admitted in June of last year, they didn't know that he/she had a legal guardian until the guardian dropped off paperwork a month later. She said the facility spoke to the attorney who validated it. The Director of Social Services said the paperwork did not include an expansion for the guardian to have advanced directive decision making powers and would have to go back to court to allow for that. Until then, she said, the Resident would remain a full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive). She said the MOLST was completed by NP #1 with the Resident on [DATE] before they knew he/she had guardianship and didn't even know the Resident had a MOLST in the chart prior to the surveyor's inquiry. During an interview on [DATE] at 11:27 A.M., Nurse #5 said when a code blue is called on the overhead pager, one staff member grabs the automated external device (AED), one grabs the code cart, and one grabs the physical chart, and they all go to the room the code was called for. She said a nurse will initiate cardiopulmonary resuscitation (CPR) or no CPR for a resident, by what the MOLST says in the chart. She said no matter what the electronic medical record says, she always goes by what it says in the chart. She said that's why someone must bring the chart to the code, to double check the MOLST. During an interview on [DATE] at 11:28 A.M., Nurse #1 said during a code situation she defers to the paper MOLST in the medical record, and someone runs for the chart and confirms the code status at the bedside. During an interview on [DATE] at 11:30 A.M., the Infection Preventionist (IP) said she uses the paper MOLST from the hard chart to confirm code status during any code to help guide her in what the ordered life sustaining wishes are for the resident. During an interview on [DATE] at 11:30 A.M., UM #2 said the expectation is that the code status is verified using the MOLST during an active code and that document is what her staff uses and how she trains new staff to verify code status even though there are scanned orders in the electronic medical record (EMR). During an interview on [DATE] at 11:31 A.M., Nurse #3 said if the Resident coded, she would look at the MOLST in the chart as well as current physician's orders to verify it. She said if the two were conflicting she'd call the physician to verify. She said if the physician didn't answer she'd have to call the Director of Nursing (DON). Nurse #3 said it would delay emergency medical treatment for the Resident because she'd need to know what she was doing. She said the physician's advanced directive order and the MOLST should be matching in the medical record. During a phone interview on [DATE] at 11:31 A.M., the DON said she spoke to Resident #31's guardian and advised him/her that he/she needed to get an expansion for the advanced directive, to have the right to make advanced directive decisions on behalf of the Resident. She said the MOLST form currently in the Resident's chart indicates a DNR status (do not resuscitate) but was a full code upon admission. The DON said there was no order from NP #1 that the advanced directive was changed and said she thought maybe the NP filled out the MOLST but didn't flag it as a new order and didn't write a note about it. The DON said they received the guardianship paperwork after the MOLST was signed by the Resident which indicated the Resident was incapacitated, therefore, it wasn't valid. The DON said the MOLST form should have been removed from the chart but was not and the Resident was currently a full code. She said if there were any discrepancy during a potential code, then the Resident would be presumed to be a full code. During an interview on [DATE] at 12:01 P.M., Nurse #4 said a resident's code status should not be conflicting and the electronic record should match the paper MOLST. She said if this occurred during a code, she would need to call the DON or representative, if that's who signed it, to verify. Nurse #4 said this could delay potential life-saving emergency treatment because she'd need to know what to do. During an interview on [DATE] at 12:14 P.M., the Medical Director said if an advanced directive is amended such as in a MOLST, then the electronic order would typically say honor the MOLST and there should be a progress note completed by the practitioner as to why the code status was changed. During an interview on [DATE] at 10:08 A.M., the Director of Social Services said when a resident is admitted , they gather information prior to coming in including whether they have a Health Care Proxy (HCP), is it invoked, and do they have legal guardianship. She said each guardianship has differences with legal matters, language specifying what the guardian is allowed to do including allowance to make advanced directive decisions. She said she wants the resident to be part of the decision-making process, but the point person would make the decisions. She said the admissions staff work in conjunction with social services staff upon admission to seek documentation of the existence of any advanced directive, but the guardian didn't tell them or provide paperwork upon admission that he/she was the legal guardian for Resident #31. The Director of Social Services said they had a quarterly IDT meeting within the first 21 days after the Resident was admitted , then quarterly discussions at care plan meetings but was not aware NP #1 completed a MOLST or that it was even in the chart. She said she wasn't sure what prompted NP #1 to even introduce that to the Resident. She said the MOLST was not valid, and the guardian didn't have the authority to select advanced directives for the Resident. She said the plan of care for each resident should be consistent with his/her documented treatment preferences and advanced directives and that the Resident had been deemed incompetent in [DATE] by a court of law but didn't know about it until [DATE]. She further said she didn't know if anyone had revisited the Resident's wishes and preferences since indicated on the [DATE] MOLST. During an interview on [DATE] at 10:37 A.M., Medical Records said professional standards are followed regarding medical record maintenance. She said guardianship, conservatorship, and the MOLST are part of a resident's record, and the medical record includes both electronic and hard copy charts. She said the medical record should be maintained for each resident, be complete, accurately documented, readily accessible, and systematically organized. She said she wasn't aware of the situation, but this did not seem to be the case for Resident #31. She further said the medical record should reflect a consistent code status and that the hard copy MOLST should have been removed from the record last year if deemed invalid.

Based on record review, interviews, and policy review, the facility failed to develop a person-centered plan of care which included post-traumatic stress disorder (PTSD- a mental health condition that is triggered by an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being) identified triggers to avoid potential re-traumatization for one Resident (#37), out of a total sample of 17 residents. Findings include: Review of the facility's policy titled Trauma Assessment and Care Guidelines, dated 6/25/2018, indicated but was not limited to the following: - the facility will ensure trauma survivors receive culturally competent trauma informed care in accordance with professional standards of practice - person-centered care planning will include trauma triggers and interventions to mitigate the risk of re-traumatization - the social service department will develop a person-centered care trauma informed care plan that addresses the assessed emotional or psychosocial needs of the resident, and will identify known triggers that the resident may discuss during interview and assessment. Resident #37 was admitted to the facility in May 2024 with diagnoses including: depression, anxiety, and PTSD. Review of the Brief Interview for Mental Status (BIMS), dated 5/16/24, indicated the Resident was moderately cognitively impaired with a score of 10 out of 15. Review of the medical record indicated the Resident was his/her own person and their healthcare proxy was not activated. Review of the medical record for Resident #37 indicated the Resident had a trauma informed assessment completed on 5/13/24, which indicated but was not limited to the following: - the Resident had experienced an event (trauma) that changed them emotionally physically, spiritually or behaviorally - the Resident indicated the experience still bothers them now - the Resident wished to discuss the experience - the Resident experienced feelings of being jumpy, easily startled and watchful - the PTSD was a result of childhood trauma and the Resident had his/her own community therapist they would continue to have sessions with while in the facility Review of the social services progress notes indicated but was not limited to the following: - 5/19/24: trigger for PTSD is a sudden surprise of plans or events with a coping strategy of being informed in advance During an interview on 6/11/24 at 11:11 A.M., the Resident said he/she is unsure if anyone at the facility is aware of what his/her trauma triggers are and was unsure if the staff do anything to prevent him/her from being re-traumatized and said that would be really helpful for them and me to avoid those things as much as possible. During an interview on 6/12/24 at 7:47 A.M., Certified Nurse Assistant #2 said she consistently cares for the Resident and is aware of the anxiety the Resident has, but was not aware the Resident had PTSD. She said she does not know of any potential triggers to avoid to help lessen the likelihood of or alleviate the Resident's anxiety and reports any episodes of anxiety to the nurse. During an interview on 6/12/24 at 8:26 A.M., the Resident said he/she was being discharged from the facility on this day and felt it was a surprise since they attempted to appeal their discharge. He/She said they do not think the facility is trying to help them avoid triggering situations. During an interview on 6/12/24 at 8:35 A.M., Nurse #1 said she is caring for Resident #37 today and is aware the Resident suffers from PTSD and has anxiety. She said she is not aware of what the PTSD stems from or what potential triggers should be avoided or could potentially exacerbate the Resident's PTSD or anxiety. During an interview on 6/12/24 at 9:21 A.M., Nurse #2 said she knows Resident #37 well and is aware the Resident suffers from PTSD and anxiety but is unaware of any potential triggers that should be avoided or could potentially increase the Resident's anxiety. She said the Resident is followed by his/her own personal therapist for management of their PTSD on an outpatient basis. Review of the current active care plans for Resident #37 indicated but were not limited to the following: FOCUS: Resident demonstrates periods of depression and anxiety related to a history of trauma. INTERVENTIONS: Encourage to attend activities of interest; review activity schedule and discuss areas of interest; encourage deep breathing exercises and relaxation techniques; help facilitate continued established sessions with community therapist during their stay; provide one to one (1:1) brief supportive visits; refer to psych as needed. FOCUS: Resident uses anti-anxiety medications related to anxiety and PTSD. INTERVENTIONS: Administer medications as ordered and monitor for effectiveness and side effects; Monitor and report any adverse reactions. FOCUS: Feelings of depression and anxiety characterized by flat affect, difficulty concentrating, lack of energy, lack of interest or pleasure in doing things, difficulty sleeping, and restlessness related to recent hospitalization and medical concerns, disruption in the home routine and diagnosis of major depressive disorder and anxiety. INTERVENTIONS: Acknowledge resident's mood in 1:1 interactions; assist with moving to a quiet room as needed; provide support and reassurance; assist with facilitating ongoing appointments with counselor as needed; encourage resident to participate in activities he/she finds appealing; involve resident in making their own schedule and sequencing activities; observe and report for mental status; provide 1:1 brief supportive visits as needed; refer to psych as needed. The care plans failed to indicate what the Resident's triggers were to prevent potential re-traumatization. During an interview on 6/12/24 at 10:23 A.M., the Director of Social Services said the process for trauma informed care included a record review, an initial meeting and interview with the residents, a trauma informed assessment if applicable, and then care plans for the residents. She said Resident #37 was willing to share his/her trauma and triggers and she documented that information in her note along with the Resident's desire to maintain weekly visits with his/her community therapist. She reviewed the care plans for Resident #37 and said although the triggers are not indicated on the care plan she felt the interventions would prevent the triggers from occurring. She said the care plan should have been more clear and specific to the Resident's trigger and can see how it is not clear for the staff to understand the potential triggers for the Resident.

Based on interview and record review, the facility failed to follow and implement physician's orders and recommendations for a hospice evaluation for 1 resident (#57) out of a total of 15 sampled residents. For Resident #57 the facility failed to implement the physician's order, written on 11/3/19, for a hospice evaluation. There was no indication in the medical record that the hospice evaluation was completed Resident #57 was admitted to the facility in (MONTH) of 2019 with [DIAGNOSES REDACTED]. Review of the Admission MDS (minimum data set) assessment for Resident #57 indicated a BIMS (Brief Interview for Mental Status) score of 8 out of 15 which indicated that he/she had moderately impaired cognition. Review of Nursing progress notes indicated that Resident #57 showed little interest in doing things, had a poor appetite and reported feeling tired or having no energy. Resident #57 was seen by the Nurse Practitioner (NP) #1 on 11/13/19. Review of the NP progress note indicated that Resident #57 had a 21 pound weight loss and was alert to name but did not follow direction. The progress note further indicated that Resident #57 had a decline in condition, was diagnosed with [REDACTED]. Resident #57 was sent to the hospital 11/14/19 and returned to the facility on [DATE]. There was no indication in the medical record that the physician's order for a hospice evaluation was reconciled on return form the facility. Resident #57 was seen by the physician on 11/19/19, for a history and physical (H&P) following the hospitalization . Review of the H&P indicated that Resident #57 now had orders for do not resuscitate, do not intubate, do not transfer to hospital and possibly comfort measures only. The H&P further indicated that aggressive treatment would only affect quality of life and cause discomfort and will not change the life expectancy of Resident #57. Hospice was further recommended by the Nurse Practitioner on 11/20/19. During an interview with the Director of Nurses on 12/5/19 12:42 P.M., she said said that hospice had not been contacted regarding Resident #57.

Based on interviews and records reviewed, for one of three sampled Residents (Resident #1), the Facility failed to ensure Housekeeper #1 respected Resident #1's right to privacy, when on 5/13/19 at approximately 10:30 A.M., Housekeeper #1 assisted Resident #1 with putting on his/her underwear. Findings include: Resident #1's most recent Admission Minimum Data Set Assessment, completed 4/30/19, indicated that his/her cognitive patterns were intact. The Surveyor did not interview Resident #1 at the request of Resident #1's Attorney. The Administrator's written statement, dated 5/13/19, indicated she interviewed Resident #1 on 5/13/19, The Statement indicated that Resident #1 told the Administrator that Housekeeper #1 tried to molest him/her and put his hand on Resident #1's underwear. The Surveyor interviewed the Occupational Therapist at 11:50 A.M. on 6/27/19. The Occupational Therapist said that on 5/13/19 at approximately 10:30 A.M. she worked with Resident #1. The Occupational Therapist said that Resident #1 became fatigued and short of breath during their session, so she left him/her to rest. The Occupational Therapist said that when she left Resident #1's room, Resident #1 was lying on his/her back in bed with the privacy curtain pulled around the bed. The Occupational Therapist said that when she returned to Resident #1's room a few minutes later, she found Housekeeper #1 in Resident #1's room. The Occupational Therapist said that a pair of underwear was around Resident #1's ankles and Housekeeper #1 was bending over Resident #1's bed near Resident #1's feet. The Occupational Therapist said that she could not tell whether Housekeeper #1 was taking off or putting on Resident #1's underwear. The Occupational Therapist said that she asked Housekeeper #1 what he was doing and Housekeeper #1 said words to the effect of, I was trying to stop (him/her) from falling, as Housekeeper #1 walked out of Resident #1's room. The Occupational Therapist said that Resident #1 told her to go get someone in charge and said that Housekeeper #1 molested him/her again. The Surveyor interviewed Nurse #1 at 1:40 P.M. on 6/10/19. Nurse #1 said that on 5/13/19 the Occupational Therapist told her that Resident #1 wanted to speak to someone in charge. Nurse #1 said that she spoke with Resident #1 and he/she reported an allegation about Housekeeper #1. Nurse #1 said that she reported Resident #1's allegation to the Administrator and the Director of Nurses. The Surveyor interviewed the Administrator and Director of Nurses at 2:00 P.M. on 6/10/19 and reviewed the Facility's Internal Investigation of the allegation Resident #1 reported on 5/13/19, with them. The Administrator and Director of Nurses said and the Internal Investigation indicated that although the Facility could not substantiate that Housekeeper #1 molested Resident #1, Housekeeper #1 told the Administrator that he went into Resident #1's room because he was worried Resident #1 would fall and assisted Resident #1 with his/her pants. Housekeeper #1 did not respond to telephone messages on 7/3/19 and 7/5/19, an email on 7/3/19 or a letter sent to his home on 7/5/19. Housekeeper #1's written statement dated 5/13/19 indicated that he saw Resident #1 with his/her underwear in his/her hand and said he (Housekeeper #1) asked Resident #1 if he needed any help. Housekeeper #1's written statement indicated that Resident #1 asked for help putting his/her underwear on and Housekeeper #1 helped put on Resident #1's underwear.

Based on records reviewed and interviews, for two of four sampled residents (Resident #1 and Resident #3), the Facility failed to ensure the accuracy of Minimum Data Set (MDS) Assessments. Findings include: 1. Resident #1 was admitted to the Facility in (MONTH) (YEAR), [DIAGNOSES REDACTED]. The Nursing Progress Note, dated 12/19/18, indicated Resident #1 became agitated, raised his/her fists and verbally threatened Resident #2. The Incident/Accident Report, dated 12/19/18 at 10:15 A.M., indicated Resident #1 had a resident to resident altercation with Resident #2 and was yelling and threatening him/her. The Quarterly Minimum Data Set (MDS) evaluation, dated 01/04/19, indicated Resident #1 had physical (hitting, kicking, pushing, scratching, grabbing, abusing others sexually) behavioral symptoms directed toward others. The Surveyor interviewed the MDS Coordinator at 4:00 P.M. on 03/20/19. The MDS Coordinator said that Resident #1's verbal threatening should not have been coded as a physical behavior, said that the incident did not occur during the assessment look back period and said his/her behavior should not have been reflected in the MDS dated [DATE]. 2. Resident #3 was admitted to the Facility in (MONTH) (YEAR), [DIAGNOSES REDACTED]. The Incident/Accident Report, dated 01/04/19 at 4:45 P.M., indicated Resident #3 hit Resident #4 in the shin. Review of the Health Care Facility Reporting System (HCFRS) Report, dated 01/04/19, indicated Resident #3 reportedly kicked Resident #4 in the lower leg. The Annual Minimum Data Set (MDS) evaluation, dated 01/07/19, indicated Resident #3 did not exhibit any physical or verbal behavioral symptoms directed/not directed toward others. The Surveyor interviewed the MDS Coordinator at 4:00 P.M. on 3/20/19. The MDS Coordinator said that Resident #3's kicking behavior should have been reflected as a physical behavior directed toward others in the annual MDS dated [DATE].

Based on observation, record review, and staff interview, the Facility failed to ensure that for 1 Resident (#18), of a total sample of 18 Residents, that the MDS accurately reflected the use of a restraint for the Resident. Findings included: Resident #18 was admitted in 6/2016 with [DIAGNOSES REDACTED]. According to the most recent MDS, signed as being completed on 8/27/18, the Resident was totally dependent for transfers, locomotion (on and off the unit), and required extensive assistance with bed mobility and transfers. The Resident was observed in the Hyannisport Dining Room on 10/23/18 at 8:55 A.M., The Resident was alert and was observed trying to speak to the female CNA who was in the room at the time. On each day of the survey, the Resident was observed seated in a high back wheelchair wearing a chest and pelvic restraint that the Resident could not release. The Resident had a padded, cloth, chest restraint across his/her chest that went under his/her arms, and fastened to the back frame of the wheelchair. The Resident had a second restraint that was positioned across the pelvic region and around the back. Each of the devices, though used to assist in positioning the Resident, restricted free movement of the Resident. The Initial Assessment for Use of Physical Restraint/Device, effective 8/21/18, indicated: A. REASON FOR RESTRAINT/DEVICE: 1. Unsafe mobility/postural instability 5. Other: Used as positioning device A1. ALTERNATIVES ATTEMPTED: 3. Encouraged common areas 4. Direct supervision B. EFFECTIVENESS OF RESTRAINT/DEVICE: 1. Is restraint/device effective? -yes 2. Comments: non restraint clip belt and chest strap while in wheel chair used for positioning secondary to increased tone. C. COMMENTS FROM MULTI-DISCIPLINARY TEAM: 1. How does restraint/device use affect the resident? Include psychosocial behavior if affected. -No adverse effect. Resident with better posture and positioning in chair, promoting comfort and decreased pain. Guardian and resident agreeable to plan, explained risks vs benefits and understand the need for the positioning devices. D. RECOMMENDATIONS: 1. Continue use of restraint/device: 1. Yes 2. Comments/Reason for decision: Due to increased tone and muscle spasms resident has secondary to [MEDICAL CONDITION], Chest strap and clip belt continue while in wheelchair for positioning and safety. Record review on 10/25/18, indicated that the Quarterly MDS, signed as being completed 8/27/18, under Section R, Restraints and Alarms, coded restraint use as, 0 (not used) under Restraints used in Chair or Out of bed. According to CMS's definition of Physical Restraint, Any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body (State Operations Manual, Appendix PP). On 10/26/18 at 8:36 A.M., the ADON (Assistant Director of Nursing) was interviewed regarding the Resident's use of the chest and pelvic restraints and the reason the restraints were not coded on the MDS as being restraints. The ADON said that the chest and pelvic restraints were used to maintain the Resident's position in the chair, kept the Resident from moving to one side or the other, and to prevent him/her from leaning/falling out of the chair due to poor trunk control and spastic movements. Surveyor #1 showed the ADON CMS's definition of Restraints. She said that although the Facility used the devices for positioning, they did not consider the chest/pelvic devices as restraints. Surveyor #1 asked the ADON to provide documentation for the two devices which showed that the Facility had determined that they were the least restrictive, and evidence to support that other alternatives were tried prior to the use of the chest and waist restraints. The ADON did not provide Surveyor #1 with the requested documentation.

Based on interview and record review, the Facility failed to ensure that laboratory services were obtained for 1 resident (#5) out of a total sample of 18 Residents. Findings include: For Resident # 5 the facility failed to ensure that a physician's interim/telephone orders was noted by a nurse (this is a process that a Nurse completes when an order is written by/obtained from the physician and then acted upon. The physician's orders [REDACTED]. Resident # 5 was admitted to the facility in 4/2018 with [MEDICAL CONDITION], dementia with delusion, transcerebral ischemic attack, fractured of the right hip and [MEDICAL CONDITION]. On 10/4/18 the physician had written an order which indicated the following: -Vitamin B12 1000 mcg IM every 4 weeks on the 21st of the month. -For 10/21/18 obtain Complete Blood Count (CBC), Basic Metabolic Panel (BMP), fasting lipid profile, aminotransferase (AST) and [MEDICATION NAME] (ALT). AST and ALT are liver function tests. Further review of the physician's interim/telephone orders indicated that the order was never noted by a Nurse, thus it was never acted upon. On 10/29/18 at 8:32 A.M. Unit Manager #1 and the Assistant Director of Nurses said that the physician order [REDACTED].

Based on record review and staff interview, the facility failed to ensure that [MEDICAL CONDITION] medications were not administered without adequate monitoring of behaviors to determine effectiveness of their use based on an assessment of the Resident's condition and documented in the medical record for 3 Residents (#8, #18 and #30), out of a total sample of 18 Residents. Findings included: 1. Resident #8 was admitted in 8/2017 with [DIAGNOSES REDACTED]. The Resident was admitted to the Facility following a geriatric psychiatric admission to the hospital. Record review on 10/25/18, revealed that the Resident received multiple [MEDICAL CONDITION] medications, including [MEDICATION NAME] (anti-anxiety), [MEDICATION NAME] (antipsychotic), and [MEDICATION NAME] (antidepressant). The Psychiatric Consultant assessment dated [DATE], indicated under the Assessment and Recommendations that Target Behaviors included: -Anxiety -Apprehension -Behavioral disturbance -Changes in mood The Facility maintained a daily Behavior Monitoring Sheets for Residents who displayed problematic behaviors and/or received psychoactive medications. Resident #8's Care Plan indicated that the Resident displayed behaviors of verbal aggression related to yelling, screaming, striking out at staff, and spitting. The Care Plan also indicated, evaluate Resident and document behaviors that warranted the medication. SEE BEHAVIOR MONITORING SHEET. The (MONTH) (YEAR) Behavior Monitoring Sheets listed the following behaviors to be monitored by licensed nurses: -Agitation -Aggression -Accusatory The Behavior Monitoring Sheets were reviewed and observed to have multiple shifts on multiple days where licensed nurses failed to document the Resident's behaviors. Interview with UM #2 (Unit Manager) said that Behavior Monitoring Sheets are to be completed every shift, daily, in order to quantify Resident behaviors, and are used as a tool to determine the efficacy of the psychoactive medications prescribed for the Resident. On the days that licensed nurses did complete the Behavior Monitoring Sheet for (MONTH) (YEAR), all entries were documented as 0. UM #2 said that the Behavior Monitoring Sheets for the Resident were not completed in accordance with the Care Plan and the Facility Policy. The Psychiatric Consultant's visit of 10/3/18, indicated that a GDR (gradual dose reduction) remains clinically inadvisable at this time, even though the Behavior Monitoring Sheets indicated 0 for agitation, aggression, and accusatory. 2. Resident #30 was admitted in 8/2018 with [DIAGNOSES REDACTED]. Record Review on 10/25/18, indicated that the Resident received multiple [MEDICAL CONDITION] medications including, [MEDICATION NAME] (antipsychotic), [MEDICATION NAME] (anti-anxiety), [MEDICATION NAME] (antidepressant), and Trazadone (antidepressant). The Resident was followed by the Psychiatric Consultant for psychopharmalogical monitoring and was evaluated on 10/3/18. The consultant listed target behaviors that included, anxiety, apprehension, changes in mood, hallucinations, recent changes in appetite, weight loss, and recent changes in sleep. Although, the Resident denied hallucinations on 10/3/18, the resident had a history of [REDACTED]. The Surveyor reviewed the Hyannisport Unit's Behavior Monitoring Sheet binder. Resident #30 did not have a Behavior Monitoring Sheet in the binder, although the Resident's Care Plan indicated to evaluate resident and document behaviors that warranted the medication. SEE BEHAVIOR MONITORING SHEET. UM #2 was interviewed on 10/25/18, regarding the lack of Behavior Monitoring Sheets for the Resident. UM #2 said that no target behaviors were being monitored for the Resident at that time. UM #2 acknowledged the Resident's use of multiple psychoactive medications, being followed by the Psychiatric Consultant, and his/her history of hallucinations of seeing a man in a top hat. 3. Resident #18 was admitted in 6/2016 with [DIAGNOSES REDACTED]. According to the most recent MDS, signed as being completed 8/27/18, the Resident displayed moods that included, feeling down, depressed or hopeless, trouble falling or staying asleep, or sleeping too much, feeling tired or having little energy, feeling bad about self, and moving or speaking so slowly that other people could have noticed. These moods were observed several days (2-6) in the last 14 days. Record Review on 10/25/18, indicated that the Resident received multiple [MEDICAL CONDITION] medications, including [MEDICATION NAME] (antipsychotic), [MEDICATION NAME] (antidepressant), Trazadone (antidepressant), and [MEDICATION NAME] (antidepressant). The Resident was followed by the Facility Psychiatric Consultant for psychopharmacological management. The Resident was assessed by the Psychiatric Consultant on 10/3/18. The consultant indicated in her assessment, that the Resident had baseline delusions and hallucinations with accusatory behaviors. Antipsychotic is needed to manage delusional thinking. Target behaviors noted in the consultant's evaluation included, anxiety/apprehension, behavioral disturbances, changes in mood, and hallucinations. The Resident's Care plan for Psychoactive Medications indicated that staff would evaluate Resident and document behaviors that warranted the medication. SEE BEHAVIOR MONITORING SHEET. Interview with UM #2 on 10/26/18 at 9:15 A.M., acknowledged that the Resident's behaviors, (hallucinations/delusions over room being moved, having her legs amputated, believing his/her roommate is calling her names, etc) were not being monitored and recorded on a Behavior Monitoring sheet, in accordance with the Resident's Care Plan. The Administrator was interviewed on 10/26/18 at 3:45 P.M. She acknowledged the Surveyor's concern over the identified Residents' Psychiatric Care Plans for Behavior monitoring were not followed.

Based on staff interview and record review, the Facility failed to ensure that staff provide care and services according to accepted standards of clinical practice for one Resident (# 5) in a total sample of 18 Residents. Findings Include: For Resident # 5 the facility failed to ensure that a physician's interim/telephone orders was noted by a nurse (this is a process that a Nurse completes when an order is written by/obtained from the physician and then acted upon. The physician's orders [REDACTED]. Resident # 5 was admitted to the facility in 4/2018 with [MEDICAL CONDITION], dementia with delusion, transcerebral ischemic attack, fractured of the right hip and [MEDICAL CONDITION]. Clinical record review indicated that on 9/15/18 the Resident was to receive a Vitamin B12 1000 mcg IM by injection. Review of the physician's interim/telephone orders indicated to hold the Vitamin B12 injection on 9/15/18 and obtain a Vitamin B12 blood level. The results of the laboratory test were to be discussed with the physician and in 2 weeks the physician would make a decision regarding ongoing Vitamin B12 injections. On 10/4/18 the physician had written an order which indicated the following: -Vitamin B12 1000 mcg IM every 4 weeks on the 21st of the month. -For 10/21/18 obtain Complete Blood Count (CBC), Basic Metabolic Panel (BMP), fasting lipid profile, aminotransferase (AST) and [MEDICATION NAME] (ALT). AST and ALT are liver function tests. Further review of the physician's interim/telephone orders indicated that the order was never noted by a Nurse, thus it was never acted upon. Further Clinical record review of the Medication Administration Record [REDACTED]. On 10/29/18 at 8:32 A.M. Unit Manager #1 and the Assistant Director of Nurses said that the physician order [REDACTED]. Please see F770.

Based on observation and interview, the facility staff failed to utilize safe and sanitary food handling techniques during meal service to minimize the risk of food borne illness. Findings include: 1. On 6/15/17 at 11:30 A.M. during observation of the lunch meal, the surveyor observed the following: a. The server did not consistently remove dirty gloves, wash hands, and donn new gloves between serving the trayline and other tasks. At the start of the trayline, the server grabbed a large serving spoon from the hanging utensil rack by the bowl (food contact end) of the spoon and not the handle as required. The server left the tray line to get coleslaw from the walk-in refrigerator and was wearing gloves at this time. Upon returning to the tray line, the server removed the gloves and donned new gloves without first washing hands. The surveyor asked the FSD (food service director) if staff washed hands before donning new gloves so as to not contaminate the new gloves. The FSD then directed the server to wash hands before donning new gloves. The server touched other surfaces and equipment such as the steam table cutting board, apron and stove while wearing the same pair of gloves to serve the meal. The server sprinkled grated cheese onto the spaghetti using the same pair of gloves for this task. The server removed hot dog rolls from loaf bags and placed the hot dog rolls onto the plate using the same pair of gloves for this task. Upon surveyor inquiry about the serving practices, the FSD provided the server a spoon to serve the grated cheese and deli tissue to serve the hot dog rolls. b. Diet Aide #1 wore gloves when touching various kitchen surfaces such as counter tops and trays, then picked up dessert bowls by touching the inside of the bowls (the food contact surface) wearing the same pair of gloves. c. Diet aide #2 wore gloves when making peanut butter sandwiches on a cutting board placed on the top of a meal truck during the tray line. A staff member interrupted the diet aide to give the diet aide a menu slip. The diet aide took the menu slip and upon returning to make sandwiches, removed her gloves and donned new gloves without first washing hands. After surveyor inquiry, the FSD took over the sandwich making task. 2. The surveyor observed that 34 of 39 plate covers on the tray line were in poor condition with the inside surface of the covers worn and/or peeling. The poor condition of the surface of these covers would prevent adequate cleaning and sanitizing. The peeling pieces on the surface also had the potential to come off and fall onto the plate and into the food. 3. During an interview on 6/15/17 at 1:30 P.M., the surveyor reviewed the above concerns with the FSD who indicated that dietary staff would be inserviced on safe food handling, hand hygiene and the appropriate use of gloves. The FSD indicated that the plate covers could be ordered by the end of the day.

Based on record review and staff interviews, the facility failed to accurately implement the medical plan of care for weight surveillance for 2 Residents (#2 and #12) in a total sample of 16. Findings include: 1. Resident #2 was admitted to the facility in 1/2017 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) with a reference date of 4/11/17, indicated that Resident #2 required extensive assistance of staff for all activities of daily living, was 68 inches tall, weighed 124 lbs and had weight loss. Review of physician's orders [REDACTED].#2 to be weighed daily for the management of [MEDICAL CONDITION] and the physician was to be notified of a weight gain greater than 2 lbs over 2 days. Review of the weight flow sheet from 4/9/17 through 6/14/17 indicated that Resident #2 had a weight gain greater than 2 lbs on 7 occasions. Further review of the medical record failed to indicate that the physician was updated about the weight gain of greater than 2 lbs according to physician's orders [REDACTED]. During interview with Unit Manager #2 on 6/16/17 at 10:50 A.M., she said that there was no documentation in the record to indicate that the physician was informed of Resident #2's weight gain according to physician's orders [REDACTED]. 2. Resident #12 was admitted to the facility in 6/2017 with [DIAGNOSES REDACTED]. The hospital discharge record dated 6/9/17, indicated the Resident had multiple hospital admissions for significant orthostatic [MEDICAL CONDITION], as well as [MEDICAL CONDITION] and Trans Ischemic Attacks. The Resident was discharged to the facility for rehabilitation and a follow-up with cardiologists. The physician orders [REDACTED]. -[MEDICATION NAME] 10 mg, three times daily for hypertension, hold for Systolic Blood Pressure (SBP) less than 180. -fludrocortisone acetate 0.1 mg, daily for [MEDICAL CONDITION], take if blood pressure is less than 130. Review of the Medication Administration Record [REDACTED].M. when his/her SBP was 144/80 and on 6/16/17 at 6:00 A.M., when his/her SBP was 138/70. Per the order, the medication should have been held, as the SBP was less than 180. In addition, according to the MAR, the fludrocortisone acetate was administered 3 times from 6/12/17 through 6/18/17, when it should have been held. On 6/12/17 - BP was 141/68, 6/14/17 - BP was 178/56 and 6/16/17, the BP was 144/80. During interview on 6/19/17 at 10:30 A.M., Unit Manager #1 reviewed the Medication Record and agreed that the medications should not have been administered.

Based on observation of the medication storage room and staff interview, the facility failed to ensure that, medications stored in the refrigerator and Emergency kits stored in the medicine room, were of current expiration date. Findings include: 1. On 6/16/17 at 10:30 A.M., during a review of the medications storage room on the second floor with Nurse #1, it was observed that the following medications were outdated: a) Two vial of House Stock Tubersol-Tuberculin Purified Protein Derivative (prescription solution that is injected just under the skin to find [DIAGNOSES REDACTED] infection) 10 test vial 5TU/0.1ML were opened and non-dated. b) The only bottle of sterile water (a clear colorless and odorless liquid) Lot # 35 in the emergency code cart had expired in March 2017. On 6/16/17 at 11:25 A.M. during an interview with Nurse #1, she said the Tubersol-Tuberculin Purified Protein Derivative vials are good for 30 days once opened and the saline should have been removed from emergency code cart, which is checked every night. Nurse #1 confirmed that the both the Tubersol-Tuberculin Purified Protein Derivative vials and the bottle of saline were outdated and removed them immediately. 2. On 6/16/17 at 11:55 A.M., during a review of the medication storage on the third floor with Nurse #2 it was observed that a Tubersol- Tuberculin Purified Protein Derivative vial was opened and non-dated. On 6/16/17 at 12:00 P.M. during an interview with Nurse #2, she said the Tubersol-Tuberculin Purified Protein Derivative vials should be dated once opened because they are good for thirty days after opening. Nurse #2 confirmed the facility policy is to date all open vials of medications with the date they were opened. Nurse #2 removed the outdated vial of Turberculin Purified Protein Derivative immediately. Nurse #2 shared these findings with the Unit Manager to ensure the non-dated and expired medications were discarded per the facility's protocol.

Based on record review and interview, the facility failed to notify the physician of changes and/or of recommendations from a consultant resulting in a delay of a treatment change and/or decisions to alter the treatment plan for 1 Residents (#9 ) in a sample of 16 Residents. For Resident #9, the Facility failed to notify the physician of (a) recommendations made by the consulting psychiatric provider, and (b) significant weight gain. Resident #9 was admitted to the facility in 10/2016 with [DIAGNOSES REDACTED]. (a) Record review indicated on 4/28/17, the physician order [REDACTED]. Record review failed to locate the assessment, however, after interview with the Assistant Director of Nurses (ADON) on 6/19/17 at 9:00 A.M., the the ADON provided the 5/5/17, Medication Management Assessment that had been conducted by the consulting psychiatric provider. According to the 5/5/17 assessment, the Resident's physician had ordered the assessment after starting the Resident on an antipsychotic medication, [MEDICATION NAME] 12.5 mg, twice daily. The psychiatric consultant indicated that the Facility staff had reported to her that the Resident had been aggressive, hostile, angry and swearing. The assessment indicated that a mood stabilizer was needed and recommended adding the medication [MEDICATION NAME] 125 mg daily (an anticonvulsant, used as a mood stabilizer). Record review failed to indicate the staff notified the physician and/or the physician's nurse practitioner of the recommendation. The Facility was unable to provide documented indication that this information was shared with the Resident's physician. (b) Review of Resident's #9 weight record indicated that from 10/28/16 through 4/5/17, his/her weights fluctuated. Review of this time period indicated the Resident's lowest weight had been 144.2 lbs and the highest 155.2 lbs. On average the Resident weighed below 153 lbs. Review of the 4/21/17, nutrition assessment indicated that she had noted the weigh fluctuation. The dietician indicated the Resident's appetite and intake fluctuated and that the gain was usually followed by a loss, then back to a gain. The dietician felt the fluctuation was not significant, but the goal was to to maintain a weight of less than or equal to 140 lbs, in order to maintain optimal glycemic control and fluid balance. The assessment indicated the Resident's most recent weight on 4/5/17 was 155.2 lbs, a 12 lb weight gain since 1/25/17. Review of the weight record on 6/15/17 indicated the following: 5/10/17 - 169.2 lbs, a weight gain of 14 lbs since 4/5/17. 5/11/17 - 169.0 lbs 6/1/17 - 174.2 lbs 6/2/17 - 175.6 lbs 6/7/17 - 174.6 lbs 6/8/17 - 175.2 lbs, 6/15/17 - 178.2 lbs a 23 lb weight gain since 4/5/17 (when weight was 155 lbs) and a 35 lb weight gain since 1/25/17 (when the Resident's weight was 144 lbs). Record review on 6/15/17 failed to indicated that the physician and/or the dietician was notified of the unplanned 23 pound variance (gain) in weight from 5/10/17 through 6/15/17. During interview on 6/15/17 at 11:00 A.M., and although Unit Manger #2 (UM #2)had previously described Resident #9, as constantly on the move and repetitively walking round the unit, during the initial tour 6/14/17 at 8:30 A.M., said the weight gain was caused by the Resident's sedate behaviors. UM #2 said the Resident spent most of his/her time in room watching television. Following the discussion and during a second review of the medical record on 6/19/17, indicated the Resident was weighed on 6/16/17. The weight was recorded at 181 lbs, an additional weight gain of 2.8 lbs in 1 day. The 6/16/17 nurses' note indicated the physician was notified of this weight and ordered the Resident be placed on a 3 day, 1800 milliliter fluid restriction, for bilateral lower extremity [MEDICAL CONDITION], to obtain a weight after the restriction and obtain a complete metabolic panel (laboratory test). During interview with the Dietician on 6/19/17 at 11:00 A.M., she said she was aware of the Resident's weight gain and had been addressing the weight gain with the Resident. The Dietician was unclear when she had last addressed the Resident's weight gain as her last progress note had been 4/21/17 and the Resident had an additional 25 lb weight gain. She said she could not provide documented evidence that she had been aware of this significant weight gain and then associated the gain with a change in the Resident's lifestyle (more sedate) and snacking. She was unaware of the new physician orders [REDACTED]. The Dietician was hesitate when asked about notification and said that the Survey team had been provided the Facility's weight policy, which included notification.

Based on record review and interview, the facility failed to ensure nursing staff provided services in accordance with professional standards of quality for 3 of sampled Residents (#1, #4 and #11) out of a total sample of 16 Residents. Findings include: Standard reference: Standard of Practice Reference: Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of registered nurse and practical nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a Registered nurse and Practical nurse respectively. The regulations stipulate that both the registered nurse and practical nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the registered nurse and practical nurse incorporate into the plan of care, and implement prescribed medical regimens. A nurse licensed by the Board shall not administer any prescription drug or non-prescription drug to any person in the course of nursing practice except as directed by an authorized prescriber. A nurse licensed by the Board shall document the handling, administration, and destruction of controlled substances in accordance with all federal and state laws and regulations and in a manner consistent with accepted standards of practice. 1. For Resident #4, the facility failed to identify instructions as to a sequence and/or pain intensity in which these options should be offered for the administration of 1 of 2 different strengths of the pain relieving medications [MEDICATION NAME] and [MEDICATION NAME]. Resident #4 was admitted to the facility in 1/2017 with [DIAGNOSES REDACTED]. Review of the most recent quarterly MDS with a reference date of 4/28/17, indicated that Resident #4 required extensive assistance of staff for activities of daily living and had frequent pain. Review of physician's orders [REDACTED]. The orders failed to include parameters identifying appropriate pain level for the administration of [MEDICATION NAME] 50 mg and [MEDICATION NAME] 650 mg, to ensure pain medication was appropriate for its effectiveness. Review of Medication Administration Records (MAR) indicated that pain medications were administered as follows: 5/2017 -[MEDICATION NAME] 25 mg was administered on 7 occasions for reported pain level from 3 to 8 (on a scale from 0 to 10) - [MEDICATION NAME] 50 mg was administered on 39 occasions for reported pain level from 3 to 8 -[MEDICATION NAME] 650 mg was not administered at all during the month of May 6/2017 -[MEDICATION NAME] 25 mg was administered on 3 occasions for reported pain level from 5 to 8 -[MEDICATION NAME] 50 mg was administered on 23 occasions for reported pain level from 2 to 8 - [MEDICATION NAME] was demister on 1 occasion for a reported pain level of 5. During interview with Unit Manager #1 and staff nurse #2 on 6/16/17 at 11:15 A.M., they said that pain medications should have defined parameters for their administration according to pain level and gave the example that a pain level of 5 would warrant the use of a higher dose of pain medication. 2. For Resident #11, the facility failed to identify instructions as to a sequence and/or pain intensity in which these options should be offered for the administration of 2 different pain relieving medications [MEDICATION NAME] and [MEDICATION NAME]. Resident #11 was admitted to the facility in 2/2016 with [DIAGNOSES REDACTED]. Review of the most recent quarterly MDS with a reference date of 4/25/17, indicated that Resident #11 required supervision of staff for activities of daily living and had pain. Review of physician's orders [REDACTED]. The orders failed to include parameters identifying appropriate pain level for the administration of [MEDICATION NAME] 50 mg and [MEDICATION NAME] 650 mg, to ensure pain medication was appropriate for its effectiveness. Review of Medication Administration Records (MAR) indicated that pain medications were administered as follows: 4/2017 -[MEDICATION NAME] 25 mg was administered on 7 occasions for reported pain level from 4 to 7 -[MEDICATION NAME] 650 mg was not administered at all during the month of April 5/2017 - [MEDICATION NAME] 25 mg was administered on 4 occasions for reported pain level from 3 to 10 -[MEDICATION NAME] 650 mg was not administered at all during the month of May 6/2017 -[MEDICATION NAME] 25 mg was administered on 11 occasions for reported pain level from 4 to 7 -[MEDICATION NAME] 650 mg was administered on 2 occasions During interview with the Director of Nursing (DON) on 6/15/17 at 12:00 P.M., he said that [MEDICATION NAME] should be used first and assessed for effectiveness before utilizing a stronger medication. 3. For Resident #1, the Facility failed to ensure that a medication was administered in accordance with the physician's orders [REDACTED].>Resident #1 was admitted to the Facility in 10/2016 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set assessment ((MDS) dated [DATE], indicated the Resident cognition and memory was intact, and required limited assistance in his/her activities of daily living. Review of the physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. The nurse signed that she had administered the [MEDICATION NAME], 2 times on 4/29/17 and 2 times on 4/30/17. Subsequently administering 20 mg daily, instead of prescribed 10 mg. Review of the medication record and nurses notes failed to indicate the extra dose was either administered in error or was documented incorrectly. During interview on 6/19/17 at 1:00 P.M., the Assistant Director of Nurses (ADON) said that she spoke with the nurse who had signed the MAR indicated [REDACTED]. The ADON said the nurse said that she had not administered the medication incorrectly. The ADON said the nurse had not recognized the error on 4/29/17 or 4/30/17 and had not written a note or error notation on the MAR. The ADON said that if the Facility had found the mistake they would completed a medication error report/incident.

Based on record review and staff interview, the facility failed to maintain clinical records in accordance with accepted professional standards that were complete and accurate for 2 Residents (#8 and #11) in a total sample of 16 Residents. Findings Include: 1. For Resident #9 the facility failed to provide accurate and complete physician's orders [REDACTED]. Resident #9 was admitted to the facility in 5/2017 with [DIAGNOSES REDACTED]. Clinical record review indicated the Resident was receiving [MEDICAL TREATMENT] services 3 times a week on Mondays, Wednesdays and Fridays with no current physician's orders [REDACTED].>On 6/15/17 at 10:20 A.M., the 2nd floor Unit Manager said the physician's orders [REDACTED]. 2. For Resident #11, the facility failed to ensure the clinical record was accurately documented to reflect the Resident's health status. Resident #11 was admitted to the facility in 2/2016 with [DIAGNOSES REDACTED]. Review of the most recent quarterly MDS with a reference date of 4/25/17, indicated that Resident #11 required supervision of staff for activities of daily living and had pain. Review of nursing progress notes indicated an entry on 4/24/17 which indicated Resident #11 was confused, had antihypertensive medications held due to low blood pressure, was dependent on oxygen therapy, had diminished lung sounds, and was diabetic. During interview with the Director of Nursing (DON) on 6/19/17 at approximately 2:00 P.M., he said that the progress note was entered into Resident #11's electronic record by mistake.

Based on record review and staff interview, the facility failed to obtain a psychiatric consult as ordered by the physician in a timely manner for 1 Resident (#7) in a total sample of 16 Residents. Findings include: For Resident #7 the facility failed to obtain a psychiatric consult for Dementia as ordered by the physician in a timely manner. Resident #7 was admitted to the facility in 5/2017 with [DIAGNOSES REDACTED]. Clinical record review indicated that on 6/4/17 the physician interim orders were as follows: 1. Pt. is a Full Code- See MOLST (Massachusetts Orders for Life Sustaining Treatment) 2. Wound Care Consult 3. Psychiatry consult for Dementia Further clinical record review indicated that the Wound Care Consult and the MOLST information had been addressed, however the Psychiatry consult for Dementia had not been addressed for the Resident to be seen by the facility's consultant psychiatric services. The Resident was not evaluated by the consultant psychiatric service until after 6/15/17, due to it being brought to the attention of the facility by the Surveyor. On 6/15/17 at 9:15 A.M., the 2nd floor Unit Manager said facility failed to obtain the psychiatric consult as ordered by the physician for Resident #7 resulting in an 11 day delay in obtaining the consult.

Based on record review, observation and interviews, the facility failed to consider behavioral interventions (non-pharmacological) prior to the addition of an antipsychotic medication for 1 resident (#9), out of a total sample of 16 residents. Findings include: Resident #9 was admitted to the facility in 10/2016 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] and the most recent Quarterly MDS dated [DATE] indicated the Resident had impaired memory loss and impaired decision making. Both MDS indicated he/she did not exhibit symptoms of behaviors associated with mood and did not exhibit any behaviors. The Resident required supervision in most areas of his/her activities of daily living. Review of the medical record indicated that according to the social service admission assessment and progress notes dated 10/28/16, 10/31/16, 11/4/16 and 11/10/16 indicated the Resident had no history of mental illness, did not exhibit behaviors and was not prescribed psychoactive medications. According to the Social Worker's progress note, the Resident was long term and was transitioned to the Facility's long term care unit in 11/2016. On 12/1/16, the Social Worker indicated the Resident had a room change and adjusted well. On 2/13/17, the social worker's progress note indicated the Resident was upset and confused. The note indicated the Resident could not express self specifically, but indicated he/she was upset with medical condition, was having problems with roommate and spoke of family. The social worker indicated the Resident was calm when she left and thanked the social worker for the visit. On 2/15/17, the Nurse Practitioner (NP) assessed the Resident's pain and indicated that she spoke with the Health Care Proxy (HCP). The HCP had indicated he/she had concerns that the pain medication ([MEDICATION NAME] (opioid pain medication) 50 mg, three times daily and [MEDICATION NAME] 50 mg, 1 tablet, every 6 hours as needed) was causing an increase in his/her dementia symptoms. The NP indicated the HCP wanted to stop the [MEDICATION NAME], but after discussion agreed to continue with the pain medication. Additional review of the medical record failed to indicate the Resident was exhibiting behaviors or an increase in his/her dementia symptoms. Review of the care plans failed to indicate that the Resident exhibited behaviors that required medication as a treatment, until after the initiation of the antipsychotic medication on 5/1/17. An activities care plan initiated on 3/2/17, indicated that the Resident could be frustrated with situations and people. The care plan identified the behaviors as the reason the Resident chose to spend time in room. The goal was to attend a lunch group twice a week and the interventions were to redirect and invite to lunch. On 3/29/17, the social worker indicated she met with Resident for a routine visit and noted the Resident was somewhat anxious. The Resident was worried about family and said that he/she felt like there was something he/she was suppose to do (pay bills). The Social Worker indicated she told the Resident not to worry and gave the Resident her business care. On 4/20/17, the Resident asked for a room change as he/she wanted a roommate he/she could converse with. The Resident was moved to another room. On 4/27/17, the Social Worker met with the Resident, after she learned of continued difficulties with roommate. The Resident became agitated during the visit when the conversation turned to the roommate. The Social Worker was unclear of the issues, but indicated the meeting was unsuccessful and left. There was no subsequent social service notes and no indication the Residents were separated or offered a room change. Further review of the medical record indicated that the Nurse Practitioner (NP) prescribed the antipsychotic medication [MEDICATION NAME] 12.5 mg, twice a day on 4/28/17. The 4/28/17, nurse's note indicated the Resident was severely upset with roommate. The nurse's note indicated the Resident and roommate had bad words against each other and the NP was called and ordered the medication and a psychiatric consult. On 5/5/17, the consulting psychiatric provider assessed the Resident. The psychiatric consultant indicated that the Facility staff had reported to her that the Resident had been aggressive, hostile, angry and swearing. The assessment indicated that a mood stabilizer was needed and recommended adding the medication [MEDICATION NAME] 125 mg daily (an anticonvulsant, used as a mood stabilizer). The assessment did not recommend discontinuing the [MEDICATION NAME], but did not provide indication for it's continued use and the physician was not made aware of the recommendation for the [MEDICATION NAME]. Additional review of the medical record failed to identify behaviors and approaches had been tried and failed prior to the implementation of an antipsychotic medication for a Resident with dementia. The record failed to identify that the Resident exhibited and/or showed signs of aggression and agitation. During the initial tour on 6/14/17 at 8:30 A.M., Unit Manager #2 said the Resident was alert and pleasant and walked the unit repetitively. The Unit Manager did not indicate the Resident exhibited problems and said that the Resident had requested his/her current roommate. During interview on 6/19/17 at 10:30 A.M., the Social Worker indicated the Resident and roommate had problems and continued with problems. She said that neither resident wanted a room change and therefore no room change was made. The Social Worker did not know what other options (nonpharmological) was tried prior to the the medication. The Assistant Director of Nurses and Director of Nurses were interviewed on 6/19/17 at 11:00 A.M. The staff provided behaviors sheets, that were initiated after the antipsychotic medication was started, but could not provide indication of alternate interventions (behavioral) that had been attempted and failed prior to the antipsychotic. The Staff were not aware of the recommendations made by the psychiatric consultant on 5/5/17. During interview and observation of Resident #9 on 6/19/17 at 10:00 A.M., the Resident was in room watching television. The Resident was alert and engaged easily in conversation. The Resident had some recall about events surrounding some recent medical assessments, but was easily distracted and changed subjects during the interview. The Resident discussed roommate and placement. The Resident discussed aging and changes in self. The Resident did not become anxious and/or agitated during the encounter.

Based on record review and staff interview, the facility failed to notify the attending physician of abnormal blood work for 1 Resident (#2) out of 16 sampled residents. Findings include: Resident #2 was admitted to the facility in 1/2017 with [DIAGNOSES REDACTED]. Review of the admission MDS with a reference date of 1/16/17, indicated that Resident #2 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 8 out of 15 and required extensive assistance of staff for all activities of daily living. Review of the medical record indicated that there was a physician's order dated 4/27/17 for Resident #2 to have blood work. This blood work included TSH ([MEDICAL CONDITION] Stimulating Hormone). Review of laboratory results indicated the facility received the on 4/28/17 and included abnormal results for TSH. Further review of the medical record failed to indicate that facility staff informed the physician of the results of the abnormal TSH results. During interview on 6/16/17 at 10:50 A.M., Unit Manager #2 and staff nurse #1 said that there was no documentation in the medical record that the physician was notified of Resident #2's abnormal lab result for TSH.

Based on record review, and confirmed by staff interview, the Facility failed to ensure that the environment for one of three sampled residents (Resident #1), remained as free of accident hazards as is possible. On [DATE] at 6:50 A.M., Resident #1 was instructed and assisted by Certified Nurse Assistant (CNA) #1 to roll toward and hold onto the right siderail while positioned in the middle of the bed for incontinence care. CNA #1 then left Resident #1 holding onto the right siderail, and she walked to the left side of the bed. Resident #1 rolled out of bed onto the floor when the siderail released from the weight of Resident #1. The Hospital Report, dated [DATE], indicated Resident #1's femoral fracture was the event that led to his/her death. Findings included: The Patient Care Referral Form to the Facility, dated [DATE], indicated Resident #1 was alert and oriented and his/her [DIAGNOSES REDACTED]. The Patient Care Referral Form indicated Resident #1 required assistance with all personal hygiene needs and was transferred via a mechanical lift into an electric wheelchair. The Face Sheet indicated Resident #1 was admitted to the Facility, [DATE]. The admission fall evaluation, dated [DATE], indicated Resident #1 was able to communicate his/her needs, was incontinent, required assistance with bed mobility and transfers, and had no history of falls in the last 30 days. The Director of Nurses (DON) was interviewed at 8:20 A.M., 11:45 A.M. and 4:30 P.M. on [DATE] and at 10:00 A.M. on [DATE]. The DON said the restrictive device evaluation, dated [DATE], indicated quarter siderails were used as a positioning enabler to promote increased mobility while in bed. The Surveyor interviewed Physical Therapist (PT) #1 at 10:15 A.M. on [DATE]. The physical therapy evaluation note, dated [DATE], indicated and PT#1 said, Resident #1 had [DIAGNOSES REDACTED]; Resident #1 remained at baseline for functional mobility, and no physical therapy was recommended at this time. The physical therapy note indicated that Resident #1 was followed by nursing and occupational therapy for an air mattress, a wheelchair cushion, and a trapeze bar that was to be set up above his/her bed. The Surveyor interviewed Occupational Therapist (OT) #1 at 4:20 P.M. on [DATE]. OT #1 said, and the occupational therapy evaluation, dated [DATE], indicated Resident #1 was dependent for positioning needs. OT #1 said Resident #1 was dependent for rolling from side to side but one staff member could roll to one side and hold onto a siderail for incontinence care. The plan of care, updated [DATE], indicated Resident #1 required 2 nursing staff member to complete bathing and dressing and required physical assistance for toileting (incontinence) needs. The certified nurse assistant care card indicated Resident #1 required the physical assistance of 1 to 2 nursing staff members for bed mobility, and used a bedpan for bowel movements. The Admission Minimum Data Set (MDS) assessment, completed on [DATE], indicated that Resident #1 required extensive assistance of two staff members for bed mobility, and required extensive assistance of one staff member for toileting needs. The MDS indicated Resident #1 weighed 184 pounds, his/her height was 75 inches, and his/her weight was unchanged during the past month. The Surveyor interviewed Certified Nurse Assistant (CNA) #1 at 8:45 A.M. on [DATE]. The Surveyor interviewed CNA #2 at 9:00 A.M. on [DATE]. CNA #1 and CNA #2 said they were assigned to provide personal care to Resident #1 during the night shift. CNA #1 and CNA #2 said Resident #1 was repositioned every two hours and required the physical assistance of two staff members when repositioning and boosting him/her in bed. CNA #1 and CNA #2 said Resident #1 required the physical assistance of one staff member during incontinence care because with one person's assistance he/she could roll to one side and hold onto the siderail during incontinence care. CNA #1 said she left Resident #1 in the middle of the bed, CNA #1 assisted Resident #1 when rolled toward the right siderail, she walked from the right siderail to the left side of the bed to complete incontinence care. The right siderail released and broke off the bed from the weight of Resident #1. CNA#1 said Resident #1 rolled out of bed onto the floor and landed onto of the siderail, and Nurse #1 was summoned for help. CNA #1 said she thought Resident #1 would be safe being rolled towards the bed siderail because the siderail was attached and would prevent a fall. The Surveyor interviewed Nurse #1 at 7:30 A.M. on [DATE]. Nurse #1 said on [DATE] at approximately 6:15 A.M. Nurse #1 was called to Resident #1's room for an emergency. Nurse #1 said she found Resident #1 lying on his/her right side on the floor. Nurse #1 said, and Nurse #1's SBAR (situation background assessment recommendation) form, dated [DATE], indicated Resident #1 fell out of bed during personal care due to a siderail failure. Nurse #1 said, and Nurse #1's SBAR form indicated Resident #1 had hit his/her head on the floor and the siderail. Resident #1 was unable to feel pain in the lower extremities due to [DIAGNOSES REDACTED], the on call physician was notified, and he/she was transferred to the hospital for evaluation. The Hospital Report, dated [DATE], indicated Resident #1 sustained a left femoral fracture that was casted and he/she returned to the facility on the same date. The Surveyor interviewed Nurse #2 at 3:00 P.M. on [DATE]. Nurse #2 said, and Nurse #2's SBAR form, dated [DATE], indicated upon arrival from the hospital Resident #1 had stroke like symptoms and he/she was immediately transported back to the hospital for further evaluation. The Hospital Report, dated [DATE], indicated Resident #1 may well be terminally ill, with the femoral fracture being the event that led to his/her demise. Resident #1 was discharged home with hospice services. The Death Certificate, dated [DATE], indicated Resident #1 died from aspiration pneumonia and the long term effect of multiple sclerosis. CNA #1 said, while on the floor awaiting transfer to the hospital, Resident #1 told her that staff were aware that the right siderail needed to be fixed with no specifics of what staff knew or what was wrong with the right siderail. The DON said she found out during the investigation that Resident #1's left siderail had been tightened in the past; however, both siderails had been functioning appropriately prior to the incident. The Surveyor interviewed CNA #3 at 3:30 P.M. on [DATE] and at 9:20 A.M. on [DATE]. CNA #3 said approximately one month ago, before [DATE], on a weekend when the Maintenance Director was not in the building, CNA #3 said he tightened Resident #1's left siderail and the rail worked appropriately after he tightened it. The Surveyor interviewed the Director of Maintenance at 3:50 P.M. on [DATE]. The Director of Maintenance said he did at least daily rounds on each unit to check the maintenance log located at each nurses station. The Director of Maintenance said he was not notified that Resident #1's left siderail was tightened by CNA#3. The Director of Maintenance said he did monthly rounds on every unit and the rounds included checking the function of each bed. The Director of Maintenance said he found no problems with Resident #1's siderails when checked in August, 2014.

Based on record reviews, observation and staff interviews, the facility failed for 6 residents (#1, #7, #10, #11, #16 and #19) of a total sample of 24 residents, to ensure that each resident receive necessary care and treatment to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The findings included: 1. For Resident #1, the facility failed to provide prompt treatment for [REDACTED]. The facility also failed to consider the recommendations of a cardiology consultant. Resident #1 had [DIAGNOSES REDACTED]. The resident's most recent quarterly Minimum Data Set Assessment (MDS) with a reference date of [DATE], indicated that the resident had some cognitive impairment and needed extensive assistance from facility staff to complete the activities of daily living. A nurses' note on [DATE] for the 7 AM -3 PM shift reported that the resident was lethargic and "listing" to the left. The nurse wrote that the condition seemed to resolve when the resident was put to bed. On [DATE], [DATE] and [DATE], nurses' notes indicated that the resident developed a productive cough. On [DATE], a facility nurse contacted the physician by telephone. an order for [REDACTED]. A nurses' note on [DATE] for the 3 PM -11 PM shift reported that the resident was leaning to the right side while in bed and continued with a productive cough. The resident ate poorly during the shift and was noted to be sleeping while up in the wheelchair. A nurses' note written on [DATE] for the 7 AM-3 PM shift, reported that the resident was lethargic and slept "all early morning." The resident reported to the nurse "I'm just pooping out." The resident's apical pulse was measured at 160 beats per minute (normal ,[DATE].) The resident's temperature was 97.5 axillary and pulse oximetry was 95%. No blood pressure or respirations were noted. The nurse wrote that the physician was notified and had not returned the call. No follow up assessment by the nurse nor follow up with the physician was evident. A nurses' note on [DATE] for the 3 PM -11 PM shift reported that the resident was afebrile with diminished breath sounds and poor appetite. No follow up assessment of the resident's pulse was completed. A nurses' note on [DATE] for the 3 PM-11 PM shift reported that the resident's vital signs were blood pressure ,[DATE], pulse 68 and temperature 97.6 degrees. On [DATE] at 11:45 AM, a facility nurse completed a change in condition form that reported that the resident was very pale, slightly cyanotic, had increased confusion and had an apical pulse greater than 110 beats per minute. The resident's physician ordered that the resident go to the hospital. Four days after the resident's condition deteriorated, the resident was admitted to the hospital with [REDACTED]. The resident was readmitted to the facility on [DATE]. The resident's medication regimen included [MEDICATION NAME] 20 mg by mouth daily. On [DATE] the resident's physician ordered that the resident receive intravenous fluids for hydration. On [DATE] the resident was seen by a cardiology consultant. The consultant recommended that the [MEDICATION NAME] be reduced to every other day if the intravenous fluids were discontinued. The intravenous fluids were discontinued on [DATE]. Per record review on [DATE], the recommendation had not been communicated to the physician and the resident continued to receive the [MEDICATION NAME] daily. The third floor unit manager was interviewed on [DATE] at 11 AM. The unit manager was not aware that the resident had a pulse of 160 on [DATE] or that the physician never contacted the facility. The unit manager, clinical consultant and the facility Director of Nurses could find no information that demonstrated any follow up to the elevated pulse until the resident was hospitalized 3 days later. The unit manager also reported no awareness that the cardiology consultant had recommended a decrease in the [MEDICATION NAME]. Subsequently, the unit manager contacted the physician who ordered that the recommendation to decrease the [MEDICATION NAME] be implemented. The resident was observed on [DATE] at 11:30 AM and [DATE] at 9 AM. The resident was in bed and appeared quite debilitated. The resident slept when spoken to and appeared frail and thin. On [DATE] the physician ordered a hospice consult. The family agreed to hospice care and the resident was admitted for hospice care on [DATE]. 2. For Resident #7, the facility failed to implement a comprehensive and consistent approach to assess, evaluate, monitor and manage the resident's constipation. The facility also failed to consistently assess the effectiveness of the bowel regimen in a systematic fashion. When the resident's complaints of rectal pain increased, the facility failed to provide timely, effective interventions and failed to timely evaluate the need for a change in treatment in order to prevent hospitalization and manual disimpaction. Resident #7 had [DIAGNOSES REDACTED]. The [DATE], quarterly minimum data set (MDS) assessment indicated that the resident's cognition and decision making ability was impaired. The resident had mood indicators of depression and daily behaviors coded as verbal abusive toward staff. The pain assessment identified the resident had constant pain that made it difficult to sleep and limited day to day activities. Per record review, according the [DATE] physician note, the resident had chronic pain with intermittent constipation that was "controlled." Review of the [DATE] physician orders [REDACTED]. The resident's medications also included Klonopin (anti-anxiety); and [MEDICATION NAME] (antidepressant); both of the medications were ordered PRN, which the resident was requesting on a regular basis. All of the medications listed above identified constipation as a possible adverse reaction. The medication orders also included scheduled [MEDICATION NAME] (stool softener). PRN laxative orders included an order for [REDACTED]. On [DATE] at 2:20 PM, the surveyor was informed by Treatment Nurse #1 that the resident was complaining of severe rectal pain. The 2:20 PM nurse's note documented that the physician was "updated on rectal pain/complaints, ordered [MEDICATION NAME] suppository 3 x day x 3 days." (steroid medication) On [DATE] at 11:30 AM, the primary physician #1 was interviewed by telephone. During discussion regarding the resident pain management regimen, the physician stated that the resident had "brittle diabetes" and that the goal was to maintain a balance between keeping the resident alert and cooperative. The physician stated that the resident had rectal pain and that he/she ordered [MEDICATION NAME] the previous day. The physician stated that he/she was waiting for nursing information regarding the resident's last bowel movement and that he/she needed to come in and do a rectal exam. The physician stated that he would probably need to get an abdominal CAT scan at some point. The clinical record was reviewed again during the extended survey on [DATE] and revealed that beginning [DATE] the resident began verbalizing repeated complaints of constipation with diminished hypoactive bowel sounds noted. On [DATE], the ,[DATE] staff administered [MEDICATION NAME] suppository for continued complaints of constipation with "fair effect, results pending." Later that evening, the resident refused the pill form of [MEDICATION NAME] but the nurses never documented if the resident had results from the suppository. On [DATE] at 12:50 PM, the nurse documented that the resident received [MEDICATION NAME] (narcotic [MEDICATION NAME]) for rectal pain,"large BM on ,[DATE]." There was no further documentation regarding an assessment of the resident bowel status until surveyor inquiry with the physician on [DATE]. Review of the [DATE], ,[DATE] nurses notes revealed that the resident was administered one bottle of magnesium [MEDICATION NAME] at 5:00 PM and had two fleets enema(s) at 9:30 PM with "no results, no BM." The nurses note stated that resident continued to complain of rectal pain and constipation and was medicated with [MEDICATION NAME] at 10:30 PM. The physician also added [MEDICATION NAME] (laxative) to the daily drug regimen. Further review revealed that the physician visited on [DATE] at 2:00 PM and documented that the resident had "impacted stool + + BM." At 10:00 PM on [DATE], the ,[DATE] nurse documented the resident continued to complain of constipation with a small hard bowel movement. Despite the repeated complaints of constipation, review of the [DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On [DATE] at 9:30 AM, Resident #7 was observed sleeping in bed. Unit Manager #1 reported that the resident complained of pain and was "very constipated" despite laxatives and enemas. Unit Manager #1 reported that the resident had positive bowel sounds. Unit Manager #1 stated that no other diagnostic evaluation had been completed. On [DATE] at 10:45 AM, the resident was sent out to the local emergency room . Per review of the nurse's note, the resident complained of rectal/abdominal pain and was medicated for pain and anxiety with poor effect." (Physician) updated on the status and current problems and ordered a transfer to (hospital) for evaluation CAT scan of abdomen ...feels we have exhausted all other options, [MEDICATION NAME] (bulk forming laxative,) [MEDICATION NAME] suppositories, magnesium [MEDICATION NAME], fleets enema. (Resident) is not complaining of constipation, positive BS (bowel sounds), abdomen non-tender ...unable to console or redirect. " Unit Manager #1 was interviewed at [DATE] at 11:30 AM regarding the circumstances prompting the resident's expedited transfer to the emergency room . Unit Manager #1 reported that the resident had complaints of increased rectal and abdominal pain. Unit Manager #1 retrieved the bowel book which identified that the resident was having regular bowel movements. The facility never attempted to reconcile the fact that, even though the bowel book stated the resident was having regular bowel movements, the resident continued to state that he/she was constipated and was not having the bowel movements that the facility said he/she had. Treatment Nurse #1, who was interviewed on [DATE] at 11:45 AM, stated that the resident was transferred to the hospital due to complaints of on-going rectal and abdominal pain. Treatment Nurse #1 described the resident as "squirming in bed" because of the pain and was requesting to go to the hospital. Treatment Nurse #1 was asked about his/her assessment of the source of the pain. Treatment Nurse #1 replied that it was most likely due to constipation and that he/she had used the term rectal pain interchangeably to mean constipation. The resident returned from the hospital at approximately 2:30 PM. According to the emergency room notes, the resident was diagnosed with [REDACTED]. The emergency room physician determined that a CAT scan was not indicated at the time. 3. For Resident #16, the facility failed to accurately assess the resident's change in condition resulting in a delay in medical treatment and a medical decline. Resident #16 was a closed record reviewed on [DATE]. The resident was admitted for short term care and had multiple [DIAGNOSES REDACTED]. The medical record indicated the resident had a hospitalization [DATE] - [DATE] for [MEDICAL CONDITION] after residing at the facility for two days. The medical record indicated the resident was initially admitted to the hospital on [DATE]. The hospital transfer summary dated [DATE] - [DATE], indicated that prior to admission, the resident had lived at home independently and for one week had poor oral intake and sustained a fall at home. The summary noted the resident was found to have acute [MEDICAL CONDITION] and had responded well with gentle IV (intravenous) hydration. The resident had hospital-acquired pneumonia, and it was resolving with IV antibiotics. Additionally, the resident had a [DIAGNOSES REDACTED]. On the day of discharge from the hospital [DATE], the resident was discharged to the nursing care facility with an anticipated length of stay of less than 30 days. The hospital summary noted the resident had some shortness of breath on exertion, and the lungs had diminished air entry bilaterally which appeared to be the resident's baseline. The resident had no extremity [MEDICAL CONDITION] and was noted to be alert and oriented to person and place. The nursing facility's resident admission assessment dated [DATE] at 1500 (3:00 PM) to the nursing care facility, indicated the resident had clear breath sounds and was observed to have bilateral lower extremity [MEDICAL CONDITION] of 1+. This initial assessment was different from the hospital's physical discharge information that reported that the resident had no lower extremity [MEDICAL CONDITION]. A review of the nurses' notes for the next day, dated [DATE] at 2300 (11:00 PM), indicated the resident had "baseline" shortness of breath, was anxious and had an increase in agitation. The note indicated a new physician's orders [REDACTED]. There was no information of the resident's response to the medication. The physician's telephone order for the above medications had a time of 1930 (7:30 PM) and also noted the resident was to have a urinalysis and psychiatric consult. Review of the next nurses' notes on [DATE] for the 11:00 PM - 7:00 AM shift, noted the resident was confused and forgetful. The next entry was at 12:35 PM and indicated the resident's lungs had right side crackles. The 2300 shift note indicated the resident was sent to the hospital with no other assessments/information of the resident's condition. The physician's telephone order indicated the physician had ordered the resident sent to the hospital at 2000 (8:00 PM). The hospital history and physical, dated [DATE], indicated the resident had complained of shortness of breath for three days at the nursing facility. The hospital report noted the resident had exhibited shortness of breath, difficulty breathing and palpitations. The report also noted the resident required 3 liters of oxygen to bring his/her saturation rate above 90%. The physical examination at the hospital noted the resident's lower extremities to have 3+ [MEDICAL CONDITION] and mottling of the toes. The resident was admitted to the hospital with [REDACTED].) The resident's exhibited symptoms noted at the hospital were not documented anywhere in the resident's record at the facility. The nursing care facility information had no assessment of the resident's shortness of breath, difficulty breathing or palpitations, and the nurse on [DATE] noted the shortness of breath as "baseline". There was no information of an assessment of the resident's lower extremities [MEDICAL CONDITION] increasing over the two days and the presence of mottling of the toes. The resident was discharged from the hospital and returned to the facility [DATE]. The hospital discharge summary dated [DATE], indicated the resident had presented to the hospital emergency room with multiple symptoms that included shortness of breath, difficulty breathing, palpitations and lower extremity [MEDICAL CONDITION]. At the time of discharge on [DATE], the physician wrote the resident's renal dysfunction was worsening and the resident had a diminished urine output. The summary noted the physician with the patient and family had agreed to Hospice care and comfort measures. A review of the readmission physician orders [REDACTED]. The closed record noted the resident had expired at 3:42 AM on [DATE]. A review of the nurses' notes dated [DATE] for the 3:00 PM - 11:00 PM shift noted the resident was alert, oriented, pleasant and smiling when readmitted . The nurse had assessed the resident's lower extremities to have no pedal [MEDICAL CONDITION] and had positive pedal pulses. The note indicated the resident was a DNR (Do Not Resuscitate) and comfort measures. The nurses' note had no documentation of the resident on Hospice services. The nurses had no documentation of assessing the resident on the next shift of 11:00 PM - 7:00 AM. On [DATE] for the 7:00 AM - 3:00 PM shift, the nurse noted the resident was lethargic and not responding to verbal stimuli. The resident had no oral intake and wrote the patient had 2+ [MEDICAL CONDITION] from the feet to the hip this AM and wrote at 12 noon the the patient was comfortable and in no acute distress. There was no documentation of any further assessing of the resident's change in condition and/or notifying the physician of the residents changes in condition when first observed by the nurse. This same note at 1:00 PM read the patient was rechecked and the nurse wrote the resident's respirations were "up to ,[DATE] % and now responding to verbal stimuli". The nurse contacted the physician who had ordered medications of an increase in [MEDICATION NAME] to every two hours for shortness of breath and agitation, [MEDICATION NAME] for secretions and [MEDICATION NAME] for anxiety. The nurse wrote the resident was admitted to the Hospice service with no time noted and described the resident's right lower leg was seeping clear serous fluids. A review of the telephone physician orders [REDACTED]. The resident expired at 3:42 AM on [DATE]. Interview and review of the record [DATE] at 4:10 PM with the Director of Nurses, stated h/she would have to review the record and would speak to the surveyor later. On [DATE] at 8:45 AM interview with the Director, could offer no explanation as to why the nurse had not contacted the physician earlier in the day when the resident's condition had changed. The Director of Nurses had no explanation of why the 11:00 PM - 7:00 AM shift nurse had not assessed and documented the resident's status during the night. The Director had offered to the surveyor that the resident was to be Hospice but could not explain why the physician had not been notified when the resident's condition had drastically changed from the time of admission. The Director of Nurses said the nursing staff had limited assessments of the resident and could offer no explanation for the lack of documentation of the resident's change in condition, when the resident had been transferred to the hospital and when readmitted back to the facility. 4. The facility failed to provide an adequate and effective bowel regimen for Resident #11 who reported to staff on several occasions symptoms of narcotic-induced constipation resulting in discomfort and distress. Resident #11 had been at the facility for 3 weeks, admitted following a hospitalization for acute alcohol withdrawal and [MEDICAL CONDITION] with acute [MEDICAL CONDITION] infarction. Resident #11 also had a previous [DIAGNOSES REDACTED]. Review of the resident's record revealed that the resident suffered significant pain due to the [MEDICAL CONDITION], particularly in the abdomen and back. At the time of record review on [DATE], the resident's pain medication regimen was for [MEDICATION NAME] 5 mg four times daily scheduled at 8:00 am, 12:00 noon, 4:00 PM and 8:00 PM. To provide coverage for breakthrough pain, there was also an order [REDACTED]. The breakthrough pain medication coverage had been increased on [DATE] to 5 mg every 4 hours prn for moderate pain and 10 mg every 4 hours for severe pain. The resident received two doses of 10 mg on both [DATE] and [DATE], and 2 doses of 5 mg on [DATE]. According to the Physician Desk Reference 2010 edition, constipation is a common side effect of [MEDICATION NAME] use. During interview on [DATE] at 11:05 am, the resident reported being in significant discomfort and distress due to constipation. The resident stated this had been going on for a long time without being able to have a "good" bowel movement, and knew it was because of all the pain medication. The resident stated that the constipation and discomfort had been reported to staff, but was unsure about receiving any routine bowel medications to help with the constipation, since it had been a problem for quite a few days. The resident thought the nurse administered some medication that morning but had not yet had any relief. Review of the resident's record following this conversation revealed that the only bowel medication ordered for Resident #11 was [MEDICATION NAME] 10 mg daily as needed for constipation, to be given either orally or by suppository. This medication had been given only once since the resident's admission, on [DATE]. The resident's care plan for "Alteration in Elimination" had only one reference to constipation, stating house protocol if no bowel movement in 3 days. A note had been added dated [DATE] which stated prune juice, prune whip on tray. Review if the facility's policy and procedure for bowel regime indicated that if the resident had not had a bowel movement for 6 consecutive shifts, the resident was to be given two tablets of [MEDICATION NAME] at bedtime, followed by a [MEDICATION NAME] suppository if no bowel movement the next morning. The policy further stated that if the constipation continued, the physician would be notified. Review of the bowel record for Resident #11 indicated that the resident had been having bowel movements less than daily, but according to statements by the resident this was not adequate for effective relief. At the time of record review on [DATE], the record showed that the resident had no bowel movement on 7 of the 20 days during [DATE]. The resident was noted to have no bowel movement on the night shift on [DATE] through three shifts on [DATE] and was given one dose of [MEDICATION NAME] tablets on [DATE]. This was the only time that [MEDICATION NAME] was administered to the resident. The bowel record again showed that the resident had no bowel movement from the night shift on [DATE] through the day shift on [DATE], but no [MEDICATION NAME] was administered to the resident. A note written by the physical therapist on [DATE] stated that the resident was complaining of "bowel movement coming on every time (the resident) stands but it doesn't come." The therapist noted that the resident complained of constipation during the session and asked for prune juice. On [DATE], the Director of Nurses completed and signed a pain evaluation form for Resident #11. The pain evaluation form included a notation that the resident was experiencing constipation as a possible drug-related side effect. There was no indication that any interventions would be initiated. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the MAR indicated [REDACTED]. At 11:30 am, Unit Manager #1 was asked and reported being unaware of any problem with constipation for Resident #11 and confirmed that the resident had no bowel regimen as part of the care plan. Staff Nurse #1, who had given medications to Resident #11 that morning, joined the conversation with Unit Manager #1. Staff Nurse #1 reported not being aware the resident had problems with constipation and that no bowel medications had been administered to Resident #11 that morning or at any time recently. 5. For Resident #19, the facility failed to ensure the resident received intravenous fluids and medication as prescribed by the physician. In addition, following the failure to implement the intravenous therapy, the facility staff failed to notify the physician so that proper and effective care and treatment could be provided. Resident #19 had lived at the facility since [DATE] and had [DIAGNOSES REDACTED]. The resident's quarterly Minimum Data Set (MDS) of [DATE] identified the resident as having intact long and short term memory, and intact decision making ability. The MDS indicated the resident required extensive assistance from staff for his/her activities of daily living. Review of the medical record revealed on [DATE] the nursing staff noted the resident was exhibiting upper respiratory symptoms which included a productive cough and his/her lung sounds were coarse with crackles. The physician was notified and ordered a chest X-ray. The X-ray report showed no infiltrate. The nurse documented the resident's appetite was poor and tolerated some fluids. Review of the subsequent nurses' notes, for the next five days, from [DATE] through [DATE], the resident continued to exhibited symptoms of an upper respiratory infection. The nurses documented the resident had cold symptoms, a persistent cough and his/her lungs were congested. The resident's oral intake of foods and fluid was poor and it was documented the resident refused medication and was noted on several occasions to be lethargic. In addition, the resident's weight was down 12 pounds since [DATE] (139 pounds down to 124 pounds). On [DATE], the nurse documented the resident exhibited increased confusion and reported the resident was afraid because he/she was unable to catch breath. The nurse wrote that the resident continued with a coarse cough, he/she color was poor and the resident was weaker. The physician was notified and ordered a chest X-ray and laboratory tests. Although, the chest X-ray was negative, the 11 to 7 nurse on [DATE] reported the resident remained confused, refused all fluids and food and bilateral lung sounds were diminished. The 7 to 3 nurse notified the physician and obtained an order for [REDACTED]. On [DATE], after the resident was placed on I and O (intake and output) monitoring, the speech therapist assessed the resident because of frequent coughing. The nursing staff attempted twice to start an intravenous (IV). The nurse documented at 4:30 PM on [DATE] only that he/she was unable to start the IV, as the resident's skin was fragile and became bruised. There was no reference in that note or any subsequent notes that the physician was notified that the IV was not started. In addition, other than a notation found on the laboratory test dated [DATE], there was no signed physician order [REDACTED]. laboratory results dated [DATE] documented the resident's sodium was 135 (normal reference range ,[DATE] mmol/L) and blood urea nitrogen (BUN) was 27 (reference ,[DATE] mg/dl). This laboratory report had written notations on it which listed three oral medications and to start an IV of D5 ? normal saline with 20 meq sodium at 75 cc per hour for 72 hours. Review of the physician orders [REDACTED]. The nurses notes documented the resident continued with symptoms that included weakness and variable oral intake. On [DATE], nine days after the failed attempt to hydrate the resident with IV fluids and medication, the nurse notified the physician of a 7 pound weight loss in one week. The physician ordered laboratory tests (complete blood count, basic metabolic panel, folic acid level, B 12 level, Vitamin D level, [MEDICAL CONDITION] level, calcium level, hepatic profile and urine analysis) to be completed on [DATE]. Record review and interview with the Director of Nurses on [DATE] at 11 AM confirmed that the laboratory test ordered by the physician on [DATE] had not been done. During interview on [DATE] at 11 AM, the Director of Nurses acknowledged that not only had the nursing staff not transcribed the physician's orders [REDACTED]. However, further discussion confirmed that there was no documentation of the resident's refusal or evidence the physician was notified of the resident's refusal so that proper and effective treatment could be provided. 6. For Resident #10, who required a 1200 ml per 24 hour fluid restriction secondary to end stage [MEDICAL CONDITIONS] and recurrent [MEDICAL CONDITIONS], the facility failed to monitor the resident's fluid intake. The facility assumed the fluid restriction would be managed by the resident without confirmation or discussion with the the resident. There was no monitoring, assessing or educating the resident of the need to maintain fluid balance. The facility also did not ensure effective communication with the [MEDICAL TREATMENT] center when there was a change in the resident's status. Resident #10 had [DIAGNOSES REDACTED]. The resident received [MEDICAL TREATMENT] three times per week.The resident's [DATE], quarterly Minimum Data Set (MDS) assessment, identified the resident as having intact memory and decision making ability.During initial tour on [DATE], Unit Manager #1 reported that Resident #10 was a [MEDICAL TREATMENT] patient with a recent hospitalization for [MEDICAL CONDITION] and pneumonia. Unit Manager #1 also reported that the resident was oxygen dependent and was on a fluid restriction that resident managed on his/her own.Per record review, on [DATE] the resident was sent to the emergency room for acute shortness of breath and congestion. The resident was diagnosed with [REDACTED]. Per record review, on [DATE] the physician visited and documented that the resident feels better after recent episode of [MEDICAL CONDITION]. According to the [DATE], 11:00 PM nurses notes, the resident was documented with a change of condition that included, shaking, a blood pressure of ,[DATE], pulse rate of 100, temperature of 99.4. The resident was reported short of breath, wheezing on exhalation, and expectorating thick green mucus.On [DATE] at 6 AM, the resident was sent to the emergency room . Review of the [DATE] emergency room record provided per surveyor's request, revealed the resident was diagnosed with [REDACTED]. There were no medication recommendations. The resident was discharged from the emergency room to the [MEDICAL TREATMENT] center and then returned to the facility on [DATE] at 4:25 PM. Review of the [MEDICAL TREATMENT] communication book, which is used to provide two way communications between the facility and [MEDICAL TREATMENT] center, revealed no documented information regarding the resid

Based on record reviews, observation and staff interviews, the facility failed for 4 residents (#1, #3, #16, #19) of a total sample of 24 residents, to ensure that each resident's physician be notified of a change in condition. The findings included: 1. For Resident #1, the facility failed to notify the physician of a critically elevated heart rate resulting in a delay in treatment. The facility also failed to notify the physician about the recommendations of a cardiology consultant. Resident #1 had [DIAGNOSES REDACTED]. The resident's most recent quarterly Minimum Data Set Assessment (MDS) with a reference date of [DATE], indicated that the resident had some cognitive impairment and needed extensive assistance from facility staff to complete the activities of daily living. A nurses' note on [DATE] for the 7 AM -3 PM shift reported that the resident was lethargic and "listing" to the left. The nurse wrote that the condition seemed to resolve when the resident was put to bed. On [DATE], [DATE] and [DATE], nurses' notes indicated that the resident developed a productive cough. On [DATE], a facility nurse contacted the physician by telephone. an order for [REDACTED]. No other vital signs were taken. A nurses' note on [DATE] for the 3 PM -11 PM shift reported that the resident was leaning to the right side while in bed and continued with a productive cough. The resident ate poorly during the shift and was noted to be sleeping while up in the wheelchair. A nurses' note written on [DATE] for the 7 AM-3 PM shift, reported that the resident was lethargic and slept "all early morning." The resident reported to the nurse "I'm just pooping out." The resident's apical pulse was measured at 160 beats per minute (normal ,[DATE].) The resident's temperature was 97.5 axillary and pulse oximetry was 95%. No blood pressure or respirations were noted. The nurse wrote that the physician was notified and had not returned the call. No follow up assessment by the nurse, nor follow up with the physician, was evident despite ongoing difficulties including diminished breath sounds and poor appetite. On [DATE] at 11:45 AM, a facility nurse completed a change in condition form that reported that the resident was very pale, slightly cyanotic, had increased confusion and had an apical pulse greater than 110 beats per minute. The resident's physician ordered that the resident go to the hospital. Four days after the resident's condition deteriorated, the resident was admitted to the hospital with [REDACTED]. The resident was readmitted to the facility on [DATE]. The resident's medication regimen included [MEDICATION NAME] 20 mg by mouth daily. On [DATE] the resident's physician ordered that the resident receive intravenous fluids for hydration. On [DATE] the resident was seen by a cardiology consultant. The consultant recommended that the [MEDICATION NAME] be reduced to every other day if the intravenous fluids were discontinued. The intravenous fluids were discontinued on [DATE]. Per record review on [DATE], the recommendation had not been communicated to the physician and the resident continued to receive the [MEDICATION NAME] daily. The third floor unit manager was interviewed on [DATE] at 11 AM. The unit manager was not aware that the resident had a pulse of 160 on [DATE] or that the physician never contacted the facility. The unit manager, clinical consultant and the facility Director of Nurses could find no information that demonstrated any follow up to the elevated pulse until the resident was hospitalized 3 days later. The unit manager also reported no awareness that the cardiology consultant had recommended a decrease in the [MEDICATION NAME]. Subsequently, the unit manager contacted the physician who ordered that the recommendation to decrease the [MEDICATION NAME] be implemented. The resident was observed on [DATE] at 11:30 AM and [DATE] at 9 AM. The resident was in bed and appeared quite debilitated. The resident slept when spoken to and appeared frail and thin. On [DATE] the physician ordered a hospice consult. The family agreed to hospice care and the resident was admitted for hospice care on [DATE]. (Please refer to F 309). 2. For Resident #16, the facility RN failed to notify the physician's prior to completing a pronouncement of death. Resident #16 was a short term care resident with multiple [DIAGNOSES REDACTED]. A closed record review was done [DATE]. It was noted that the resident had expired at 3:42 AM on [DATE]. Per review of the nurses' note dated [DATE] for the 11 PM - 7 AM shift, the resident had received [MEDICATION NAME] (narcotic pain medication) and [MEDICATION NAME] (anti-anxiety medication) at 1:00 AM and 3:00 AM. The nurse then wrote the resident expired at 3:42 AM. There was no information of the RN conducting an assessment of the resident and documenting the RN pronouncement. A review of the facility's RN death pronouncement policy indicated the RN was to verify the absence of pulse, blood pressure and of respiration. The nurse was to document the above information along with notification of the physician and a physician's orders [REDACTED]. The medical record had a copy of the RN pronouncement of death and indicated the time of death was at 3:42 AM. A review of the telephone physician's orders [REDACTED]. The nurse had not notified the physician prior to the pronouncement of death. Interview and review of the medical record with the Director of Nursing on [DATE] at 3:45 PM, confirmed the nurse had not followed the facility's policy for the RN pronouncement of death final assessment and documentation. 3. The facility failed to notify the physician of a drug error in the transcribed dose of the antibiotic [MEDICATION NAME] for six months for Resident #3. The facility changed the transcribed order without the physician's authorization, without conducting an assessment of Resident #3's status after receiving half of the prescribed dose for this six month period and without reporting Resident #3's status to the physician so the physician could determine the appropriate course of treatment. Resident #3 had been living at the facility for over three years, and had current [DIAGNOSES REDACTED]. The resident also had a documented Extended-spectrum beta-lactamase (ESBL), or antibiotic-resistant infection of the urine. Historical documentation in the record indicated that the resident had suffered from the [MEDICAL CONDITION] infection since at least [DATE], when the physician noted it in a progress note. According to interview with the Director of Nursing on [DATE] at 2:35 PM, the physician initially ordered [MEDICATION NAME] at that time. Review of the physician orders [REDACTED]. Review of the resident's record revealed an interim order from the physician, dated [DATE], stating to "Reduce [MEDICATION NAME] to 125 mg by mouth daily." Review of the Medication Administration Record (MAR) for February 2011 showed that on [DATE] the original order was discontinued and the new order was transcribed as "[MEDICATION NAME] 250 mg/5 ml give 1.25 cc by mouth daily." As written, this transcribed order would provide 62.5 mg of [MEDICATION NAME] in 1.25 cc, half of the dose ordered by the physician. According to the MAR, the 62.5 mg dose was administered through the end of February 2011. All of the MARs and monthly physician order [REDACTED]. for administration each day during those months. On the [DATE] MAR and physician order [REDACTED]. However, the "1.25 ml" was crossed out by hand and "2.5 ml = 125 mg" was handwritten under the printed order. There were no initials indicating who made the change or date when it was made. It could not be determined by a review of the MAR when the change was made. Review of the nurses' notes for [DATE] revealed no documentation related to identification of the drug error and no evidence that the physician was advised of the error or of the resident's condition after receiving half of the prescribed treatment dose for six months. The documentation related to the [MEDICATION NAME] error was reviewed with the Director of Nurses on [DATE] at 12:15 PM. The Director acknowledged being unaware of any reported error. On [DATE] at 4:00 PM, the Director of Nurses reported that no other documentation of the drug transcription error or discussion with the physician had been located, and that there had been no "Medication Error Report" completed and forwarded to the Director of Nurses as required by facility policy. (Please refer to F 329) 4. Resident #19 had lived at the facility since [DATE] and had [DIAGNOSES REDACTED]. The resident's quarterly Minimum Data Set (MDS) of [DATE] identified the resident as having intact long and short term memory, and intact decision making ability. The MDS indicated the resident required extensive assistance from staff for his/her activities of daily living. On [DATE], the nurse documented the resident exhibited increased confusion and reported the resident was afraid because he/she was unable to catch breath. The nurse wrote that the resident continued with a coarse cough. The resident's color was poor, and the resident was weaker. The physician was notified and ordered a chest X-ray and laboratory tests. Although the chest X-ray was negative, the 11 to 7 nurse on [DATE] reported the resident remained confused, refused all fluids and food, and bilateral lung sounds were diminished. The 7 to 3 nurse notified the physician and obtained an order for [REDACTED]. laboratory results dated [DATE] documented the resident's sodium was 135 (normal reference range ,[DATE] mml/L) and blood urea nitrogen (BUN) was 27 (reference ,[DATE] mg/dl). This laboratory report had written notations on it which listed three oral medications and to start an IV of D 5 ? normal saline with 20 meq sodium at 75 cc per hour for 72 hours. On [DATE], after the resident was placed on I and O (intake and output) monitoring, the speech therapist assessed the resident because of frequent coughing. The nursing staff attempted twice to start an intravenous (IV). The nurse documented at 4:30 PM on [DATE] only that he/she was unable to start the IV, as the resident's skin was fragile and became bruised. There was no reference in that note or any subsequent notes that the physician was notified that the IV was not started as ordered.