Every finding on record at Pinellas Point Nursing and Rehab Center

Based on interview and record review, the facility failed to follow the resident's written care plan for mechanical lift transfers when staff attempted to transfer one resident (#1) out of three sampled residents without using the required mechanical lift.Findings included:Record review revealed Resident #1 was admitted on [DATE] with diagnoses including muscle wasting, chronic obstructive pulmonary disease, weakness, and a history of falls.Record review of physician orders for August 2026 showed an order dated 8/13/26 for a pressure relieving mattress with instructions to check functionality every shift.Review of the admission Minimum Data Set (MDS) dated [DATE] showed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 13, meaning intact cognition and required maximal assistance for mobility needs.Review of the care plan initiated on 8/13/26 showed Resident #1 required a mechanical lift with two staff for transfers.During an interview on 8/26/26 at 9:33 AM, Resident #1 stated, two CNA's tried to get her out of bed about two weeks ago, around the 8/16/26 and she told them she wasn't supposed to be lifted out of bed like without using the mechanical lift.During an interview on 8/26/26 at 10:34 AM, Staff A, Certified Nursing Assistant (CNA), stated she floated throughout the facility and verified transfer status through the Electronic Health Record (EHR) and Kardex (A quick reference nursing tool that summarizes essential information about a resident's care needs). She stated that on 8/16/26 she assisted Staff D, CNA with Resident #1 after being called because the resident's mattress had deflated, leaving the resident lying on the metal frame. Staff A stated this was her first time working with Resident #1 and she was not aware of the resident's transfer method. She reported that she and Staff D repositioned the resident to the side of the bed and attempted to stand her to transfer her to a wheelchair. She stated the resident's legs began to give out, and she supported the resident's legs while Staff D supported her upper body. Together they repositioned Resident #1 back onto the bed. Staff A confirmed she received in service training upon hire on resident rights and Kardex use.During an interview on 8/26/26 at 11:28 AM, Staff B, Licensed Practical Nurse (LPN), stated she learned of the incident after the resident spoke with a family member. She stated staff attempted to transfer the resident and during the transfer the resident's knees buckled. She stated staff intercepted the fall and returned the resident to bed, although the resident later reported she fell to the floor. Staff B stated she reported the incident on 8/16/26. She completed a skin assessment, neurological strength assessment, and pain evaluation. An X ray was ordered and was negative on 8/17/26. Staff B stated she had cared for Resident #1 on three occasions and knew the resident required a two person Hoyer lift transfer. She stated staff did not use a Hoyer lift during the transfer and that the aides should have used it.During an interview on 8/26/26 at 12:02 PM, Staff C, Registered Nurse (RN) Unit Manager, stated she was notified shortly after first shift change that the aides stated they were assisting Resident #1 get out of bed because her air mattress was deflated. Staff C stated the aides reported the resident was positioned at the edge of the bed and when they attempted to stand her, her knees buckled, so they placed her back in bed. Staff C stated the aides reported Resident #1 never fell to the floor. Staff C contacted the physician, who instructed her to obtain an X ray and labs. During her assessment, the resident reported she was scared but not injured and had no pain. Staff C noted a small abrasion on the resident's left knee. She emphasized staff should have followed the resident's care planned transfer method using a Hoyer lift.During an interview on 8/26/26 at 12:19 PM, Staff D, CNA, stated the resident activated her call light and when she entered the room, the bed was completely flat, and the resident was lying on the hard frame. Staff D stated she attempted to lift Resident #1 off the frame and called Staff A for help. She stated they positioned the resident at the edge of the bed and then returned her to a lying position. Staff D stated she did not stand the resident up and believed there was nothing to report because the resident was never fully out of bed. She stated she was unaware of the resident's transfer status. During an interview on 8/26/26 at 1:29 PM, the Director of Nursing (DON) stated, Our root cause analysis of this event showed the CNA's did not follow the care plan using the mechanical lift with Resident #1.Review of the Comprehensive Person Centered Care Plan policy, dated 8/2023, showed the center would develop a comprehensive care plan that includes measurable objectives and timetables to meet medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment. The policy stated care would meet professional standards of quality and be provided by qualified persons in accordance with the resident's written plan of care. The facility did not follow Resident #1's care plan requiring a mechanical lift with two staff for transfers.

Based on observations, interview and record review the facility failed to maintain the dish machine in a clean manner. Findings included: An observation on 04/29/24 at 9:15 a.m. of the facility's dish machine revealed a soiled white rag stored on top of the machine. Closer observation of the dish machine revealed the top of the dish machine was covered with crumbs and debris. An interview at this time with Staff D, Dietary Aide revealed the top of the dish machine should not be dirty and the rag should not be on top of the machine. Another interview at this time with the Certified Dietary Manager confirmed the top of the dish machine was dirty and she reported it was cleaned on Saturday (4/27/24). (Photographic Evidence Obtained) Review of the facility policy titled, Food and Nutrition-Kitchen Sanitation, with a revised date of 03/26/2019, revealed the following: Proper cleaning and sanitation of equipment ensures removal of residual food, chemicals, and bacteria. The Food and Nutrition staff shall maintain the sanitation of the kitchen through compliance with written, comprehensive cleaning schedules developed by the Food and Nutrition manager or designee. Sanitizing cloths should be placed in sanitizing buckets when not in use. These buckets need to be changed every two (2) hours or more frequently, as needed and must be at the proper concentrations.

Based on record review and interview the facility failed to ensure that three residents (#29, #33, #41) of three residents sampled for binding arbitration agreements acknowledged that they understood the agreement prior to signing the document. Findings included: 1. Review of Resident #29's clinical record revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. Review of the Minimum Data Set (MDS), dated [DATE], showed in Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact). Review of Resident #29's medical record revealed that she signed a binding arbitration form on 9/11/23. There was no acknowledgement from the resident that she understood the agreement prior to signing it. During an interview on 05/01/24 at 12:38 p.m. with Resident #29 she revealed that no one explained the binding arbitration agreement to her and that no one explained that she did not have to sign the agreement. 2. Review of Resident #33's Admission Record revealed she was initially admitted to the facility on [DATE] and readmitted on [DATE]. Review of the Minimum Data Set (MDS), dated [DATE], showed in Section C - Cognitive Patterns a BIMS score of 14 (cognitively intact). Review of Resident #33's medical record revealed that she signed a binding arbitration form on 11/19/22. There was no acknowledgement from the resident that she understood the agreement prior to signing it. During an interview on 05/01/24 at 12:42 p.m. with Resident #33 she revealed that she does not remember signing the binding arbitration agreement document and could not be sure if it was explained to her that she did not have to sign the agreement. 3. Review of Resident #41's Admission Record revealed she was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS), dated [DATE], showed in Section C - Cognitive Patterns a BIMS score of 12 (moderately impaired cognition). Review of Resident #41's medical record revealed that she signed a binding arbitration form on 2/8/23. There was no acknowledgement from the resident that she understood the agreement prior to signing it. During an interview on 05/01/24 at 12:40 p.m. with Resident #41 she revealed that no one explained the binding arbitration agreement to her and that no one explained that she did not have to sign the agreement. During an interview on 05/01/24 at 12:32 p.m. with Staff F, Administrative Assistant and the Nursing Home Administrator (NHA), Staff F reported that she verbally explains to the resident about going into the arbitration agreement, and she gives them the option to sign it verbally. During an interview on 05/01/24 at 12:44 p.m. with the NHA he reported the binding arbitration agreement itself indicates that the resident has a choice to sign the document.

Based on observation and interview the facility failed to maintain a safe and sanitary environment for one of one resident laundry room and one of one resident adaptive equipment storage room. Findings included: A tour of the laundry room was conducted on 5/1/24 at 12:00 p.m. with the Environmental Services Director (EVS). The laundry room was in a building separate from the nursing home but still on the same grounds as the facility. The washing and drying area were separated by a wall and door. There were three washing machines and three dryers. A laundry aide was observed to be in the drying area, wearing a gown, hanging residents' personal clothing onto a rack. The EVS Director said one dryer door did not stay closed while running, if there was a large load in it. Directly behind the washing machine was broken sheet rock with a large hole and debris on the ground. On the other side of the large hole, behind the washing machine, was deteriorated sheet rock and the debris on the ground behind the washing machine was visible from the other side of the wall through the deteriorated sheet rock. Directly next to the washing machine was more deteriorated sheet rock with rust colored edging on the bottom of the wall. An interview was conducted with the EVS Director at the time of the observation and he said the wall has been that way for about seven to eight months. He stated the Maintenance Director was made aware of it and has not fixed it because they said we were going to get an industrial washing machine. During the observation, the Nursing Home Administrator (NHA) arrived in the laundry room and was interviewed. He said the wall damage must have been from when the washing machines broke and there was a flood. He said the wall has been that way since before he started in June of 2023. Also, in the building housing the laundry room was a storage room with resident wheelchairs, positioning devices, walkers, and shower chairs. The walls of the storage room were not secured to the wall frames leaving large open areas to the outside. The walls were also deteriorated leaving large holes and an opening to the outside towards the floor of the building. During this observation an interview was conducted with the Director of Rehabilitation, and she said the equipment is used by residents when they need it, and this is where they store the equipment. An interview was conducted on 5/1/24 at 12:38 p.m. with the Maintenance Director. He said the only thing he knows about the laundry room was there is money set aside to tear it down and rebuild but he does not know when that is going to happen. An interview was conducted on 5/1/24 at 1:20 p.m. with the Maintenance Director. He said, there is a budget on the laundry room building to tear down, but they are looking at financing at this point and they do not have a hard start date. A safe, and clean environment policy was requested and the facility did not have one to provide. (Photographic Evidence Obtained)

Based on observations, record reviews, and interviews, the facility failed to maintain an effective pest control program for two residents (#7 and #44) and two facility wings (East and West) of three facility wings and one of one emergency supply shed. Findings included: 1. A review of the Admission Record showed Resident #7 was initially admitted to the facility 06/15/23 with a primary diagnosis to include acute and chronic respiratory failure with hypercapnia. Section C- Cognitive Patterns of the Minimum Data Set (MDS) dated [DATE] showed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating cognitively intact. On 04/29/24 at 10:21 a.m., Resident #7 stated fruit flies were bad in her room. Two fruit flies were observed on a napkin on the over the bed table next to a meal tray (Photographic Evidence Obtained). Two more fruit flies were observed flying around. An orange round container that showed 960 Fruit Fly was observed on the bedside table. Resident #7 stated the container was given to her by maintenance. She stated her family member brought in a light to plug in the wall for bugs (Photographic Evidence Obtained). Resident #7 reported that she saw roaches in the room also and her roommate confirmed. The resident reported she sees a person from pest control in the facility, but they have never sprayed her room. A review of the Pest Sighting/Evidence Log only showed two pest issues since December 2023 to present. No issues with fruit flies were documented. On 04/30/24 at 3:26 p.m. the Maintenance Director reported pest control comes out monthly on the 2nd or 3rd Monday. He had noticed a couple of fruit flies but not extreme. There had been a resident or two that say they have fruit flies and when he walks in the room, he does not see anything. The Maintenance Director reported he did not recognize the container that stated 960 Fruit Fly. He stated staff should be logging pest sightings. There is a pest control book on the south hall near the nursing station. When they had an employee meeting, he brought up a concern related to the pest control book because staff were not documenting in the book. Pest control checks the pest control book and initials off on concerns documented by the staff. 48823 2. On 04/29/24 at 10:09 a.m. Resident #44 was observed sitting in his room on his bed, flies and fruit flies were noted throughout the room. On 04/30/24 at 8:30 a.m. during medication pass observation on the East Wing fruit flies were noted throughout the hallway. On 04/30/24 at 12:30 p.m. during a medication pass observation, on the East Wing, of Staff A, Licensed Practical Nurse (LPN) as she went to empty her ice bin, fruit flies and flies were observed in the container. On 04/30/24 at 12:50 p.m. during an interview with the Director of Nursing (DON) she verified there are fruit flies and flies throughout the building. On 05/01/24 at 12:15 p.m. fruit flies were observed around the reception desk. 50570 3. An observation on 04/29/24 at 9:45 a.m. of the emergency supply shed which contained the facility's emergency food supply revealed black oblong droppings with a white tip on top of boxes which contained plastic portion cups. (Photographic Evidence Obtained). A combination of similar droppings and all black oblong droppings were observed on the floor, beside and in front of boxes of insulated containers (Photographic Evidence Obtained). Further observations revealed a combination of similar droppings and all black oblong droppings on the floor below a rack where food cans were stored, and on the left side/corner upon entering the shed (Photographic Evidence Obtained). An interview was conducted with the Certified Dietary Manager (CDM), at this time and she confirmed she is the one who oversees the emergency food supply and should have reported the droppings, but she has not. During an interview conducted on 04/29/24 at 11:27 a.m. the Maintenance Director stated [vendor name] services the facility and comes once a month. The Maintenance Director reported he thinks the droppings are from lizards. Review of the Pest Sighting/Evidence Log on 4/29/2024 revealed no documentation of droppings in the emergency food shed prior to 4/29/2024. On 4/29/24 at 11:30 a.m. the Maintenance Director documented lizards on the pest sighting log and indicated the location was in the emergency supply shed. Service date invoices were reviewed for the dates of 1/2024 to 4/2024 which all revealed, no findings noted during the service. Materials were applied to the interior and exterior areas of the facility; however, the serviced locations did not include the emergency food supply shed. Review of the facility's policy titled, Pest Control, with a revised date of 8/2023, revealed the following: Keep all food storage and preparation areas clean. For documentation, the policy revealed the facility should Maintain a written record of pest sightings and remedial actions.

Based on record reviews, and interview the facility failed to confirm the accuracy of the Pre-Admission Screening and Resident Review (PASRR) Level I and failed to complete a PASRR Level II for three residents (#4, #13, and #29) out of sixteen residents sampled. Findings included: 1. Review of the Admission Record revealed Resident #4 was originally admitted on [DATE] and the most current readmission was on 3/18/24. The Admission Record revealed the following diagnoses for Resident #4: metabolic encephalopathy (11/10/2023), dementia (10/1/2022), schizoaffective disorder (3/18/2024), obsessive compulsive disorder 9/7/2023), depressive disorder (5/14/2019), obsessional thoughts and acts (12/30/2016), and anxiety (5/12/2015). Review of the physician orders, dated 5/1/2024, for Resident #4 revealed: memantine extended release 28-10 milligram daily for dementia (3/18/2024), sertraline tablet 50 milligram daily for depression (11/10/2023). Review of Minimum Data Set (MDS), dated [DATE], for Resident #4 revealed in Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 05 (severe cognitive impairment). Section I - Active Diagnoses showed other neurological conditions, metabolic encephalopathy, depression, other symptoms and signs with cognitive functions and awareness, other symbolic dysfunctions, and obsessive-compulsive personality disorder. Section N - Medications showed antidepressant is taking, and indication noted. Review of the care plan focus, printed 5/1/2024, revealed for Resident #4: behavior related to diagnoses of schizophrenia, anxiety, agitation, and dementia; impaired cognition/communication, behaviors related to vascular dementia, obsessive-compulsive disorder, schizoaffective disorder, anxiety disorder and seizure disorder; at risk for adverse effect due to antidepressive medications; and nutrition management related to dementia. Review of the Level I PASRR, dated 9/9/2013, for Resident #4 revealed: Section IA -Schizoaffective disorder, bipolar disorder Section 1B - serious mental illness Section II: Part A - mental illness, yes is identified for Resident #4 she has a diagnosis of serious mental illness. Section III revealed Resident #4 has a primary diagnosis of dementia. No PASRR Level II was present in record. Review of psychiatric diagnostic evaluations for Resident #4 dated 1/29/2024, 12/18/2023, and 11/20/2023, revealed all three contained chief complaint for psychotropic medication response for depression and anxiety, resident has had a past psychiatric admission (dates unknown), current plan of care is to continue medications and monitor nutrition for weight management. Diagnoses listed, anxiety with obsessional features, major depressive disorder, dementia, During an interview on 5/01/24 at 10:39 a.m. the Director of Nursing (DON) stated the current PASRR for Resident #4 was reviewed yesterday and the resident has not had a change in her conditions or a new diagnoses, she has been out of the facility to the hospital related to her seizure disorder, based on the current PASRR there should be a Level II completed. The DON also stated that social services is responsible for the PASRR, however the position is vacant at this time, and she is completing the PASRR. 39866 2. Review of Resident #13's Admission Record revealed he was admitted to the facility on [DATE] with diagnoses of bipolar disorder and dementia. Review of Resident #13's Level I PASRR, dated 1/20/23, revealed no mental illness diagnoses and a recommendation for a Level II PASRR. Review of the medical record revealed the resident was not assessed for PASRR Level II. Review of Resident #13's Admission Minimum Data Set (MDS), dated [DATE], Section I - Active Diagnoses revealed no psychiatric/mood disorder diagnoses. Review of the 5-day MDS, dated [DATE], and Quarterly MDS dated [DATE], 7/29/23, 10/29/23, and 4/28/24 revealed in Section I- Active Diagnoses a psychiatric/mood disorder diagnosis of bipolar disorder. Review of the Annual MDS, dated [DATE], Section I - Active Diagnoses revealed the resident has a Psychiatric/Mood disorder of bipolar disorder. An interview was conducted on 4/30/24 at 2:14 p.m. with the DON and she said social services and herself are responsible for ensuring PASRRs are accurate and complete. She confirmed the facility does not have social service personnel at this time but she will look to see if Resident #13 has a Level II PASRR. An interview was conducted on 4/30/24 at 2:40 p.m. with the DON and she confirmed there was no Level II assessment for Resident #13. She reviewed Resident #13's PASRR, dated 1/20/24, and confirmed the PASRR was not accurate. She said PASRRs are reviewed by social services upon admission for accuracy and she was the back up while the facility did not have social services personnel. 20311 3. During a review of Resident #29's record revealed that based on the results of a PASRR Level I evaluation dated 3/4/22, a Level II PASRR was completed. Review of the PASRR Level II, dated 3/16/22, revealed that specialized services were not recommended, however the evaluation did indicate the following recommendations: - Psychiatric Medication Management - Individual Therapy. Review of the resident record revealed that psychiatric services comes to the facility to review the resident related to psychotropic medications. The last documented psychiatric service note was dated 2/22/24 with recommendations to follow up as needed. Further review of the record revealed there was no documentation in the record that would indicate individual therapy was being provided to the resident. During an interview on 5/01/24 at 10:30 a.m. the DON reported that she was unsure if the resident was receiving individual therapy. She stated she would need to check with medical records to see if visits were uploaded and to see if the resident was on the list for therapy services from an outside vendor. The DON was unable to provide documentation that would indicate Resident #29 was receiving individual therapy as recommended in the PASRR Level II evaluation. A policy related to PASRRs was requested from the facility, but not provided.

Based on record review and interview the facility failed to ensure baseline care plans were developed and accurate for two residents (#105, #205) of 28 sampled residents. Findings included: 1. A review of Resident #105's Clinical Profile revealed he was admitted to the facility on [DATE] with diagnoses that included cerebrovascular disease, and history of transient ischemic attack. A review of Resident #105's care plan revealed he had a care plan in place to address advance directives which indicated that Advance Directives in place to include (SPECIFY). Review of the interventions revealed DNR [do not resuscitate] with an initiated date of 4/25/24. Review of the resident's physician orders revealed the resident was a full code under Code Status and an actual physician order dated 4/24/24 for Full Code. During a review of the Hospital History and Physical with a print date of 4/16/24 indicated the resident was a Full Code status on Page 2 of 36, and Page 23 of 36. During an interview with Resident #105's family member on 04/30/24 at 9:09 a.m. she reported the resident was a Do Not Resuscitate (DNR), and the facility has the paperwork. During an interview on 4/30/24 at 10:47 a.m. with the Director of Nursing (DON), she revealed that she updated the care plan today after speaking to the POA (power of attorney) this morning. She confirmed the resident has a living will and does not have a DNR and if that is what they want then DNR paperwork has to be signed for the DNR to be valid. During an interview on 4/30/24 at 10:56 a.m. Staff E, Minimum Data Set (MDS) Coordinator/Registered Nurse (RN), revealed between the DON and herself they were responsible for making sure the care plan is accurate. She reported that she has not looked at Resident #105 yet for his code status. She reported the nurses create the baseline care plan and she goes back and reviews it. She reported that she is doing it now because his ARD date is tomorrow, and that is when she makes sure the care plan is accurate. 39866 2. Review of Resident #205's Admission Record revealed he was admitted to the facility on [DATE] with diagnoses of cardiac arrest, cardiac arrest due to other underlying condition, malignant neoplasm of prostate, type 2 diabetes mellitus without complications, end stage renal disease, and dependence on renal dialysis. Review of Resident #205's physician order with an order date of 4/24/24 and no end date revealed Full Code. Review of the medical record was conducted on 4/29/24 at 12:05 p.m. and did not reveal an advanced directive care plan was in place. An interview was conducted on 4/30/24 at 2:10 p.m. with Resident #205. He said he would want life saving measures if anything were to happen to him and he has not had a care plan meeting since he has been here. A review of the medical record was conducted on 4/30/24 10:59 a.m. and revealed an advanced directive care plan with a creation date of 4/30/24 for Resident #205. An interview was conducted on 4/24/24 at 10:30 a.m. with the Director of Nursing (DON) and she said baseline care plans are created based on the information from the admission data set. She said she doesn't think baseline care plans include advanced directives. She said advanced directives are determined upon admission and a physician's order is put in. She reviewed Resident #205's care plan and confirmed it was created on 4/30/24. Review of the facility's Baseline (Interim/Initial/IPOC) Plan of Care policy, revised on 8/2023, revealed: Policy The center will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care. The baseline care plan will be developed within 48 hours of a resident's admission. Fundamental Information (F655) Completion and implementation of the baseline care plan within 48 hours of a resident's admission is intended to promote continuity of care and communication among nursing home staff, increased resident safety, and safeguard against adverse events that are most likely to occur right after admission; if applicable; are informed of the initial plan for delivery of care and services by receiving a written summary of the baseline care plan. (F655, N0072). A Comprehensive care plan can be developed in the place of the Baseline Care Plan . The Baseline Care Plan includes the minimum healthcare information necessary to properly care for a resident including, but not limited to: Information received from the referring center, .physician's orders, .social services orders, .

Based on observations, interviews and record reviews, the facility did not ensure side effect monitoring of psychotropic medications was in place for two residents (#33 and #39) of seven sampled residents reviewed for unnecessary medication. Findings included: 1. On 04/29/24 at 10:51 a.m. an interview was conducted with Resident #33. She said she felt drowsy and tired. Resident #33 stated she felt the feeling is related to Parkinson's medication she is prescribed. Resident #33 was observed drooling during the interview. Staff A, Licensed Practical Nurse (LPN) was seen outside the resident's room and when asked about the drooling, she confirmed that Resident #33 drools. A review of the Admission Record showed the resident was initially admitted on [DATE] with a readmission on 2/23/24. A review of active physician orders as of 05/01/24 revealed the following: Venlafaxine HCl ER Tablet Extended Release 24 Hour 75 MG (milligrams). Give 1 tablet one time a day for depression. Start date 02/23/24. QUEtiapine Fumarate Oral Tablet. Give 75 mg at bedtime related to unspecified psychosis not due to a substance or known physiological condition. Start date 02/24/24. KlonoPIN Oral Tablet 1 MG (Clonazepam). Give 0.5 tablet in the morning for Anxiety, give 0.5 tablet in the afternoon for Anxiety, and give 1 tablet at bedtime for Anxiety. Start dates 03/05/24, 03/06/24. Carbidopa-Levodopa Tablet 25-100 MG. Give 1 tablet every 12 hours as needed for Parkinson. Start date 04/10/24. Sinemet Oral Tablet 25-100 MG (Carbidopa-Levodopa). Give 1 tablet two times a day for Parkinson's Disease. Start date 04/10/24. Amantadine HCl Oral Capsule 100 MG (Amantadine HCl). Give 1 capsule by mouth in the afternoon for Parkinson's Disease. Start date 04/17/24. Neupro Transdermal Patch 24 Hour 4 MG/24HR (Rotigotine). Apply 1 patch one time a day for Parkinson's. Start date 04/19/24. Stalevo 150 Oral Tablet 37.5-150-200 MG (Carbidopa-Levodopa-Entacapone). Give 1 tablet five times a day for Parkinson's disease. Start date 04/19/24. Review of Resident #33's Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14 (intact cognition). Review of Resident #33's care plan, initiated on 11/19/22 and revised on 01/26/23, revealed a focus for [Resident #33] uses Psychotropic Medication Therapy r/t [related to] anxiety, depression, insomnia. The goals included: Resident will reduce the use of psychotropic medication through the review date, Resident will show decreased episodes through the review date, and Resident will be free from discomfort or adverse reactions related to psychotropic therapy through the review date. Interventions included: Educate family/caregivers about risks, benefits and the side effects of medications. Further review of Resident 33's care plan initiated on 11/28/22 and revised on 03/07/24, revealed a focus for [Resident #33] has impaired cognitive function/impaired thought process r/t Disease Process, Psychotropic drug use and BIMS evaluation. Interventions included: Monitor any changes in cognitive function, specifically changes in: decision making, memory recall, general awareness, level of consciousness, mental status and/or difficulty expressing self/understanding others. Review of Resident #33's medical record revealed there was no side effects monitoring. On 04/30/24 at 12:37 p.m. an interview was conducted with the Director of Nursing (DON) regarding side effect monitoring. The DON stated staff monitors side effects by exception. The DON stated if the resident does not have side effects to medications, then staff do not document anything. She said if the resident does have side effects, then the staff documents. The DON stated the side effect documentation would be found in the progress notes. Review of Resident #33's progress notes from 04/03/24 - 4/26/24, did not reveal any documentation of symptoms and/or side effects related to drowsiness, tiredness, and drooling. A review of a nurse progress note dated 04/15/24, revealed the family member was notified of Resident #33's off state. No specific side effects or symptoms were documented. On 04/30/24 at 2:01 p.m. an interview was conducted with the DON. The DON stated she spoke to the nurse for Resident #33. She stated on 4/15/24 a barium swallow study was ordered due to drooling related to Parkinson's. She said, The Parkinson's medications were adjusted because at one point the resident was receiving 5 times a day PRN [as needed]. Further review of the progress note revealed that on 4/15/24 a nurse's progress note showed .new orders received for Barium swallow study. No specific side effects or symptoms were documented. On 05/01/24 at 1:19 p.m. a phone interview was conducted with the Pharmacy Consultant. The Pharmacy Consultant stated she reviews the admissions on Monday, Wednesday, and Friday. She said she conducts full reviews monthly for every resident. The Pharmacy Consultant stated she utilizes the Gradual Dose Reduction (GDR) tracker and makes recommendations. She stated side effect monitoring for psychotropic medications is important to ensure no new side effects are occurring on a regular basis. She said for residents who are established she will just spot check for the behaviors and side effects, meaning she will select more than a few residents to ensure they have behavior and side effect monitoring. She said certain medications have side effects, such as drooling, but that every resident is different. She said the importance for monitoring side effects for residents on psychotropic medications is because of the risk of tardive dyskinesia. 39438 2. On 04/29/24 at 10:52 a.m. Resident #39 was observed sitting outside making facial expressions as if she was crying. On 04/30/24 at 2:15 p.m. the resident was observed sitting in the common area next to the couch in her wheelchair. Her face was red, and she was moaning. A review of the Admission Record showed the resident was initially admitted on [DATE] with diagnoses to include anxiety disorder, major depressive disorder, dementia, pseudobulbar affect, and Alzheimer's disease. A review of the Order Summary Report with active orders as of 04/30/24 revealed the following: buspirone HCl oral tablet 10 MG- Give 1 tablet by mouth two times a day for anxiety (04/19/24), desvenlafaxine oral tablet extended release 24-hour 50 MG (01/17/24)- Give 1 tablet by mouth one time a day related to major depressive disorder, rexulti oral tablet (02/04/24)- Give 2 mg by mouth one time a day for dementia and associated agitation and psychosis, tamoxifen citrate oral tablet 20 MG (01/23/24)- Give 1 tablet by mouth one time a day for mood disorder, and valproic acid oral solution 250 MG/5ML (01/17/24)- Give 5 ml by mouth three times a day for mood disorder. The Medication Administration Record (MAR) for February 2024, March 2024, and April 2024 showed no behavior monitoring for tamoxifen. The MAR for February 2024, March 2024, and April 2024 revealed no side effect monitoring for buspirone HCl oral tablet 10 MG, desvenlafaxine oral tablet extended release 24-hour 50 MG, rexulti oral tablet, tamoxifen citrate oral tablet 20 MG, and valproic acid oral solution 250 MG/5ML. Review of the care plan related to antidepressants, initiated on 07/07/21, revealed the following intervention: monitor ongoing signs and symptoms of depression unaltered by antidepressant medications: sad, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, suicidal ideations, mood/comments, slowed movement, agitation, disrupted sleep, fatigue, lethargy, does not enjoy usual activities, changes in cognition, changes in weight/appetite, fear of being alone or with others, unrealistic fears, attention seeking, concern with body, functions, anxiety, and constant reassurance. On 04/30/24 at 2:05 p.m. the Director of Nursing (DON) stated she would expect to see behavior monitoring for tamoxifen. For side effects, staff chart by exception. She would expect to see the observation of crying documented. The policy provided titled, Psychotropic Medication Assessment & Monitoring, revised 08/2023, revealed the following: c. The Interdisciplinary Team assesses the appropriateness, effectiveness, and side effects associated with psychotropic medications for each resident via the MDS [minimum data set] process. d. Monitoring of residents receiving antipsychotic medication will be completed by a licensed nurse as per acceptable standards of practice using the behavior monitoring record.

49227 Based on interviews, record review, and policy review the facility failed to protect the residents' right to be free from neglect related to neglecting to complete ordered laboratory tests for one resident (#3), not noticing a change of condition and notifying the physician and for two residents (#3 and #1) out of three reviewed for change of condition, and not performing cardiopulmonary resuscitation (CPR) according to policy for one resident (#1) out of three reviewed for the CPR process. These failures created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Residents #3 and #1 and resulted in the determination of Immediate Jeopardy which began on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to an E after verification of removal of the Immediate Jeopardy. Findings included: Review of a facility policy titled Abuse & Neglect Prohibition, effective [DATE], showed the following: Policy, Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, exploitation, and misappropriation of property. Definitions: Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death of a resident. Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Procedure: Screening 1. The center will screen for employees with a history of abusive behavior or who may be at risk for being abusive. 2. The center will ensure that prospective temporary or agency staff will have background screen conducted in accordance with state law. 3. The center will observe for potentially abusive individuals involved with the resident who are not providing a professional service. 4. The center will screen for potentially abusive residents. Training 1. The center will train each employee regarding these policies. 2. The center will ensure that such training is provided during orientation, annually, and more often as determined by the center. 3. The center will provide ancillary training regarding related policies and procedures. 4. The center will provide auxiliary education for those additional individuals involved with the resident. Prevention 2. Center supervisors will immediately correct and intervene in reported or identified situations in which abuse, neglect or misappropriation of resident property is at risk for occurring. Identification 1. The administrator will designate an Abuse Coordinator who shall be responsible for the implementation and oversight of the centers [sic] Abuse Prohibition Program. 2. The center Quality Assessment & Assurance (QA&A) Committee will investigate occurrences, patterns and trends that may indicate the presence of abuse, neglect, or misappropriation of resident property and to determine the direction of the investigation/intervention, through analysis of systems, audits, and reports. 3. The center supervisory staff will integrate into the supervisory process monitoring the behavior of staff members and residents, which are indicative of high stress levels that may lead to abuse/neglect or may escalate a continuum of aggression. 4. The center staff may accommodate special needs of a resident or staff member who have [sic] been affected by past abuse experiences. Investigation 1. The center will investigate any alleged abuse/neglect or misappropriation of resident property in accordance with state or federal law. 2. The center will report such allegations to the state, as per state/federal regulation. The center will report immediately but not later than 2 hours after forming the suspicion if the events that cause the allegation involve abuse or result in serious bodily injury. 3. The center will report reportable investigation findings in accordance with State law, including to the state survey agency within 5 working days of the incident, and if the alleged violation is verified, appropriate corrective action will be taken. 4. The center will investigate patterns, trends or incidents that suggest the possible presence of abuse, neglect or misappropriation of property and exploitation related to unauthorized photos identified though analysis conducted by the QA&A Committee, with intervention, reporting or policy/procedure modification conducted as appropriate. Protection 1. The center will protect residents from harm during the investigation. 2. The center will make referrals to the appropriate state agencies as necessary, to ensure the protection of the resident or resident's property. Reporting and Response 1. The center will report all allegations and substantiated occurrences of abuse, neglect, and misappropriation of property to the state/federal agency and law enforcement officials as designated by state/federal law. Resident #3 Review of the Resident #3's electronic medical record admission profile showed she was admitted on [DATE] with diagnoses including dementia with other behavioral disturbances, hypertension, hypothyroidism, encephalopathy, anxiety disorder, and low back pain. Review of Resident #3's most recent Minimum Data Set (MDS) for Significant Change, completed [DATE], revealed Section C, Cognitive Patterns, showed resident had a Brief Interview for Mental Status (BIMS) Score of 4, indicating severely impaired cognition. Section GG, Functional Abilities and Goals, showed Resident #3 was dependent for eating, toileting, hygiene, transfers, sitting to lying and lying to sitting. It showed the resident used a wheelchair but was dependent for locomotion. The significant change assessment was completed due to a new skin tear. Review of lab results dated [DATE] for Resident #3 showed she had scheduled monthly labs drawn on [DATE] which were reported back to the facility with critical values the same day. Results showed her white blood cell count (WBC) was critically high at 36.2 with the reference range being 4XXX,d+[DATE].9 and her Blood Urea Nitrogen (BUN) level was critically high at 97 with a reference range of ,d+[DATE]. A high white blood cell count usually means one of the following has increased the making of white blood cells: An infection, Reaction to a medicine, A bone marrow disease, An immune system issue, Sudden stress such as hard exercise, Smoking. According to the Mayo Clinic at https://www.mayoclinic.org/symptoms/high-white-blood-cell-count/basics/causes/sym-20050611, viewed on [DATE]. A common blood test, the blood urea nitrogen (BUN) test reveals important information about how well your kidneys are working. A BUN test measures the amount of urea nitrogen that's in your blood. A BUN test can reveal whether your urea nitrogen levels are higher than normal, suggesting that your kidneys may not be working properly, according to the Mayo Clinic at https://www.mayoclinic.org/tests-procedures/blood-urea-nitrogen/about/pac-2038482, viewed on [DATE]. Review of progress notes for Resident #3 showed a nurse's note written by Staff B, Registered Nurse (RN) dated [DATE] at 6:23 p.m., reviewed critical labs with [primary care provider (PCP)] with new orders to start IV (intravenous solution), D 5 ,d+[DATE] NS [normal saline] at 75 [milliliters]mL/[hour] hr x 3 days, UA [urinalysis], CXR [chest x-ray], repeat CBC [completed blood count]/BMP [basic metabolic panel] in 4 days Review of physician orders for Resident #3 showed the following orders entered into the computer by Staff B, RN: -[DATE] at 3:13 p.m. Dextrose-NaCL (Sodium) Solution ,d+[DATE] 0.45%. Use 75 ml/hr intravenously every hour for abnormal labs for 3 days. -[DATE] at 3:21 p.m. May insert IV for delivery of fluids. One time for 3 days. -[DATE] 4:09 p.m. Urinalysis. Culture and Sensitivity. STAT(immediately) for abnormal labs. -[DATE] 6:43 p.m. Chest x-ray STAT. According to the progress notes, these orders were all received from the provider in the same phone call, however they were entered into the computer over a 3 ,d+[DATE] hour period. Review of Resident #3's Treatment Administration Record (TAR) for February 2024 showed the STAT urinalysis and STAT chest x-ray were not signed off as completed on [DATE]. Review of Resident #3's lab and radiology results did not show results for the STAT urinalysis or chest x-ray on [DATE]. An interview was conducted on [DATE] at 2:02 p.m. with the third-party lab that processed labs for this facility. The lab representative reviewed their records for Resident #3 and stated they did not have orders for a STAT urinalysis in their system for Resident #3 on [DATE] and had no documentation indicating the nurse notified the lab of STAT orders. The lab representative said STAT orders were typically completed and reported back to the facility within ,d+[DATE] hours. An interview was conducted on [DATE] at 2:17 p.m. with the x-ray service that provided imaging services for this facility. The company representative reviewed their records for Resident #3 and said they did not receive orders for x-rays on [DATE] for the resident. They said the nurse typically placed the STAT orders into their system online and would sometimes call if it was STAT. The company representative said they did show an order for a chest x-ray placed into the system on [DATE] at 4:00 a.m. but it was not a STAT order. Review of Resident #3's vital signs on [DATE] at 10:19 a.m. showed a blood pressure (BP) of ,d+[DATE], a pulse (P) of 121, respirations (RR) of 20 per minute, and a temperature (T) of 97.5 Fahrenheit (F.) The resident's routine weekly blood pressure typically ran 116-,d+[DATE]-90 and her heart rate was normally ,d+[DATE]. Review of Resident #3's medical record did not show documentation that a provider was notified of the abnormal vital signs of BP ,d+[DATE] and P 121. There was no documentation an assessment was performed on [DATE] at 10:19 a.m. when the resident had these abnormal vital signs. Review of Resident #3's progress notes showed a nurses note on [DATE] 11:40 a.m.Attempted to reach [family member], concerning residents condition. No answer but did leave message to contact the facility at his earliest convenience[sic]. Review of radiology results showed a chest x-ray was completed due to a cough on [DATE] at 5:30 p.m. with the following finding: The heart is normal in size and configuration. The mediastinum is unremarkable. There is a mild airspace opacity in the right upper lobe. No acute osseous abnormality is visualized. The lungs are hyperinflated, consistent with chronic obstructive pulmonary disease. Mild degenerative changes are seen. CONCLUSION: Mild right upper lobe infiltrate. The differential primarily includes subsegmental atelectasis or infection. Correlation with history and symptomatology is advised. Review of Resident #3's medical records showed a Change of Condition Evaluation, dated [DATE] at 8:42 p.m. The evaluation showed the resident had shortness of breath and was unresponsive. Her blood pressure was ,d+[DATE], heart rate was 32 and irregular, her respirations were 32 per minute, and oxygen saturation was 84%. Nursing observations, evaluations, and recommendations showed Resident noted to have shortness of breath with order received to send resident to the hospital, and in the process of being sent to the hospital ER when she stopped breathing. Code Blue initiated by nurses with CPR in progress as resident is 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]. 911 called, MD on call notified. [Name] Fire and Rescue Paramedics and [Name] Paramedics came to facility and took over CPR. Resident transferred to [hospital name] ER [emergency room ] for evaluation and treatment. Review of Resident #3's progress notes showed a nursing progress note, written by Staff B RN, dated [DATE] at 10:25 p.m., showing the hospital called and notified the nurse that the resident expired in the emergency room . An interview was conducted on [DATE] at 4:57 p.m. with Staff B, RN. Staff B said she cared for Resident #3 every time she worked. She said she received critical lab values on [DATE] and notified the doctor. She said the doctor gave STAT orders. She said she put the orders in and called the lab and x-ray to tell them. Staff B said she assumed the labs and x-ray were completed. She said she was assigned to care for Resident #3 on [DATE]. Staff B said she did not check if the orders had been completed, she assumed they came in and got the labs. She said the lab would do STAT labs immediately if they had time. Staff B said she did not remember Resident #3's low blood pressure on [DATE] and did not talk to any providers about it. Staff B said Resident #3 was weak, wanted to sleep, and was laying down and did not want to get up. Staff B said she only worked weekends and had the resident the previous Saturday and Sunday ,d+[DATE] and [DATE]. She said the previous weekend the resident was on a restorative program and was sitting up eating while being cued by a staff member and was more alert. (A restorative program helps resident function at their highest potential) Staff B said the weekend of [DATE] and [DATE] Resident #3 was totally different, had a poor appetite, would moan, only take small bites or food, and was lethargic. Staff B said she did not recall the resident having breathing issues. An interview was conducted on [DATE] at 1:49 p.m. with the Director of Nursing (DON). She said when STAT labs or imaging was ordered the nurse should put the order in then call the lab and/or x-ray to let them know. The DON said STAT orders should be completed within ,d+[DATE] hours. She said labs and x-rays could be done anytime day or night, even on weekends. She said for the urinalysis the nurse would collect the specimen and the lab would pick it up. The DON reviewed Resident #3's medical record and confirmed there was a STAT order for the urinalysis and chest x-ray and they were not marked off as completed. She said the lab results populated in the medical record directly from the lab, so if they were done the results would have been in the medical record. She reviewed the orders and confirmed the resident's STAT orders were entered into the computer over a 3 ,d+[DATE] hour window and she did not know why there was a delay between the (intravenous)IV order, the urinalysis order and the chest x-ray order for Resident #3. The DON said when a provider gave orders for STAT labs she would expect them to be put in immediately. The DON reviewed Resident #3's vital signs in the medical record. The DON said, I want to say they sent her out when she had the BP of ,d+[DATE]. She then verified the resident was still at the facility the evening of [DATE] when she went into cardiac arrest. The DON said she would have expected the provider to be notified of the abnormal vital signs Resident #3 had on [DATE] at 10:19 a.m. The DON confirmed there was no documentation in the record a provider had been notified and no intervention was put in place by the nurse. An interview was conducted on [DATE] at 4:12 p.m. with Resident #3's primary care doctor. The doctor said she knew Resident #3 well. She said she was notified of the resident's critical lab values on [DATE] by text message. She said the facility should call the answering service after hours and on weekends for a timely response. She said she was not on call and fortunately happened to see her phone but was only provided with the lab results not an assessment of how the resident was doing. The doctor said she responded, giving orders for STAT labs and x-rays and told the nurse to call the on-call provider as soon as the results came back. She said she would expect STAT labs and x-rays to be completed within four hours, but it can vary by facility. The doctor said she was unaware the STAT orders were not completed on [DATE] and that would be considered a delay in care. The doctor stated she was not notified of Resident #3's blood pressure of ,d+[DATE] and heart rate of 121 on the morning of [DATE]. She said, she [Resident #3] should have gone to the hospital. She said with the resident having the high WBC the day before and having a BP of ,d+[DATE] and heart rate of 121 she should have been sent out because by definition that was sepsis. The doctor said after the resident passed, she saw a chest x-ray result from [DATE] and the resident at a minimum had pneumonia. She said the portable x-rays were not as detailed and clear but taking the results showing subsegmental atelectasis or infection combined with the abnormal labs from [DATE], the resident most likely had pneumonia and possibly additional infections. She said it had been a struggle to get staff to let me know right away and don't wait with changes in resident's condition and they were still working on it. The doctor said with Resident #3, definitely things were not carried out the way they should have. A Cleveland Clinic article titled Sepsis, reviewed on [DATE], provided the following information: Sepsis occurs when your immune system has a dangerous reaction to an infection. It causes extensive inflammation throughout your body that can lead to tissue damage, organ failure and even death. Many different kinds of infections can trigger sepsis, which is a medical emergency. The quicker you receive treatment, the better your outcome will be. Common sepsis symptoms include urinary issues, low energy/weakness, fast heart rate, low blood pressure, fever or hypothermia, shaking or chills, warm or clammy sweaty skin, confusion or agitation, hyperventilation (rapid breathing) or extreme pain or discomfort. Sepsis treatment needs to begin immediately. The most important concern in sepsis protocol is a quick diagnosis and prompt treatment. If your provider diagnoses you with sepsis, they'll usually place you in the intensive care unit (ICU) of the hospital for special treatment. With quick diagnosis and treatment, many people with mild sepsis survive. Without treatment, most people with more serious stages of sepsis will die. Septic shock can cause death in as little as 12 hours. (The article was accessed on [DATE] at https://my.clevelandclinic.org/health/diseases/12361-sepsis ) Resident #1 Review of the resident's electronic medical record admission profile showed Resident #1 was admitted to the facility on [DATE] with diagnoses including pneumonia, syncope and collapse, chronic kidney disease, benign prostatic hyperplasia. Review of Resident #1's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form 3008, dated [DATE] showed the resident had a discharge diagnosis of pneumonia upon leaving the hospital, where he was admitted on [DATE]. Form 3008 showed the resident was discharged on antibiotics for pneumonia, on oxygen 2 liters (L) as needed, and requested Full code status. Review of Resident #1's MDS, completed [DATE], Section C, Cognitive Patterns, showed resident had a BIMS Score of 3, indicating severely impaired cognition. Review of Resident #1's medical records showed a care plan in place, dated [DATE], for Advance Directives (Full Code) with a goal of advance directives will be honored by staff. A review of Resident #1's physician orders revealed the following: -Full Code, dated [DATE]. -Oxygen via nasal cannula 2 Liters (L) as needed, dated [DATE]. - Doxycycline Hyclate Oral Capsule 100 milligram (mg). Give 1 capsule by mouth every 12 hours for pneumonia for 5 Days, dated [DATE]. - Cefuroxime Axetil Oral Tablet 500 mg. Give 1 tablet by mouth two times a day for pneumonia for 5 Days, dated [DATE]. - RN to release remains to funeral home of family's choice. [DATE] at 5:18 a.m. Review of Resident #1's January and February 2024 Medication Administration Record (MAR) showed the resident completed the physician ordered antibiotics for pneumonia, Doxycycline Hyclate and Cefuroxime Axetil, on [DATE]. Review of Resident #1's medical records showed Skilled Nursing Notes on ,d+[DATE], ,d+[DATE], and [DATE] noting resident had normal breathing, clear lung sounds, and no respiratory complications. There was no Skilled Nursing Note completed on [DATE]. Review of the Skilled Nursing Note, dated [DATE] at 4:19 p.m., entered by Staff F, Licensed Practical Nurse (LPN) as follows: Resident has intermittent confusion. Mood indicators displayed by resident: Little interest/pleasure in doing things. Poor appetite or overeating. Behaviors displayed: See eMAR for behavior(s) exhibited & pharmacological/non-pharmacological interventions provided . RESPIRATORY: Normal breathing noted. Abnormal lung sounds noted in RUL [right upper lobe,] RLL [right lower lobe,] LUL [left upper lobe,] LLL [left lower lobe.] diminished. Free from respiratory complications. Respiratory equipment in use: oxygen supplies. Nursing services provided: Head of bed elevated. Encouraged pursed-lip breathing. O2 tubing changed/filter cleaned. Response/Comments: Resident is confused and unable to make his needs known. Residents [sic] lung sounds are diminished in all four fields. Resident is on 3l [liters] oxygen via nasal cannula. Residents [sic] appetite is poor. Resident refuses to eat and take his medication. Residents [sic] abdomen is soft with positive bowel sounds in all four quadrants. Resident is incontinent of bowel and bladder. Resident shows no s/s of pain. Resident does not complain of pain or discomfort. Nurse will continue to monitor for comfort and safety. A Skilled Nursing Note written by Staff B, RN, dated [DATE], noted normal breathing and clear lungs, but noted she encouraged pursed-lip breathing. A Healthline article titled Pursed Lip Breathing, updated [DATE], gave the following information: Pursed lip breathing is a technique designed to make your breaths more effective by making them slower and more intentional . Pursed lip breathing gives you more control over your breathing, which is particularly important for people with lung conditions such as COPD [Chronic obstructive pulmonary disease] .Pursed lip breathing can help improve and control your breathing in several ways, including: -relieving shortness of breath by slowing the breath rate -keeping the airways open longer, which decreases the work that goes into breathing -improving ventilation by moving old air (carbon dioxide) trapped in the lungs out and making room for new, fresh oxygen. (Accessed on [DATE] at https://www.healthline.com/health/pursed-lip-breathing ) Review of Resident #1's medical records and vital signs dated [DATE] to [DATE] revealed no documentation of Oxygen saturation readings; on [DATE] respiratory rate was not documented when the resident began using PRN (as needed) oxygen and had diminished lung sounds. Oxygen saturation is a crucial measure of how well the lungs are working. A resting oxygen saturation level between 95% and 100% is regarded as normal for a healthy person at sea level. People should contact a health care provider if their oxygen saturation readings drop below 92%, as it may be a sign of hypoxia, a condition in which not enough oxygen reaches the body's tissues. If blood oxygen saturation levels fall to 88% or lower, seek immediate medical attention . According to Yalemedicinje.org, viewed on 3.26.2024 at https://www.yalemedicine.org/conditions/pulse-oximetry Review of the progress notes for Resident #1 showed no documentation of provider notification of Resident #1 having diminished lung sounds, requiring the as needed oxygen or that the resident was refusing his medication. Review of Resident #1's February 2024 MAR did not show documentation that Oxygen was being administered from [DATE] to [DATE]. Review of Resident #1's medical record, a nurses' progress note entered by Staff B, RN on [DATE] at 5:15 a.m. showed Called to residents [sic] room by CNA [Certified Nursing Assistant] found resident absent of breath sounds and apical pulse for full two minutes. [Family member] and MD made aware of death. New order received to release remains to funeral home of family's choice. There was no documentation CPR was initiated for Resident #1 on [DATE] at 5:15 a.m. There was no additional documentation in the resident's medical record as to the condition of the resident when he was found, observations made, why a code blue was not called, or the time of death. Code blue indicates there is a resident requiring resuscitation or otherwise in need of immediate medical attention, often as the result of a respiratory or cardiac arrest. An interview was conducted on [DATE] at 11:12 a.m. with Staff F, LPN. She said she knew Resident #1 and took care of him on [DATE]. She said as days went on after his admission, Resident #1 did not want to eat or drink, and he stopped having interest in food. Staff F said Resident #1 took medications and never refused for her. She said she did not remember if Resident #1 had breathing issues or was on oxygen. She said if a resident needed oxygen when they had a PRN order, the nurse would take their oxygen saturation and document it under vital signs and call and let the doctor know. She said if the resident stayed on oxygen their saturation should be checked every shift. An interview was conducted on [DATE] at 12:19 p.m. with Staff E, CNA. She said on the morning of [DATE] she saw Resident #1 in bed when she did routine rounds around 3:00 a.m. She said Resident #1 was the same as he had been. Staff E said the resident had the pattern of breathing like people have when they are going to die but were still holding on. She said a few days prior to that, she could not remember the date, she had let the unit manager and nurse know Resident #1 was not breathing right and they put oxygen on him. She said on that day he was breathing a little shallow and low. She said at first, she thought he was gone but she called his name several times and he moaned letting her know he was still there. She said since that night he had been doing that breathing so the nurse should have known. She said he did not get any better. Staff E said on the morning of [DATE] she went in the room and was checking his brief, and he did not move. She said she rubbed his chest a little like she usually did, and he did not respond. She said Resident #1 was lying on his back and his eyes were partially open like they normally were when he slept. She said he often slept with his mouth open because he would breathe through his mouth all the time like he was trying to get more air. Staff E said the resident was floppy and she was scared. She confirmed Resident #1 had oxygen on during that shift. Staff E said she called the nurse and said she did not think Resident #1 was alive. She said both nurses on duty, Staff B, RN and Staff D, RN, came to assess and see if he was breathing. She said the nurses were like ok, they left out and no one ever came back. Staff E said the nurse never said if the resident was a full code or do not resuscitate (DNR). She said she figured he must have been a DNR because if he had been a full code the nurse would have grabbed the chart and normally they jump and run, and they did not do that. Staff E said she cleaned Resident #1 up and covered him like she normally did when someone died . She said when she touched him his body was still warm, only his face was a little cool. She said he was not stiff or anything. She said when she cleaned up his brief, he was still flexible, not rigid. Staff E said in her career she had it happen when a resident was cold and stiff and he [Resident #1] was not like that. Staff E said Resident #1's arm was flopping. She said, If I would have known he was a full code I would have expected us to get busy. Staff E said when she was leaving work that morning, Staff B, RN was outside crying and She [Staff B] said I think I messed up. He was a full code. I should have known. A follow-up interview was conducted on [DATE] at 2:46 p.m. with Staff E, CNA. Staff E said no other staff members helped with Resident #1 or came in the room on the morning of [DATE]. She said she provided a statement to the Nursing Home Administrator (NHA) about what happened. She said she let the NHA know Resident #1's face was a little cool, but not cold and his body was warm. Staff E said she did not know why others were saying he was stiff because when she rolled him from front to back to clean him, he just flopped over and if he was stiff he would not have done that. An interview was conducted on [DATE] at 4:57 a.m. with Staff B, RN. She confirmed she worked the shift from 7:00 p.m. on [DATE] to 7:00 a.m. on [DATE] and was assigned to Resident #1. Staff B said she tried several times throughout the evening to get the resident to take his medication and he refused. She said Resident #1 often refused his medication. Staff B said when a resident refused medication, she would try a few times to coerce them and after a few tries she would mark in the MAR that the resident refused. She said during that shift Resident #1 was normal, he slept, he had oxygen on, and he was not having breathing problems. She said when a resident was on oxygen, saturation should be checked every shift and documented in the MAR. She said she did not know why Resident #1 was on oxygen. Staff B said the CNA, Staff E, called the nurses. Staff B said Staff D, RN got to the room first and said she thought Resident #1 was dead. Staff B said I told her I think you are right. Staff B said Resident #1 was cold, stiff, his arms were rigid, he had a stare, he had no heart and lung sounds, and the top half of his body was stiff. Staff B said she could not move Resident #1's shoulders, his jaw was open and fixed, his lower arms were stiff, and he was completely immobile. Staff B said she decided there was no use in trying to code him. Staff B said she had not seen the resident since around 10:00 or 11:00 p.m. on [DATE], but the CNA had done rounds every 2 hours. Staff B said she called Resident #1's primary care provider's (PCP) answering service and left a message for the on-call provider to call her back. She said she left a message for the family of Resident #1 to call her. Staff B said when she left the faciity on [DATE] she had still not received a call back from a provider regarding Resident #1's death. When asked which provider gave her the order she entered on [DATE] at 5:15 a.m. to release Resident #1's remains to the funeral home, she said she put it in presumptively and reconfirmed she never spoke with a provider. Staff B said, that's on me. Staff B said on [DATE] around 6:40 a.m. the next shift started coming in. She said Staff C, Licensed Practical Nurse (LPN) was going to take over her assignment. Staff B said she let Staff C know Resident #1 had passed and they did not do CPR. Staff B said Staff C panicked and freaked out because he was a full code. She said Staff C told her she needed to call the Director of Nursing (DON). Staff B said Staff C called the DON but she did not hear what the conversation entailed she was just standing and waiting. Staff B said the next thing she knew a code blue was being called on the loudspeaker for Resident #1. Staff B said, it was told to me when EMS [Emergency Medical Services] got there you better be running that code. Staff B said she and Staff F, LPN started CPR on Resident #1 and continued for around ,d+[DATE] minutes until EMS arrived and took over. She said EMS did compressions, hooked the resident to their monitor and then pronounced him deceased . She said EMS packed up and left and she was allowed to leave work then. An interview was conducted on [DATE] at 11:37 a.m. with Staff D, RN. She confirmed she worked the shift from 7:00 p.m. on [DATE] to 7:00 a.m. on [DATE] with Staff B, RN. Staff D said Resident #1 was not assigned to her and she did not know the resident. She said the CNA came out and asked if she was assigned Resident #1 and she told her no. Staff B, RN walked up and [Staff B] said oh my god, don't tell me something [NAME][TRUNCATED]

49227 Based on record review, interviews, facility documentation, and policy review, the facility failed to ensure the nursing staff was competent to recognize and respond to a change in condition for two (#3 and #1), out of three residents reviewed for change in condition, failed to ensure nursing staff were competent to process labs and x-rays appropriately for one (#3) out of three residents reviewed for change in condition and failed to ensure nursing staff were competent to initiate Cardiopulmonary Resuscitation (CPR) according to policy for one (#3) out of three residents reviewed for CPR administration. These failures created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Resident #3 and Resident #1 and resulted in the determination of Immediate Jeopardy which began on [DATE] with a scope and severity of K. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to an E after verification of removal of the Immediate Jeopardy. Findings included: Resident #3 Review of the Resident #3's electronic medical record admission profile showed she was admitted on [DATE] with diagnoses including dementia with other behavioral disturbances, hypertension, hypothyroidism, encephalopathy, anxiety disorder, and low back pain. Review of Resident #3's most recent Minimum Data Set (MDS) for Significant Change, completed [DATE], revealed Section C, Cognitive Patterns, showed resident had a Brief Interview for Mental Status (BIMS) Score of 4, indicating severely impaired cognition. Section GG, Functional Abilities and Goals, showed Resident #3 was dependent for eating, toileting, hygiene, transfers, sitting to lying and lying to sitting. It showed the resident used a wheelchair but was dependent for locomotion. The significant change assessment was completed due to a new skin tear. Review of lab results dated [DATE] for Resident #3 showed she had scheduled monthly labs drawn on [DATE] which were reported back to the facility with critical values the same day. Results showed her white blood cell count (WBC) was critically high at 36.2 with the reference range being 4XXX,d+[DATE].9 and her Blood Urea Nitrogen (BUN) level was critically high at 97 with a reference range of ,d+[DATE]. A high white blood cell count usually means one of the following has increased the making of white blood cells: An infection, Reaction to a medicine, A bone marrow disease, An immune system issue, Sudden stress such as hard exercise, Smoking. According to the Mayo Clinic at https://www.mayoclinic.org/symptoms/high-white-blood-cell-count/basics/causes/sym-20050611, viewed on [DATE]. A common blood test, the blood urea nitrogen (BUN) test reveals important information about how well your kidneys are working. A BUN test measures the amount of urea nitrogen that's in your blood. A BUN test can reveal whether your urea nitrogen levels are higher than normal, suggesting that your kidneys may not be working properly, according to the Mayo Clinic at https://www.mayoclinic.org/tests-procedures/blood-urea-nitrogen/about/pac-2038482, viewed on [DATE]. Review of progress notes for Resident #3 showed a nurse's note written by Staff B, Registered Nurse (RN) dated [DATE] at 6:23 p.m., reviewed critical labs with [primary care provider (PCP)] with new orders to start IV (intravenous solution), D 5 ,d+[DATE] NS [normal saline] at 75 [milliliters]mL/[hour] hr x 3 days, UA [urinalysis], CXR [chest x-ray], repeat CBC [completed blood count]/BMP [basic metabolic panel] in 4 days Review of physician orders for Resident #3 showed the following orders entered into the computer by Staff B, RN: -[DATE] at 3:13 p.m. Dextrose-NaCL (Sodium) Solution ,d+[DATE] 0.45%. Use 75 ml/hr intravenously every hour for abnormal labs for 3 days. -[DATE] at 3:21 p.m. May insert IV for delivery of fluids. One time for 3 days. -[DATE] 4:09 p.m. Urinalysis. Culture and Sensitivity. STAT(immediately) for abnormal labs. -[DATE] 6:43 p.m. Chest x-ray STAT. According to the progress notes, these orders were all received from the provider in the same phone call, however they were entered into the computer over a 3 ,d+[DATE] hour period. Review of Resident #3's Treatment Administration Record (TAR) for February 2024 showed the STAT urinalysis and STAT chest x-ray were not signed off as completed on [DATE]. Review of Resident #3's lab and radiology results did not show results for the STAT urinalysis or chest x-ray on [DATE]. An interview was conducted on [DATE] at 2:02 p.m. with the third-party lab that processed labs for this facility. The lab representative reviewed their records for Resident #3 and stated they did not have orders for a STAT urinalysis in their system for Resident #3 on [DATE] and had no documentation indicating the nurse notified the lab of STAT orders. The lab representative said STAT orders were typically completed and reported back to the facility within ,d+[DATE] hours. An interview was conducted on [DATE] at 2:17 p.m. with the x-ray service that provided imaging services for this facility. The company representative reviewed their records for Resident #3 and said they did not receive orders for x-rays on [DATE] for the resident. They said the nurse typically placed the STAT orders into their system online and would sometimes call if it was STAT. The company representative said they did show an order for a chest x-ray placed into the system on [DATE] at 4:00 a.m. but it was not a STAT order. Review of Resident #3's vital signs on [DATE] at 10:19 a.m. showed a blood pressure (BP) of ,d+[DATE], a pulse (P) of 121, respirations (RR) of 20 per minute, and a temperature (T) of 97.5 Fahrenheit (F.) The resident's routine weekly blood pressure typically ran 116-,d+[DATE]-90 and her heart rate was normally ,d+[DATE]. Review of Resident #3's medical record did not show documentation that a provider was notified of the abnormal vital signs of BP ,d+[DATE] and P 121. There was no documentation an assessment was performed on [DATE] at 10:19 a.m. when the resident had these abnormal vital signs. Review of Resident #3's progress notes showed a nurses note on [DATE] at 11:40 a.m.Attempted to reach [family member], concerning residents condition. No answer but did leave message to contact the facility at his earliest convenience[sic]. Review of radiology results showed a chest x-ray was completed due to a cough on [DATE] at 5:30 p.m. with the following finding: The heart is normal in size and configuration. The mediastinum is unremarkable. There is a mild airspace opacity in the right upper lobe. No acute osseous abnormality is visualized. The lungs are hyperinflated, consistent with chronic obstructive pulmonary disease. Mild degenerative changes are seen. CONCLUSION: Mild right upper lobe infiltrate. The differential primarily includes subsegmental atelectasis or infection. Correlation with history and symptomatology is advised. Review of Resident #3's medical records showed a Change of Condition Evaluation, dated [DATE] at 8:42 p.m. The evaluation showed the resident had shortness of breath and was unresponsive. Her blood pressure was ,d+[DATE], heart rate was 32 and irregular, her respirations were 32 per minute, and oxygen saturation was 84%. Nursing observations, evaluations, and recommendations showed Resident noted to have shortness of breath with order received to send resident to the hospital, and in the process of being sent to the hospital ER when she stopped breathing. Code Blue initiated by nurses with CPR in progress as resident is 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]. 911 called, MD on call notified. [Name] Fire and Rescue Paramedics and [Name] Paramedics came to facility and took over CPR. Resident transferred to [hospital name] ER [emergency room ] for evaluation and treatment. Review of Resident #3's progress notes showed a nursing progress note, written by Staff B RN, dated [DATE] at 10:25 p.m., showing the hospital called and notified the nurse that the resident expired in the emergency room . An interview was conducted on [DATE] at 4:57 p.m. with Staff B, RN. Staff B said she cared for Resident #3 every time she worked. She said she received critical lab values on [DATE] and notified the doctor. She said the doctor gave STAT orders. She said she put the orders in and called the lab and x-ray to tell them. Staff B said she assumed the labs and x-ray were completed. She said she was assigned to care for Resident #3 on [DATE]. Staff B said she did not check if the orders had been completed, she assumed they came in and got the labs. She said the lab would do STAT labs immediately if they had time. Staff B said she did not remember Resident #3's low blood pressure on [DATE] and did not talk to any providers about it. Staff B said Resident #3 was weak, wanted to sleep, and was laying down and did not want to get up. Staff B said she only worked weekends and had the resident the previous Saturday and Sunday ,d+[DATE] and [DATE]. She said the previous weekend the resident was on a restorative program and was sitting up eating while being cued by a staff member and was more alert. (A restorative program helps resident function at their highest potential) Staff B said the weekend of [DATE] and [DATE] Resident #3 was totally different, had a poor appetite, would moan, only take small bites or food, and was lethargic. Staff B said she did not recall the resident having breathing issues. An interview was conducted on [DATE] at 1:49 p.m. with the Director of Nursing (DON). She said when STAT labs or imaging was ordered the nurse should put the order in then call the lab and/or x-ray to let them know. The DON said STAT orders should be completed within ,d+[DATE] hours. She said labs and x-rays could be done anytime day or night, even on weekends. She said for the urinalysis the nurse would collect the specimen and the lab would pick it up. The DON reviewed Resident #3's medical record and confirmed there was a STAT order for the urinalysis and chest x-ray and they were not marked off as completed. She said the lab results populated in the medical record directly from the lab, so if they were done the results would have been in the medical record. She reviewed the orders and confirmed the resident's STAT orders were entered into the computer over a 3 ,d+[DATE] hour window and she did not know why there was a delay between the (intravenous)IV order, the urinalysis order and the chest x-ray order for Resident #3. The DON said when a provider gave orders for STAT labs she would expect them to be put in immediately. The DON reviewed Resident #3's vital signs in the medical record. The DON said, I want to say they sent her out when she had the BP of ,d+[DATE]. She then verified the resident was still at the facility the evening of [DATE] when she went into cardiac arrest. The DON said she would have expected the provider to be notified of the abnormal vital signs Resident #3 had on [DATE] at 10:19 a.m. The DON confirmed there was no documentation in the record a provider had been notified and no intervention was put in place by the nurse. An interview was conducted on [DATE] at 4:12 p.m. with Resident #3's primary care doctor. The doctor said she knew Resident #3 well. She said she was notified of the resident's critical lab values on [DATE] by text message. She said the facility should call the answering service after hours and on weekends for a timely response. She said she was not on call and fortunately happened to see her phone but was only provided with the lab results not an assessment of how the resident was doing. The doctor said she responded, giving orders for STAT labs and x-rays and told the nurse to call the on-call provider as soon as the results came back. She said she would expect STAT labs and x-rays to be completed within four hours, but it can vary by facility. The doctor said she was unaware the STAT orders were not completed on [DATE] and that would be considered a delay in care. The doctor stated she was not notified of Resident #3's blood pressure of ,d+[DATE] and heart rate of 121 on the morning of [DATE]. She said, she [Resident #3] should have gone to the hospital. She said with the resident having the high WBC the day before and having a BP of ,d+[DATE] and heart rate of 121 she should have been sent out because by definition that was sepsis. The doctor said after the resident passed, she saw a chest x-ray result from [DATE] and the resident at a minimum had pneumonia. She said the portable x-rays were not as detailed and clear but taking the results showing subsegmental atelectasis or infection combined with the abnormal labs from [DATE], the resident most likely had pneumonia and possibly additional infections. She said it had been a struggle to get staff to let me know right away and don't wait with changes in resident's condition and they were still working on it. The doctor said with Resident #3, definitely things were not carried out the way they should have. A Cleveland Clinic article titled Sepsis, reviewed on [DATE], provided the following information: Sepsis occurs when your immune system has a dangerous reaction to an infection. It causes extensive inflammation throughout your body that can lead to tissue damage, organ failure and even death. Many different kinds of infections can trigger sepsis, which is a medical emergency. The quicker you receive treatment, the better your outcome will be. Common sepsis symptoms include urinary issues, low energy/weakness, fast heart rate, low blood pressure, fever or hypothermia, shaking or chills, warm or clammy sweaty skin, confusion or agitation, hyperventilation (rapid breathing) or extreme pain or discomfort. Sepsis treatment needs to begin immediately. The most important concern in sepsis protocol is a quick diagnosis and prompt treatment. If your provider diagnoses you with sepsis, they'll usually place you in the intensive care unit (ICU) of the hospital for special treatment. With quick diagnosis and treatment, many people with mild sepsis survive. Without treatment, most people with more serious stages of sepsis will die. Septic shock can cause death in as little as 12 hours. (The article was accessed on [DATE] at https://my.clevelandclinic.org/health/diseases/12361-sepsis ) Resident #1 Review of the resident's electronic medical record admission profile showed Resident #1 was admitted to the facility on [DATE] with diagnoses including pneumonia, syncope and collapse, chronic kidney disease, benign prostatic hyperplasia. Review of Resident #1's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form 3008, dated [DATE] showed the resident had a discharge diagnosis of pneumonia upon leaving the hospital, where he was admitted on [DATE]. Form 3008 showed the resident was discharged on antibiotics for pneumonia, on oxygen 2 liters (L) as needed, and requested Full code status. Review of Resident #1's MDS, completed [DATE], Section C, Cognitive Patterns, showed resident had a BIMS Score of 3, indicating severely impaired cognition. Review of Resident #1's medical records showed a care plan in place, dated [DATE], for Advance Directives (Full Code) with a goal of advance directives will be honored by staff. A review of Resident #1's physician orders revealed the following: -Full Code, dated [DATE]. -Oxygen via nasal cannula 2 Liters (L) as needed, dated [DATE]. - Doxycycline Hyclate Oral Capsule 100 milligram (mg). Give 1 capsule by mouth every 12 hours for pneumonia for 5 Days, dated [DATE]. - Cefuroxime Axetil Oral Tablet 500 mg. Give 1 tablet by mouth two times a day for pneumonia for 5 Days, dated [DATE]. - RN to release remains to funeral home of family's choice. [DATE] at 5:18 a.m. Review of Resident #1's January and February 2024 Medication Administration Record (MAR) showed the resident completed the physician ordered antibiotics for pneumonia, Doxycycline Hyclate and Cefuroxime Axetil, on [DATE]. Review of Resident #1's medical records showed Skilled Nursing Notes on ,d+[DATE], ,d+[DATE], and [DATE] noting resident had normal breathing, clear lung sounds, and no respiratory complications. There was no Skilled Nursing Note completed on [DATE]. Review of the Skilled Nursing Note, dated [DATE] at 4:19 p.m., entered by Staff F, Licensed Practical Nurse (LPN) as follows: Resident has intermittent confusion. Mood indicators displayed by resident: Little interest/pleasure in doing things. Poor appetite or overeating. Behaviors displayed: See eMAR for behavior(s) exhibited & pharmacological/non-pharmacological interventions provided . RESPIRATORY: Normal breathing noted. Abnormal lung sounds noted in RUL [right upper lobe,] RLL [right lower lobe,] LUL [left upper lobe,] LLL [left lower lobe.] diminished. Free from respiratory complications. Respiratory equipment in use: oxygen supplies. Nursing services provided: Head of bed elevated. Encouraged pursed-lip breathing. O2 tubing changed/filter cleaned. Response/Comments: Resident is confused and unable to make his needs known. Residents [sic] lung sounds are diminished in all four fields. Resident is on 3l [liters] oxygen via nasal cannula. Residents [sic] appetite is poor. Resident refuses to eat and take his medication. Residents [sic] abdomen is soft with positive bowel sounds in all four quadrants. Resident is incontinent of bowel and bladder. Resident shows no s/s of pain. Resident does not complain of pain or discomfort. Nurse will continue to monitor for comfort and safety. A Skilled Nursing Note written by Staff B, RN, dated [DATE], noted normal breathing and clear lungs, but also noted she encouraged pursed-lip breathing. A Healthline article titled Pursed Lip Breathing, updated [DATE], gave the following information: Pursed lip breathing is a technique designed to make your breaths more effective by making them slower and more intentional . Pursed lip breathing gives you more control over your breathing, which is particularly important for people with lung conditions such as COPD [Chronic obstructive pulmonary disease] .Pursed lip breathing can help improve and control your breathing in several ways, including: -relieving shortness of breath by slowing the breath rate -keeping the airways open longer, which decreases the work that goes into breathing -improving ventilation by moving old air (carbon dioxide) trapped in the lungs out and making room for new, fresh oxygen. (Accessed on [DATE] at https://www.healthline.com/health/pursed-lip-breathing ) Review of Resident #1's medical records and vital signs dated [DATE] to [DATE] revealed no documentation of Oxygen saturation readings; on [DATE] respiratory rate was not documented when the resident began using PRN (as needed) oxygen and had diminished lung sounds. Oxygen saturation is a crucial measure of how well the lungs are working. A resting oxygen saturation level between 95% and 100% is regarded as normal for a healthy person at sea level. People should contact a health care provider if their oxygen saturation readings drop below 92%, as it may be a sign of hypoxia, a condition in which not enough oxygen reaches the body's tissues. If blood oxygen saturation levels fall to 88% or lower, seek immediate medical attention . According to Yalemedicinje.org, viewed on 3.26.2024 at https://www.yalemedicine.org/conditions/pulse-oximetry Review of the progress notes for Resident #1 showed no documentation of provider notification of Resident #1 having diminished lung sounds, requiring the as needed oxygen or that the resident was refusing his medication. Review of Resident #1's February 2024 MAR did not show documentation that Oxygen was being administered from [DATE] to [DATE]. Review of Resident #1's medical record, a nurses' progress note entered by Staff B, RN on [DATE] at 5:15 a.m. showed Called to residents [sic] room by CNA [Certified Nursing Assistant] found resident absent of breath sounds and apical pulse for full two minutes. [Family member] and MD made aware of death. New order received to release remains to funeral home of family's choice. There was no documentation CPR was initiated for Resident #1 on [DATE] at 5:15 a.m. There was no additional documentation in the resident's medical record as to the condition of the resident when he was found, observations made, why a code blue was not called, or the time of death. Code blue indicates there is a resident requiring resuscitation or otherwise in need of immediate medical attention, often as the result of a respiratory or cardiac arrest. An interview was conducted on [DATE] at 11:12 a.m. with Staff F, LPN. She said she knew Resident #1 and took care of him on [DATE]. She said as days went on after his admission, Resident #1 did not want to eat or drink, and he stopped having interest in food. Staff F said Resident #1 took medications and never refused for her. She said she did not remember if Resident #1 had breathing issues or was on oxygen. She said if a resident needed oxygen when they had a PRN order, the nurse would take their oxygen saturation and document it under vital signs and call and let the doctor know. She said if the resident stayed on oxygen their saturation should be checked every shift. An interview was conducted on [DATE] at 12:19 p.m. with Staff E, CNA. She said on the morning of [DATE] she saw Resident #1 in bed when she did routine rounds around 3:00 a.m. She said Resident #1 was the same as he had been. Staff E said the resident had the pattern of breathing like people have when they are going to die but were still holding on. She said a few days prior to that, she could not remember the date, she had let the unit manager and nurse know Resident #1 was not breathing right and they put oxygen on him. She said on that day he was breathing a little shallow and low. She said at first, she thought he was gone but she called his name several times and he moaned letting her know he was still there. She said since that night he had been doing that breathing so the nurse should have known. She said he did not get any better. Staff E said on the morning of [DATE] she went in the room and was checking his brief, and he did not move. She said she rubbed his chest a little like she usually did, and he did not respond. She said Resident #1 was lying on his back and his eyes were partially open like they normally were when he slept. She said he often slept with his mouth open because he would breathe through his mouth all the time like he was trying to get more air. Staff E said the resident was floppy and she was scared. She confirmed Resident #1 had oxygen on during that shift. Staff E said she called the nurse and said she did not think Resident #1 was alive. She said both nurses on duty, Staff B, RN and Staff D, RN, came to assess and see if he was breathing. She said the nurses were like ok, they left out and no one ever came back. Staff E said the nurse never said if the resident was a full code or do not resuscitate (DNR). She said she figured he must have been a DNR because if he had been a full code the nurse would have grabbed the chart and normally they jump and run, and they did not do that. Staff E said she cleaned Resident #1 up and covered him like she normally did when someone died . She said when she touched him his body was still warm, only his face was a little cool. She said he was not stiff or anything. She said when she cleaned up his brief, he was still flexible, not rigid. Staff E said in her career she had it happen when a resident was cold and stiff and he [Resident #1] was not like that. Staff E said Resident #1's arm was flopping. She said, If I would have known he was a full code I would have expected us to get busy. Staff E said when she was leaving work that morning, Staff B, RN was outside crying and She [Staff B] said I think I messed up. He was a full code. I should have known. A follow-up interview was conducted on [DATE] at 2:46 p.m. with Staff E, CNA. Staff E said no other staff members helped with Resident #1 or came in the room on the morning of [DATE]. She said she provided a statement to the Nursing Home Administrator (NHA) about what happened. She said she let the NHA know Resident #1's face was a little cool, but not cold and his body was warm. Staff E said she did not know why others were saying he was stiff because when she rolled him from front to back to clean him, he just flopped over and if he was stiff he would not have done that. An interview was conducted on [DATE] at 4:57 a.m. with Staff B, RN. She confirmed she worked the shift from 7:00 p.m. on [DATE] to 7:00 a.m. on [DATE] and was assigned to Resident #1. Staff B said she tried several times throughout the evening to get the resident to take his medication and he refused. She said Resident #1 often refused his medication. Staff B said when a resident refused medication, she would try a few times to coerce them and after a few tries she would mark in the MAR that the resident refused. She said during that shift Resident #1 was normal, he slept, he had oxygen on, and he was not having breathing problems. She said when a resident was on oxygen, saturation should be checked every shift and documented in the MAR. She said she did not know why Resident #1 was on oxygen. Staff B said the CNA, Staff E, called the nurses. Staff B said Staff D, RN got to the room first and said she thought Resident #1 was dead. Staff B said I told her I think you are right. Staff B said Resident #1 was cold, stiff, his arms were rigid, he had a stare, he had no heart and lung sounds, and the top half of his body was stiff. Staff B said she could not move Resident #1's shoulders, his jaw was open and fixed, his lower arms were stiff, and he was completely immobile. Staff B said she decided there was no use in trying to code him. Staff B said she had not seen the resident since around 10:00 or 11:00 p.m. on [DATE], but the CNA had done rounds every 2 hours. Staff B said she called Resident #1's primary care provider's (PCP) answering service and left a message for the on-call provider to call her back. She said she left a message for the family of Resident #1 to call her. Staff B said when she left the faciity on [DATE] she had still not received a call back from a provider regarding Resident #1's death. When asked which provider gave her the order she entered on [DATE] at 5:15 a.m. to release Resident #1's remains to the funeral home, she said she put it in presumptively and reconfirmed she never spoke with a provider. Staff B said, that's on me. Staff B said on [DATE] around 6:40 a.m. the next shift started coming in. She said Staff C, Licensed Practical Nurse (LPN) was going to take over her assignment. Staff B said she let Staff C know Resident #1 had passed and they did not do CPR. Staff B said Staff C panicked and freaked out because he was a full code. She said Staff C told her she needed to call the Director of Nursing (DON). Staff B said Staff C called the DON but she did not hear what the conversation entailed she was just standing and waiting. Staff B said the next thing she knew a code blue was being called on the loudspeaker for Resident #1. Staff B said, it was told to me when EMS [Emergency Medical Services] got there you better be running that code. Staff B said she and Staff F, LPN started CPR on Resident #1 and continued for around ,d+[DATE] minutes until EMS arrived and took over. She said EMS did compressions, hooked the resident to their monitor and then pronounced him deceased . She said EMS packed up and left and she was allowed to leave work then. An interview was conducted on [DATE] at 11:37 a.m. with Staff D, RN. She confirmed she worked the shift from 7:00 p.m. on [DATE] to 7:00 a.m. on [DATE] with Staff B, RN. Staff D said Resident #1 was not assigned to her and she did not know the resident. She said the CNA came out and asked if she was assigned Resident #1 and she told her no. Staff B, RN walked up and [Staff B] said oh my god, don't tell me something happened. Staff D said she went to Resident #1's room with Staff B and they checked on him and he had no pulse. She said when they got to the room Resident #1 was stiff/rigid, his mouth was open, and he was cool to the touch. Staff D said if you see a patient deceased you cannot make that call. She said you still check the code status and if they are a full code, you have to do CPR on the resident. Staff D said she thought Staff B had checked Resident #1's code status. She said she asked Staff B if she needed her to do anything or needed her help. Staff B told her no she had already called the doctor and taken care of the paperwork. A follow-up interview was conducted on [DATE] at 10:55 a.m. with Staff D, RN. She said she assumed Staff B checked Resident #1's code status. Staff D said she figured he must have been a DNR. Staff D reiterated Resident #1 was cool, stiff, rigid, and mouth ajar. She said his whole body was cool, not cold. An interview was conducted on [DATE] at 1:09 p.m. with Staff C, LPN. She said on [DATE] she came on for her shift and Staff B, RN was giving her report when Staff B informed her Resident #1 had passed away. Staff C said she asked Staff B if CPR was done and she said no he was dead. Staff C said she told Staff B to call the DON because the facility protocol was to do CPR. Staff C said she told Staff B, I will not accept responsibility without DON notification of the incident. Staff C confirmed a code blue was called for Resident #1 after Staff B talked to the DON. Staff C said she did not go in Resident #1's room due to several others being in there already. She said EMS arrived and pronounced the resident. Staff C said when she originally spoke with Staff B, Staff B did not elaborate on why she did not do CPR for Resident #1 when they found him unresponsive approximately 2 hours earlier. A follow-up interview was conducted with Staff C, LPN on [DATE] at 11:29 a.m. Staff C said she did not call the DON the morning of [DATE] to notify her of the incident with Resident #1, she had Staff B, RN call her. Staff C said she did not call the doctor to get an order to release Resident #1's remains to the funeral home because Staff B, RN already had an order in the computer. Staff C said she did not hear the conversation Staff B had with the DON but she did witness her on the phone. A follow-up interview was conducted on [DATE] at 11:38 a.m. with Staff B, RN. Staff B initially reconfirmed she did not call the DON the morning of [DATE] then said she did. Staff B said she told the DON Resident #1 had passed, was a full code, and CPR was not done. She said the DON did not give her time to explain and did not ask why, she kind of panicked and started calling other people. Everyone's phone was ringing. Staff B said the DON did not mention anything to her about calling a code she only told her not to leave the facility and the DON started calling other people. When asked to verify the condition Resident #1 was in when he was found unresponsive at approximately 5:00 a.m. on [DATE], Staff B said she got her stethoscope and checked him, his jaw was still, and his upper arms were stiff at the shoulder. She said she did not check his body because he was still under the blankets. An interview was conducted on [DATE] at 12:16 p.m. with Staff H, LPN. She said she came in for the day shift on [DATE]. Staff H said Staff C, LPN told her what happened. Staff H said she saw Staff B, RN walk out the back door and called the DON. Staff B came back inside and said the DON told her they needed to call a code. Staff H said she got on the overhead speaker and called a code blue for Resident #1. Staff H said Staff B told her the resident was gone and she made the assessment there wasn't anything that could have been done for him. Staff H said that is not how it works because when someone was a full code, you have to do CPR. Staff H said, it is not at my discretion. That is like day [TRUNCATED]

49227 Based on record review, interviews, and review of the facility policy and procedure the facility failed to implement policies and procedures to honor the resident's right to choose an advance directive for one resident (#1) out of three reviewed for Advance Directives. Resident #1 was found not breathing with no pulse. The nursing staff did not honor the resident's wish to have all resuscitative efforts made until approximately 2 hours after the resident was discovered. Resident #1 expired in the facility. These failures created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Resident #1 and resulted in the determination of Immediate Jeopardy which began on [DATE] with a scope and severity of J. The findings of Immediate Jeopardy were determined to be past noncompliance with a correction date of [DATE] after surveyor verification af actions implemented removed and corrected the noncompliance. Findings included: An interview was conducted on [DATE] at 10:45 a.m. with the Social Services Director (SSD) She said on admission she always checked a resident's advance directives. The SSD said if the resident had a DNR (Do Not Resuscitate Order) she verified that it was legitimate and if they had a power of attorney (POA) she verified it was legal. An interview was conducted on [DATE] at 10:50 a.m. with Staff G, LPN/Unit Manager (UM). She said every resident had a physician order in the medical record for their code status (Advance Directive choice). She said the resident's code status showed up at the top of the electronic medical record for each resident and that had to be put in separate from the order. If the electronic medical record system is down Staff G said there is a computer back up of the Medication Administration Record (MAR) they can print that had the resident's code status on the top. When asked if the facility had a DNR book or paper copy of resident code status she stated, I'm trying to think of that one .don't think we have a book. Review of a facility policy titled Advance Directives, reviewed [DATE], showed the following: Policy, The resident has the right to accept or refuse medical or surgical treatment and, at the individual's option, formulate an advance directive. Procedure 1. Provide information about advance directives to resident. a. The facility provides the resident (or their legal surrogate) with the Facility Guide at the time of admission. The guide provides written information about advance directives. b. If the resident was incompetent at the time of admission but later becomes able to receive and understand the guide, the information is given to the resident. c. The resident or surrogate does not have to write an advance directive to partake of facility services or as a condition of admission. 2. The resident and/or surrogate will be questioned at the time of admission about the existence of any advance directive written prior to admission. a. Photocopy all previously written advance directives, placing the copy in the medical record. b. Return the original advance directive to the resident/surrogate. 3. Should the resident or surrogate wish to write an advance directive, as defined by law, the facility shall assist the resident or surrogate to obtain the necessary forms. a. Make copies of a newly written advance directive, placing the copy in the medical record. b. Return the original advance directive to the resident/surrogate. 4. The attending physician shall record in the medical record pertinent information related to the formulation or implementation of the advance directive. Such information includes, but is not limited to: a. Any verbal advance directive that was written in his or her presence; b. Any diagnosis that the resident has a terminal or irreversible condition; c. Specific treatment steps to be taken when the advance directive is implemented; and d. All revocations or limitations placed on the advance directive in his or her presence. 5. The attending physician must document in the medical record the discussion with the resident or surrogate regarding choices and decision of advance directives. a. Upon executing any valid Advance Directive, the designated paperwork will be placed in the resident's medical record under the Advance Directive tab. b. When responding to a call for assistance, health care professionals and emergency personnel will honor the advance directive. 6. The resident or a probate court may revoke an advance directive. a. Document in the medical record, under the advance directive tab, the date, time and place of the revocation. b. The resident will complete a new Advance Directive/Medical Treatment Decisions Form to reflect new changes. The prior advance directive form will be placed in the medical record overflow chart in the medical records department. c. Update the face sheet to reflect the revocation. 7. Upon transfer or discharge, include a copy of all executed advanced directives in the document sent to the receiving facility. 8. Licensed Nursing Staff and Social Service staff will receive annual in-service education on Advance Directives. Resident #1 Review of the resident's electronic medical record admission profile showed Resident #1 was admitted to the facility on [DATE] with diagnoses including pneumonia, syncope and collapse, chronic kidney disease, benign prostatic hyperplasia. Review of Resident #1's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form 3008, dated [DATE] showed the resident had a discharge diagnosis of pneumonia upon leaving the hospital, where he was admitted on [DATE]. Form 3008 showed the resident was discharged on antibiotics for pneumonia, on oxygen 2 liters (L) as needed, and requested Full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive) status. Review of Resident #1's MDS (Minimum Data Set) Assessment, completed [DATE], Section C, Cognitive Patterns, showed resident had a BIMS (Brief Interview of Mental Status) Score of 3, indicating severely impaired cognition. Review of Resident #1's medical records showed a care plan in place, dated [DATE], for Advance Directives (Full Code) with a goal of advance directives will be honored by staff. A review of Resident #1's physician orders revealed the following: -Full Code, dated [DATE]. -Oxygen via nasal cannula 2 Liters (L) as needed, dated [DATE]. - Doxycycline Hyclate Oral Capsule 100 milligram (mg). Give 1 capsule by mouth every 12 hours for pneumonia for 5 Days, dated [DATE]. - Cefuroxime Axetil Oral Tablet 500 mg. Give 1 tablet by mouth two times a day for pneumonia for 5 Days, dated [DATE]. - RN (Registered Nurse) to release remains to funeral home of family's choice. [DATE] at 5:18 a.m. Review of Resident #1's medical record, a nurses' progress note entered by Staff B, RN on [DATE] at 5:15 a.m. showed Called to residents [sic] room by CNA [Certified Nursing Assistant] found resident absent of breath sounds and apical pulse for full two minutes. [Family member] and MD made aware of death. New order received to release remains to funeral home of family's choice. There was no documentation CPR was initiated for Resident #1 on [DATE] at 5:15 a.m. There was no additional documentation in the resident's medical record as to the condition of the resident when he was found, observations made, why a code blue was not called, or the time of death. Code blue indicates there is a resident requiring resuscitation or otherwise in need of immediate medical attention, often as the result of a respiratory or cardiac arrest. An interview was conducted on [DATE] at 12:19 p.m. with Staff E, CNA. She said on the morning of [DATE] she saw Resident #1 in bed when she did routine rounds around 3:00 a.m. She said Resident #1 was the same as he had been. Staff E said the resident had the pattern of breathing like people have when they are going to die but were still holding on. She said a few days prior to that, she could not remember the date, she had let the unit manager and nurse know Resident #1 was not breathing right and they put oxygen on him. She said on that day he was breathing a little shallow and low. She said at first, she thought he was gone but she called his name several times and he moaned letting her know he was still there. She said since that night he had been doing that breathing so the nurse should have known. She said he did not get any better. Staff E said on the morning of [DATE] she went in the room and was checking his brief, and he did not move. She said she rubbed his chest a little like she usually did, and he did not respond. She said Resident #1 was lying on his back and his eyes were partially open like they normally were when he slept. She said he often slept with his mouth open because he would breathe through his mouth all the time like he was trying to get more air. Staff E said the resident was floppy and she was scared. She confirmed Resident #1 had oxygen on during that shift. Staff E said she called the nurse and said she did not think Resident #1 was alive. She said both nurses on duty, Staff B, RN and Staff D, RN, came to assess and see if he was breathing. She said the nurses were like ok, they left out and no one ever came back. Staff E said the nurse never said if the resident was a full code or do not resuscitate (DNR). She said she figured he must have been a DNR because if he had been a full code the nurse would have grabbed the chart and normally they jump and run, and they did not do that. Staff E said she cleaned Resident #1 up and covered him like she normally did when someone died . She said when she touched him his body was still warm, only his face was a little cool. She said he was not stiff or anything. She said when she cleaned up his brief, he was still flexible, not rigid. Staff E said in her career she had it happen when a resident was cold and stiff and he [Resident #1] was not like that. Staff E said Resident #1's arm was flopping. She said, If I would have known he was a full code I would have expected us to get busy. Staff E said when she was leaving work that morning, Staff B, RN was outside crying and She [Staff B] said I think I messed up. He was a full code. I should have known. A follow-up interview was conducted on [DATE] at 2:46 p.m. with Staff E, CNA. Staff E said no other staff members helped with Resident #1 or came in the room on the morning of [DATE]. She said she provided a statement to the Nursing Home Administrator (NHA) about what happened. She said she let the NHA know Resident #1's face was a little cool, but not cold and his body was warm. Staff E said she did not know why others were saying he was stiff because when she rolled him from front to back to clean him, he just flopped over and if he was stiff he would not have done that. An interview was conducted on [DATE] at 4:57 a.m. with Staff B, RN. She confirmed she worked the shift from 7:00 p.m. on [DATE] to 7:00 a.m. on [DATE] and was assigned to Resident #1. Staff B said the CNA, Staff E, called the nurses. Staff B said Staff D, RN got to the room first and said she thought Resident #1 was dead. Staff B said I told her I think you are right. Staff B said Resident #1 was cold, stiff, his arms were rigid, he had a stare, he had no heart and lung sounds, and the top half of his body was stiff. Staff B said she could not move Resident #1's shoulders, his jaw was open and fixed, his lower arms were stiff, and he was completely immobile. Staff B said she decided there was no use in trying to code him. Staff B said she had not seen the resident since around 10:00 or 11:00 p.m. on [DATE], but the CNA had done rounds every 2 hours. Staff B said she called Resident #1's primary care provider's (PCP) answering service and left a message for the on-call provider to call her back. She said she left a message for the family of Resident #1 to call her. Staff B said when she left the faciity on [DATE] she had still not received a call back from a provider regarding Resident #1's death. When asked which provider gave her the order she entered on [DATE] at 5:15 a.m. to release Resident #1's remains to the funeral home, she said she put it in presumptively and reconfirmed she never spoke with a provider. Staff B said, that's on me. Staff B said on [DATE] around 6:40 a.m. the next shift started coming in. She said Staff C, Licensed Practical Nurse (LPN) was going to take over her assignment. Staff B said she let Staff C know Resident #1 had passed and they did not do CPR. Staff B said Staff C panicked and freaked out because he was a full code. She said Staff C told her she needed to call the Director of Nursing (DON) Staff B said Staff C called the DON but she did not hear what the conversation entailed she was just standing and waiting. Staff B said the next thing she knew a code blue was being called on the loudspeaker for Resident #1. Staff B said, it was told to me when EMS [Emergency Medical Services] got there you better be running that code. Staff B said she and Staff F, LPN started CPR on Resident #1 and continued for around ,d+[DATE] minutes until EMS arrived and took over. She said EMS did compressions, hooked the resident to their monitor and then pronounced him deceased . She said EMS packed up and left and she was allowed to leave work then. An interview was conducted on [DATE] at 11:37 a.m. with Staff D, RN. She confirmed she worked the shift from 7:00 p.m. on [DATE] to 7:00 a.m. on [DATE] with Staff B, RN. Staff D said Resident #1 was not assigned to her and she did not know the resident. She said the CNA came out and asked if she was assigned Resident #1 and she told her no. Staff B, RN walked up and [Staff B] said oh my god, don't tell me something happened. Staff D said she went to Resident #1's room with Staff B and they checked on him and he had no pulse. She said when they got to the room Resident #1 was stiff/rigid, his mouth was open, and he was cool to the touch. Staff D said if you see a patient deceased you cannot make that call. She said you still check the code status and if they are a full code, you have to do CPR on the resident. Staff D said she thought Staff B had checked Resident #1's code status. She said she asked Staff B if she needed her to do anything or needed her help. Staff B told her no she had already called the doctor and taken care of the paperwork. A follow-up interview was conducted on [DATE] at 10:55 a.m. with Staff D, RN. She said she assumed Staff B checked Resident #1's code status. Staff D said she figured he must have been a DNR. Staff D reiterated Resident #1 was cool, stiff, rigid, and mouth ajar. She said his whole body was cool, not cold. An interview was conducted on [DATE] at 1:09 p.m. with Staff C, LPN. She said on [DATE] she came on for her shift and Staff B, RN was giving her report when Staff B informed her Resident #1 had passed away. Staff C said she asked Staff B if CPR was done and she said no he was dead. Staff C said she told Staff B to call the DON because the facility protocol was to do CPR. Staff C said she told Staff B, I will not accept responsibility without DON notification of the incident. Staff C confirmed a code blue was called for Resident #1 after Staff B talked to the DON. Staff C said she did not go in Resident #1's room due to several others being in there already. She said EMS arrived and pronounced the resident. Staff C said when she originally spoke with Staff B, Staff B did not elaborate on why she did not do CPR for Resident #1 when they found him unresponsive approximately 2 hours earlier. A follow-up interview was conducted with Staff C, LPN on [DATE] at 11:29 a.m. Staff C said she did not call the DON the morning of [DATE] to notify her of the incident with Resident #1, she had Staff B, RN call her. Staff C said she did not call the doctor to get an order to release Resident #1's remains to the funeral home because Staff B, RN already had an order in the computer. Staff C said she did not hear the conversation Staff B had with the DON but she did witness her on the phone. A follow-up interview was conducted on [DATE] at 11:38 a.m. with Staff B, RN. Staff B initially reconfirmed she did not call the DON the morning of [DATE] then said she did. Staff B said she told the DON Resident #1 had passed, was a full code, and CPR was not done. She said the DON did not give her time to explain and did not ask why, she kind of panicked and started calling other people. Everyone's phone was ringing. Staff B said the DON did not mention anything to her about calling a code she only told her not to leave the facility and the DON started calling other people. When asked to verify the condition Resident #1 was in when he was found unresponsive at approximately 5:00 a.m. on [DATE], Staff B said she got her stethoscope and checked him, his jaw was still, and his upper arms were stiff at the shoulder. She said she did not check his body because he was still under the blankets. An interview was conducted on [DATE] at 12:16 p.m. with Staff H, LPN. She said she came in for the day shift on [DATE]. Staff H said Staff C, LPN told her what happened. Staff H said she saw Staff B, RN walk out the back door and called the DON. Staff B came back inside and said the DON told her they needed to call a code. Staff H said she got on the overhead speaker and called a code blue for Resident #1. Staff H said Staff B told her the resident was gone and she made the assessment there wasn't anything that could have been done for him. Staff H said that is not how it works because when someone was a full code, you have to do CPR. Staff H said, it is not at my discretion. That is like day one 1 basics. An interview was conducted on [DATE] at 1:50 p.m. with the DON. The DON said Staff B, RN called her on [DATE] around 7:,d+[DATE]:10 a.m. to inform her Resident #1 was deceased and no CPR had been initiated. The DON said she told Staff B to initiate CPR. The DON said at this time of this discussion they did not talk about Resident #1 not breathing, being cold and rigid, or his chin being in a fixed position. She said CPR started and continued for approximately 5 minutes, EMS arrived at 7:34 a.m. and pronounced the resident at 7:40 a.m. The DON said Staff B did not tell her she did not call a code due to her observations. The DON said for Resident #1 she would have expected the staff to call a code blue and initiate CPR. The DON reviewed Resident #1's medical record and verified there had been no documentation of oxygen saturation during his stay. Regarding change in condition, she said she would expect staff to document oxygen saturation levels before and after applying supplemental oxygen and notify a provider if the resident was having breathing issues. She confirmed there were no vital signs recorded when the resident was found unresponsive on [DATE] at approximately 5:00 a.m. The DON said she would not expect staff to obtain vitals when CPR was initiated on a resident or if they are deceased . An interview was conducted on [DATE] at 4:12 p.m. with Resident #'1 PCP. She said Resident #1 was frail but stable. She said if she had been called and told a resident that was a full code expired and no interventions were done, she would have educated them. An interview was conducted on [DATE] at 2:24 p.m. with the Nursing Home Administrator (NHA), DON and the Regional Clinical Director. The NHA said he received a call on [DATE] from the DON telling him Resident #1 passed and they were doing a full code right then. He said he reported the incident to the state, the police, and the Department of Children and Families. He said they then began investigating. He said during the investigation he and the DON decided a code did not have to be called because rigor mortis was setting in for Resident #1. The DON said when the nurses went into Resident #1's room and there were signs of death, their observations should have been documented. An interview was conducted on [DATE] at 1:06 p.m. with the DON. She said with Resident #1 it was pretty cut and dry, if they were not a DNR you follow the process. Facility immediate actions to correct deficient practice and remove the Immediate Jeopardy included: 1. ADHOC (for this situation) QAPI (Quality Assessment Performance Improvement) Meeting for Honoring Advanced Directives / CPR. Completed [DATE]. 2. QAA (Quality Assurance and Assessment)/QAPI review: [DATE] 3. QAA/QAPI review within 72 hours. Completed [DATE] 4. Initiate investigation through statements, record review, interview, and video review. Completed [DATE]. 5. Validate licenses, background check and clearinghouse of staff involved in incident. Completed [DATE]. 6. Validate CPR certification of staff involved in incident. Completed [DATE]. 7. Audit current residents to ensure advance directives/code status is entered in EMR and is accurate. Completed [DATE]. 8. Validate DNR transport paper is appropriately filled out and yellow paper is available to print transport paperwork. Completed [DATE]. 9. Validate CPR certification of all nurses. Completed [DATE]. 10. Education to all licensed nurses on the location of Advance Directives and code status in EMR and CPR procedure with emphasis on timely response to code status. Completed education with all licensed nurses on [DATE]. 11. Education to all licensed nurses on the appropriate documentation for Advance Directives, CPR process and obvious signs of death. Completed [DATE]. 12. CPR drills every shift for 7 consecutive days. To include validate unresponsive, review code status in EMR and initiate CPR or do not resuscitate per physician order and resident wishes. Completed [DATE]. Monitoring procedure to ensure that the removal plan is effective and that specific deficiency cited remains corrected and/or in compliance with the regulatory requirements: 13. Newly admitted residents will have Advance Directives / code status order in place. Ongoing 14. Residents will be evaluated quarterly and with significant change for accuracy of advance directives / code status and plan of care updated as warranted. Ongoing 15. Audit new admissions for advance directives daily and ensure order is in place. Ongoing 16. Conduct CPR drills once every shift every month. Ongoing 17. Newly hired RN/LPN will be educated on advanced directives and CPR procedure. Ongoing 18. NHA, Director of Nursing, ADON, SDC (Staff Development Coordinator), Unit Managers, Evening Supervisor and Weekend Supervisor will validate the nursing staff's retention of the education presented by conducting performance observation validation audits 3 times a week for 12 weeks. 19. Audits and drills audit will be reviewed in monthly QA&A/QAPI meeting. Ongoing 20. QA&A/QAPI Committee will determine need for further auditing or until substantial compliance is achieved. NHA, Director of Nursing, ADON, SDC, Unit Managers, Evening Supervisor and Weekend Supervisor will validate there is sufficient staffing to meet the residents needs. Ongoing. Verification of the facility's removal plan was conducted by the survey team on [DATE]. An interview was conducted on [DATE] at 6:12 p.m. with the NHA, DON, and [NAME] President of Operations (VPO). Copies of all education provided to staff were reviewed. Audits the facility completed related to code status were reviewed. They confirmed all nurses were educated on the CPR process and advanced directives. The DON was educated by the Regional Clinical Director. The VPO said going forward one of the key things is validating and verifying. The NHA said from a risk standpoint they need to validate what they expect and make sure things are done properly. Interviews were conducted and education confirmed for 11 out of 11 licensed nurses. Staff members signed in-service education and/or were able to state that they had been trained and were knowledgeable about the policies. Based on verification of the facility's Immediate Jeopardy removal plan the immediate jeopardy was determined to be past noncompliance with a correction date of [DATE].

49227 Based on record review, interviews, and policy review, the facility failed to ensure cardiopulmonary resuscitation (CPR) was performed according to professional standards for one resident (#1) out of three reviewed for CPR. Resident #1 was found not breathing with no pulse. Nursing staff did not initiate CPR until approximately 2 hours after the resident was discovered. Resident #1 expired in the facility. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Resident #1 and resulted in the determination of Immediate Jeopardy starting on [DATE]/24. The findings of Immediate Jeopardy were determined to be Past noncompliance with a compliance date of [DATE] after surveyor verification of actions implemented removed and corrected the noncompliance. Findings included: Review of the resident's electronic medical record admission profile showed Resident #1 was admitted to the facility on [DATE] with diagnoses including pneumonia, syncope and collapse, chronic kidney disease, benign prostatic hyperplasia. Review of Resident #1's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form 3008, dated [DATE] showed the resident had a discharge diagnosis of pneumonia upon leaving the hospital, where he was admitted on [DATE]. Form 3008 showed the resident was discharged on antibiotics for pneumonia, on oxygen 2 liters (L) as needed, and requested Full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive) status. Review of Resident #1's MDS (Minimum Data Set) Assessment, completed [DATE], Section C, Cognitive Patterns, showed resident had a BIMS Score of 3, indicating severely impaired cognition. Review of Resident #1's medical records showed a care plan in place, dated [DATE], for Advance Directives (Full Code) with a goal of advance directives will be honored by staff. A review of Resident #1's physician orders revealed the following: -Full Code, dated [DATE]. -Oxygen via nasal cannula 2 Liters (L) as needed, dated [DATE]. - Doxycycline Hyclate Oral Capsule 100 milligram (mg). Give 1 capsule by mouth every 12 hours for pneumonia for 5 Days, dated [DATE]. - Cefuroxime Axetil Oral Tablet 500 mg. Give 1 tablet by mouth two times a day for pneumonia for 5 Days, dated [DATE]. - RN to release remains to funeral home of family's choice. [DATE] at 5:18 a.m. Review of Resident #1's medical record, a nurses' progress note entered by Staff B, RN on [DATE] at 5:15 a.m. showed Called to residents [sic] room by CNA [Certified Nursing Assistant] found resident absent of breath sounds and apical pulse for full two minutes. [Family member] and MD made aware of death. New order received to release remains to funeral home of family's choice. There was no documentation CPR was initiated for Resident #1 on [DATE] at 5:15 a.m. There was no additional documentation in the resident's medical record as to the condition of the resident when he was found, observations made, why a code blue was not called, or the time of death. Code blue indicates there is a resident requiring resuscitation or otherwise in need of immediate medical attention, often as the result of a respiratory or cardiac arrest. An interview was conducted on [DATE] at 12:19 p.m. with Staff E, CNA. She said on the morning of [DATE] she saw Resident #1 in bed when she did routine rounds around 3:00 a.m. She said Resident #1 was the same as he had been. Staff E said the resident had the pattern of breathing like people have when they are going to die but were still holding on. She said a few days prior to that, she could not remember the date, she had let the unit manager and nurse know Resident #1 was not breathing right and they put oxygen on him. She said on that day he was breathing a little shallow and low. She said at first, she thought he was gone but she called his name several times and he moaned letting her know he was still there. She said since that night he had been doing that breathing so the nurse should have known. She said he did not get any better. Staff E said on the morning of [DATE] she went in the room and was checking his brief, and he did not move. She said she rubbed his chest a little like she usually did, and he did not respond. She said Resident #1 was lying on his back and his eyes were partially open like they normally were when he slept. She said he often slept with his mouth open because he would breathe through his mouth all the time like he was trying to get more air. Staff E said the resident was floppy and she was scared. She confirmed Resident #1 had oxygen on during that shift. Staff E said she called the nurse and said she did not think Resident #1 was alive. She said both nurses on duty, Staff B, RN and Staff D, RN, came to assess and see if he was breathing. She said the nurses were like ok, they left out and no one ever came back. Staff E said the nurse never said if the resident was a full code or do not resuscitate (DNR). She said she figured he must have been a DNR because if he had been a full code the nurse would have grabbed the chart and normally they jump and run, and they did not do that. Staff E said she cleaned Resident #1 up and covered him like she normally did when someone died . She said when she touched him his body was still warm, only his face was a little cool. She said he was not stiff or anything. She said when she cleaned up his brief, he was still flexible, not rigid. Staff E said in her career she had it happen when a resident was cold and stiff and he [Resident #1] was not like that. Staff E said Resident #1's arm was flopping. She said, If I would have known he was a full code I would have expected us to get busy. Staff E said when she was leaving work that morning, Staff B, RN was outside crying and She [Staff B] said I think I messed up. He was a full code. I should have known. A follow-up interview was conducted on [DATE] at 2:46 p.m. with Staff E, CNA. Staff E said no other staff members helped with Resident #1 or came in the room on the morning of [DATE]. She said she provided a statement to the Nursing Home Administrator (NHA) about what happened. She said she let the NHA know Resident #1's face was a little cool, but not cold and his body was warm. Staff E said she did not know why others were saying he was stiff because when she rolled him from front to back to clean him, he just flopped over and if he was stiff he would not have done that. An interview was conducted on [DATE] at 4:57 a.m. with Staff B, RN. She confirmed she worked the shift from 7:00 p.m. on [DATE] to 7:00 a.m. on [DATE] and was assigned to Resident #1. Staff B said the CNA, Staff E, called the nurses. Staff B said Staff D, RN got to the room first and said she thought Resident #1 was dead. Staff B said I told her I think you are right. Staff B said Resident #1 was cold, stiff, his arms were rigid, he had a stare, he had no heart and lung sounds, and the top half of his body was stiff. Staff B said she could not move Resident #1's shoulders, his jaw was open and fixed, his lower arms were stiff, and he was completely immobile. Staff B said she decided there was no use in trying to code him. Staff B said she had not seen the resident since around 10:00 or 11:00 p.m. on [DATE], but the CNA had done rounds every 2 hours. Staff B said she called Resident #1's primary care provider's (PCP) answering service and left a message for the on-call provider to call her back. She said she left a message for the family of Resident #1 to call her. Staff B said when she left the faciity on [DATE] she had still not received a call back from a provider regarding Resident #1's death. When asked which provider gave her the order she entered on [DATE] at 5:15 a.m. to release Resident #1's remains to the funeral home, she said she put it in presumptively and reconfirmed she never spoke with a provider. Staff B said, that's on me. Staff B said on [DATE] around 6:40 a.m. the next shift started coming in. She said Staff C, Licensed Practical Nurse (LPN) was going to take over her assignment. Staff B said she let Staff C know Resident #1 had passed and they did not do CPR. Staff B said Staff C panicked and freaked out because he was a full code. She said Staff C told her she needed to call the Director of Nursing (DON) Staff B said Staff C called the DON but she did not hear what the conversation entailed she was just standing and waiting. Staff B said the next thing she knew a code blue was being called on the loudspeaker for Resident #1. Staff B said, it was told to me when EMS [Emergency Medical Services] got there you better be running that code. Staff B said she and Staff F, LPN started CPR on Resident #1 and continued for around ,d+[DATE] minutes until EMS arrived and took over. She said EMS did compressions, hooked the resident to their monitor and then pronounced him deceased . She said EMS packed up and left and she was allowed to leave work then. An interview was conducted on [DATE] at 11:37 a.m. with Staff D, RN. She confirmed she worked the shift from 7:00 p.m. on [DATE] to 7:00 a.m. on [DATE] with Staff B, RN. Staff D said Resident #1 was not assigned to her and she did not know the resident. She said the CNA came out and asked if she was assigned Resident #1 and she told her no. Staff B, RN walked up and [Staff B] said oh my god, don't tell me something happened. Staff D said she went to Resident #1's room with Staff B and they checked on him and he had no pulse. She said when they got to the room Resident #1 was stiff/rigid, his mouth was open, and he was cool to the touch. Staff D said if you see a patient deceased you cannot make that call. She said you still check the code status and if they are a full code, you have to do CPR on the resident. Staff D said she thought Staff B had checked Resident #1's code status. She said she asked Staff B if she needed her to do anything or needed her help. Staff B told her no she had already called the doctor and taken care of the paperwork. A follow-up interview was conducted on [DATE] at 10:55 a.m. with Staff D, RN. She said she assumed Staff B checked Resident #1's code status. Staff D said she figured he must have been a DNR. Staff D reiterated Resident #1 was cool, stiff, rigid, and mouth ajar. She she his whole body was cool, not cold. An interview was conducted on [DATE] at 1:09 p.m. with Staff C, LPN. She said on [DATE] she came on for her shift and Staff B, RN was giving her report when Staff B informed her Resident #1 had passed away. Staff C said she asked Staff B if CPR was done and she said no he was dead. Staff C said she told Staff B to call the DON because the facility protocol was to do CPR. Staff C said she told Staff B, I will not accept responsibility without DON notification of the incident. Staff C confirmed a code blue was called for Resident #1 after Staff B talked to the DON. Staff C said she did not go in Resident #1's room due to several others being in there already. She said EMS arrived and pronounced the resident. Staff C said when she originally spoke with Staff B, Staff B did not elaborate on why she did not do CPR for Resident #1 when they found him unresponsive approximately 2 hours earlier. A follow-up interview was conducted with Staff C, LPN on [DATE] at 11:29 a.m. Staff C said she did not call the DON the morning of [DATE] to notify her of the incident with Resident #1, she had Staff B, RN call her. Staff C said she did not call the doctor to get an order to release Resident #1's remains to the funeral home because Staff B, RN already had an order in the computer. Staff C said she did not hear the conversation Staff B had with the DON but she did witness her on the phone. A follow-up interview was conducted on [DATE] at 11:38 a.m. with Staff B, RN. Staff B initially reconfirmed she did not call the DON the morning of [DATE] then said she did. Staff B said she told the DON Resident #1 had passed, was a full code, and CPR was not done. She said the DON did not give her time to explain and did not ask why, she kind of panicked and started calling other people. Everyone's phone was ringing. Staff B said the DON did not mention anything to her about calling a code she only told her not to leave the facility and the DON started calling other people. When asked to verify the condition Resident #1 was in when he was found unresponsive at approximately 5:00 a.m. on [DATE], Staff B said she got her stethoscope and checked him, his jaw was still, and his upper arms were stiff at the shoulder. She said she did not check his body because he was still under the blankets. An interview was conducted on [DATE] at 12:16 p.m. with Staff H, LPN. She said she came in for the day shift on [DATE]. Staff H said Staff C, LPN told her what happened. Staff H said she saw Staff B, RN walk out the back door and called the DON. Staff B came back inside and said the DON told her they needed to call a code. Staff H said she got on the overhead speaker and called a code blue for Resident #1. Staff H said Staff B told her the resident was gone and she made the assessment there wasn't anything that could have been done for him. Staff H said that is not how it works because when someone was a full code, you have to do CPR. Staff H said, it is not at my discretion. That is like day one basics. An interview was conducted on [DATE] at 1:50 p.m. with the DON. The DON said Staff B, RN called her on [DATE] around 7:,d+[DATE]:10 a.m. to inform her Resident #1 was deceased and no CPR had been initiated. The DON said she told Staff B to initiate CPR. The DON said at this time of this discussion they did not talk about Resident #1 not breathing, being cold and rigid, or his chin being in a fixed position. She said CPR started and continued for approximately 5 minutes, EMS arrived at 7:34 a.m. and pronounced the resident at 7:40 a.m. The DON said Staff B did not tell her she did not call a code due to her observations. The DON said for Resident #1 she would have expected the staff to call a code blue and initiate CPR. The DON reviewed Resident #1's medical record and verified there had been no documentation of oxygen saturation during his stay. Regarding change in condition, she said she would expect staff to document oxygen saturation levels before and after applying supplemental oxygen and notify a provider if the resident was having breathing issues. She confirmed there were no vital signs recorded when the resident was found unresponsive on [DATE] at approximately 5:00 a.m. The DON said she would not expect staff to obtain vitals when CPR was initiated on a resident or if they are deceased . An interview was conducted on [DATE] at 4:12 p.m. with Resident #'1 PCP. She said Resident #1 was frail but stable. She said if she had been called and told a resident that was a full code expired and no interventions were done, she would have educated them. An interview was conducted on [DATE] at 2:24 p.m. with the Nursing Home Administrator (NHA), DON and the Regional Clinical Director. The NHA said he received a call on [DATE] from the DON telling him Resident #1 passed and they were doing a full code right then. He said he reported the incident to the state, the police, and the Department of Children and Families. He said they then began investigating. He said during the investigation he and the DON decided a code did not have to be called because rigor mortis was setting in for Resident #1. The DON said when the nurses went into Resident #1's room and there were signs of death, their observations should have been documented. An interview was conducted on [DATE] at 1:06 p.m. with the DON. She said with Resident #1 it was pretty cut and dry, if they were not a DNR you follow the process. Review of a facility policy titled Cardiopulmonary Resuscitation, revised [DATE], showed the following: The center shall provide basic life support, including CPR - Cardiopulmonary Resuscitation when a resident requires such emergency care, prior to the arrival of emergency medical services, subject to physician order, and resident choice indicated in the resident's advance directives. CPR will be initiated unless: -A valid Do Not Resuscitate Order (DNR) is in place or -Resident presents with obvious clinical signs of irreversible death (e.g. rigor mortis, dependent lividity, decapitation, transection or decomposition) or -Initiating CPR could cause injury or peril to the rescuer. CPR certified licensed staff will be available on all shifts. Procedure: 1. In the event of cardiac or respiratory arrest, identify code status. If no DNR order exists, or if the resident has no obvious clinical signs of irreversible death, begin CPR. 2. Activate emergency response system by clearly paging over the PA system. Code Blue and the area/room number. 3. Continue CPR until either: -the resident responds or -healthcare practitioner arrives and takes over or -EMS arrives and takes over 4. Notify the physician of resident status and obtain further orders. 5. Notify family/resident representative. 6. Document appropriate information in the medical record. Review of a facility policy titled Death of a Resident in the Facility, revised [DATE], showed the following: Policy Upon death of a resident, the facility will notify the MD and responsible party. If there is not a do not resuscitate order, emergency response will be called. The resident will receive proper postmortem care, including bathing, clean linens and gown. Upon physician's release of the body, the mortician will be notified for transportation of the body to the mortuary of choice. The family/responsible party will be provided the opportunity to spend time alone with the body prior to mortician removal. Resident belongings will be packed and stored for removal by family/responsible party. Facility immediate actions to correct deficient practice included: 1. ADHOC (for this situation) QAPI (Quality Assessment Performance Improvement) Meeting for Honoring Advanced Directives / CPR. Completed [DATE]. 2. QAA (Quality Assurance and Assessment)/QAPI review: [DATE] 3. QAA/QAPI review within 72 hours. Completed [DATE]. 4. Initiate investigation through statements, record review, interview, and video review. Completed [DATE]. 5. Validate licenses, background check and clearinghouse of staff involved in incident. Completed [DATE]. 6. Validate CPR certification of staff involved in incident. Completed [DATE]. 7. Audit current residents to ensure advance directives/code status is entered in EMR (Electronic Medical Record) and is accurate. Completed [DATE]. 8. Validate DNR transport paper is appropriately filled out and yellow paper is available to print transport paperwork. Completed [DATE]. 9. Validate CPR certification of all nurses. Completed [DATE]. 10. Education to all licensed nurses on the location of Advance Directives and code status in EMR and CPR procedure with emphasis on timely response to code status. Completed education with all licensed nurses on [DATE]. 11. Education to all licensed nurses on the appropriate documentation for Advance Directives, CPR process and obvious signs of death. Completed [DATE]. 12. CPR drills every shift times 7 consecutive days. To include validate unresponsive, review code status in EMR and initiate CPR or do not resuscitate per physician order and resident wishes. Completed [DATE]. Monitoring procedure to ensure that the removal plan is effective and that specific deficiency cited remains corrected and/or in compliance with the regulatory requirements: 13. Newly admitted residents will have Advance Directives / code status order in place. Ongoing 14. Residents will be evaluated quarterly and with significant change for accuracy of advance directives / code status and plan of care updated as warranted. Ongoing 15. Audit new admissions for advance directives daily and ensure order is in place. Ongoing 16. Conduct CPR drills once every shift every month. Ongoing 17. Newly hired RN/LPN will be educated on advance directives and CPR procedure. Ongoing 18. NHA, Director of Nursing, ADON, SDC, Unit Managers, Evening Supervisor and Weekend Supervisor will validate the nursing staff's retention of the education presented by conducting performance observation validation audits 3 times a week for 12 weeks. 19. Audits and drills audit will be reviewed in monthly QA&A/QAPI meetings. Ongoing 20. QA&A/QAPI Committee will determine need for further auditing or until substantial compliance is achieved. NHA, Director of Nursing, ADON, SDC, Unit Managers, Evening Supervisor and Weekend Supervisor will validate there is sufficient staffing to meet the resident's needs. Ongoing. Verification of the facility's removal plan was conducted by the survey team on [DATE]. An interview was conducted on [DATE] at 6:12 p.m. with the NHA, DON, and [NAME] President of Operations (VPO). Copies of all education provided to staff were reviewed. Audits the facility completed related to code status were reviewed. They confirmed all nurses were educated on the CPR process and advance directives. The DON was educated by the Regional Clinical Director. The VPO said going forward one of the key things is validating and verifying. The NHA said from a risk standpoint they need to validate what they expect and make sure things are done properly. Interviews were conducted and education confirmed for 11 out of 11 licensed nurses. Staff members signed in-service education and/or were able to state during an interview that they had been trained and were knowledgeable about the policies. Based on verification of the facility's Immediate Jeopardy removal plan the immediate jeopardy was determined to be past noncompliance with a correction date of [DATE].

Based on interview, record review, and policy review, the facility failed to ensure adequate supervision with assistance devices to prevent accidents for two residents (#5 and #6) out of three residents reviewed for use of mechanical and sit to stand lifts. Findings included: 1. Review of admission records showed Resident #5 was admitted on [DATE] with congestive heart failure, kidney disease, chronic venous hypertension with ulcer in lower extremity, and sacral pressure ulcer stage 3. Review of Resident #5's admission MDS (Minimum Data Set), dated 2/8/24 showed he had a BIMS (Brief Interview of Mental Status) score of 14, indicating he was cognitively intact. Review of Resident #5's medical record showed a care plan in place for Activities of Daily Living (ADL) Self Care Performance. Interventions included use of a mechanical lift for transfers, dated 2/9/24 and mechanical lift dependent assist of two, dated 2/7/24. An interview was conducted on 3/12/24 at 10:24 a.m. with Resident #5. The resident said he did not get out of bed everyday but when he did staff used a mechanical lift to get him up. Resident #4 said typically one staff member used the lift to transfer him, not two. Resident #4 said he had not had a fall using the lift. 2. Review of admission records showed Resident #6 was admitted on [DATE] with diagnosis including paraplegia, disorders of bone density and structure, and idiopathic peripheral autonomic neuropathy. Review of Resident #6's quarterly MDS, dated [DATE], showed he had a BIMS score of 13, indicated he was cognitively intact. Review of Resident #6's medical record showed a care plan in place for Risk for Falls. Interventions included two person assist utilizing sit to stand lift, dated 11/12/14, and use the mechanical lift with transfers if indicated at time of transfer, dated 5/5/15. An interview was conducted on 3/12/24 at 4:51 p.m. with Resident #6. He stated he needed the use of a sit to stand to transfer from his bed to his wheelchair. He said mostly two staff members help with the transfer but every now and then only one staff member used the sit to stand to help him transfer. Resident #5 said he had not had any falls while using the sit to stand. An interview was conducted on 3/13/24 at 2:42 p.m. with the Director of Rehabilitation (DOR). She confirmed two staff members should assist with the use of a sit to stand or mechanical lift, never just one. She said Resident #5 should be transferred by two staff members using a mechanical lift and Resident #6 should be transferred by two staff members using a sit to stand lift. An interview was conducted on 3/12/24 at 10:38 a.m. with the Director of Nursing (DON.) She said the facility did not have a policy for falls and did not have a policy for the use of a sit to stand or mechanical lift. The DON said they followed the manufacturer's guidelines. She said if a resident is being transferred from one spot to the next using a sit to stand lift or mechanical lift, they should be assisted by two staff members. The DON said if a lift was supposed to be used to transfer a resident, no other method should be used. Review of a facility provided user manual for their specific mechanical lift showed the manufacturer recommends that two assistants be used for all lifting preparation, transferring from and transferring to procedures . Review of a facility provided use manual for their specific sit to stand lift showed the manufacturer recommended a health care professional evaluate the need for assistance and determine whether more than one assistant is appropriate in each case to safely perform the transfer. It also showed the use of the lift by one assistant should be based on evaluation of the healthcare professional for each individual case.

Based on observations, interviews and record reviews, the facility failed to ensure one resident (#43) received adequate supervision and assistance to prevent at least four falls over twenty-two days resulting in transfer to a higher level of care and diagnoses of fracture of humerus to the right arm out of 21 sampled residents. Findings Included: An observation of Resident #43 on 3/02/22 at 2:07 p.m. while wheeling herself to the bathroom wearing a splint and sling on her right arm revealed Resident #43 sliding her arm out of the sling to wash her hands in the doorway of the bathroom. Then she backed her wheelchair up for an interview and stated she used to go to the bathroom all the time but fell and hurt herself. Resident #43 stated she would use her call light, and no one would come so she would go on her own. Now she said she wears a brief, and her roommate will remind her to use the call light if she needs to be changed or assistance. Review of an incident report dated 12/27/21 at 9:08 a.m. for Resident #43 reflected: Resident observed on the floor in front of the toilet and next to her wheelchair. Resident had full body assessment with no visible injuries or bruising noted. Active range of motion conducted. Resident assisted from floor by multiple staff members to her chair. Relayed to physician that resident had multiple falls this shift. Orders received to send the resident to the hospital. Family and physician notified. Review of a nursing progress note dated 12/27/21 at 2:54 p.m. written by the Director of Nursing (DON), reflected: Hospital called to get information for previous ortho doctor. The Resident reinjured an old humerus fracture and will need to follow up with ortho. admitted overnight for observations. Review of a Fall Risk Evaluation dated 12/30/21 at 8:48 p.m. reflected the resident is a fall risk. Review of an incident report dated 12/11/21 at 3:28 p.m. for Resident #43 reflected: Resident's roommate notified staff that the patient was in the bathroom on the floor. Resident observed sitting on the floor without injury observed. Resident stated she was trying to get on the toilet and slipped and hit her head. Resident was evaluated, no injuries noted. Resident sitting in room watching TV reminded to use call light. Family and physician notified. Review of the post-fall review reflected on 12/11/21 at 3:15 p.m., Resident #43 was found on the floor in the bathroom. Resident stated she was trying to get on the toilet and slipped and hit her head. Resident assessed by the nurse. No injuries. Resident reminded to use call light for assistance. Interdisciplinary team summary: Resident educated to call for assistance when needed. Medication review sent, therapy referral sent for evaluation. Review of the Fall Risk Evaluation dated 12/11/21 at 3:10 p.m. revealed the resident is a fall risk. Review of an incident report dated 12/6/21 at 6:58 p.m. for Resident #43 reflected: Certified nurse's assistant (CNA) notified the nurse that his resident was on her bedroom floor, nurse went to resident's room, resident on the floor beside bed and denied hitting her head. Resident stated she slid off the bed to the floor when she was trying to climb into bed. Resident assessed, denied pain, no injuries noted. Resident assisted to bed by staff and reminded to use call light for assistance. Review of the post-fall review reflected on 12/6/21 at 6:15 p.m., Resident #43 fell getting into bed unassisted and she said she slid to the ground. No injuries noted. Interdisciplinary note summary: Resident independent with transfers, educated to ask for assistance as needed. Therapy referral sent for evaluation. Review of the Fall Risk Evaluation dated 12/6/21 at 6:15 p.m. revealed the resident is a fall risk. Review of the post-fall review reflected on 12/6/21 at 10:30 p.m., Resident #43 fell in the bathroom. Resident said she was going from her wheelchair to the toilet when she slipped. No injuries noted. Interdisciplinary note summary: Staff to do 30-minute checks to anticipate needs. Resident re-educated to ask for assistance when needed. During an interview with the DON on 3/02/22 at 1:04 p.m. she confirmed she investigates falls if they are considered adverse then she will document and create a file. The DON confirmed she did not do investigations related to the three falls including the one fracture for Resident #43 as she did not consider them to be adverse. The DON stated the resident is non-compliant and although she may have gone to the hospital and re-fractured her arm it was not adverse. The DON read from the incident form the nurse completed for the 12/27/21 fall and was asked about the statement, multiple falls this shift which the nurse documented on the incident form. The DON said she would expect to have seen multiple notes related to the falls and confirmed she never even noticed multiple falls this shift. The DON looked on the computer to recall that day and confirmed she did not get witness statements or investigate the last time the resident was observed or if she had multiple falls that shift. The DON confirmed she did not complete or investigate for a root cause as these were not considered adverse to her and said the resident used to transfer on her own to the toilet and transfer herself prior to the last fall on 12/27/21. The DON then stated the investigation was completed but not documented and did not have witness statements to the last time the resident was observed. The DON confirmed the resident fractured her right arm at an old fracture site but was unsure if the fracture was from the 12/27/21 fall or prior. The DON stated the resident was picked up for therapy when she returned from the hospital for strengthening and transfers. The DON confirmed the resident is still non weight bearing on her right arm since her fall 12/27/21. The DON stated the resident had been transferring on her own and going to the bathroom since she was admitted as she was continent and knew when she needed to go the bathroom, so she did not update her care plan related to toileting or start a bowel and bladder program because the resident self-propels around the facility in her wheelchair. During the interview with the DON the Rehabilitation Program Manager joined on 3/2/22 at 1:18 p.m. to confirm therapy picked up the resident on 12/8/21 after her fall from 12/6/21 and kept her on therapy until 2/24/22. The Rehabilitation Manager stopped the DON when the DON said the resident transferred and toileted herself and reiterated to the DON the resident was not safe and should not have been transferring and ambulating without assistance since 12/8/21 when therapy started working with the resident. She was an assist of one during ambulation and transfers. The Rehabilitation Manager stated she is still in therapy and non-weight bearing with her right arm but is non-compliant since she continues to self-propel in the facility. Review of the 12/11/21 fall at 3:10 p.m., the DON read notes from the computer and stated the resident fell in the bathroom trying to use the toilet. The DON confirmed they did not put interventions in place and that no witness statements were taken to see when the resident was last observed or taken to the bathroom. Review of the 12/6/21 fall at 6:15 p.m., the DON read notes from the computer reflected the resident fell transferring from her wheelchair to the toilet when she slipped. No injuries noted and the resident was placed on every 30-minute checks. The DON stated the resident was continent, and she did not consider placing her on a toileting program. The DON confirmed she did not do an investigation related to the fall to see when the resident was last taken to the bathroom or last seen. During an interview on 3/02/22 at 2:00 p.m. with Staff C, CNA he stated the resident doesn't stand and needs help with everything. Staff C confirmed the resident used to go to the bathroom on her own and yell for help. Now, she can't stand and wears a brief since she came back from the hospital. She tells us when she needs to be changed now. She has tried to use bathroom with therapy but now her legs are too weak. During an interview on 3/02/22 at 2:03 p.m. with Staff A, Licensed Practical Nurse (LPN), she stated the resident would toilet herself and not ask for assistance and was obsessed with the bathroom and her bowels and would go in the bathroom on her own. The resident was never placed on a bowel protocol. She would constantly want to go to the bathroom. She drinks a lot of water and is more incontinent now than before. She can't move around as well as she did before she fractured her arm. During an interview on 3/02/22 at 1:44 p.m. with Staff B, LPN he stated he was working on 12/27/21 and was given report the resident had multiple falls that night or morning but could not remember the nurse who gave the report. Staff B stated the resident was observed on the bathroom floor not long after his shift started. She was sitting on her bottom in the bathroom. Staff B, LPN confirmed he filled out the report on the computer and called the physician to let him know he was given a report she had multiple falls prior to his shift then called the family to let them know she was going to the hospital. Staff B, stated the process after a fall is to assess the resident, call the physician and family and if the resident needed a higher level of care they would get the order and transfer documents ready and fill out an incident form on the computer. Staff B would then alert the supervisor or DON and would get statements if needed which are documented in the computer. Staff B said he did not remember witness statements being documented on the 12/27/21 fall. Review of the Kardex reflected the resident requires assist of one for transfers and toileting. Staff to assist with toileting upon arising, before and after meals, at bedtime and as needed. Review of restorative notes dated 12/14/21 at 6:58 p.m. reflected the resident was on a restorative nursing program to ambulate with four wheeled walker and gait belt for safety, gait was steady but slow, ambulated 100 feet. Review of restorative notes dated 12/15/21 at 1:45 p.m. reflected the resident was discontinued from restorative to work with physical therapy. Review of the care plan focus area for self-care deficits and requires assistance with activities of daily living initiated on 3/17/20, revised on 5/22/21 revealed interventions of toileting using one person assist initiated on 3/17/20 revised on 5/22/21, transfers require one person assist, initiated on 8/22/20 and revised on 12/31/21. Staff to assist with toileting upon arising, before and after meals, at night and as needed, initiated on 1/26/22 and created on 2/7/22. Review of care plan focus area at risk for falls initiated on 3/17/20 revealed a focus area initiated on 3/17/20 for staff assist as needed. Focus area of fall identified with no injury, initiated on 12/6/21 revealed an intervention to educate to ask for assistance, if cognitively intact. Medication review initiated on 12/13/21. Review of the Minimum Data Set (MDS) completed on 1/26/22, review of Section C Cognitive status, a Brief Interview for Mental Status (BIMS) of 10, indicating moderate impairment. Review of Section G. Functional status, revealed transfer requires extensive assistance of one-person physical assist, walk in room occurred once or twice in room with one-person physical assist, toilet use requires total dependence with one-person physical assist. Section G0300, balance during transitions and walking revealed moving from seated to standing position was not steady, but able to stabilize with staff assistance, walking with assistive device is used was not steady, but able to stabilize with staff assistance, moving on and off the toilet was not steady, but able to stabilize with staff assistance. On 3/2/22 at 3:00 p.m. the DON brought in completed documents called an investigation checklist and a fishbone diagram. The DON stated these documents were dated 12/27/21 but were just completed by the Corporate Vice president on 3/2/22. and that she did not complete any the documents on 12/27/21. She confirmed she did not complete any investigations in writing and did not feel the falls were adverse including the fall on 12/27/21 that required a higher level of care and refracture of the right arm. Review of facility policy, Incident reporting for residents or visitors revised 1/17, five pages, reflected: All accidents and unusual occurrences involving a resident or visitor will be documented and reported so as to meet all regulatory and insurance carrier requirements. Unusual occurrence or event: any event reportable to federal and state agencies as defined by those agencies. An event or happening involving a resident with unintended, undesirable, or unexpected results or outcomes. 1. When an unusual occurrence is discovered, the employee making the discovery will notify his or her immediate supervisor of the discovery. The supervisor will notify the Administrator and DON immediately. 4. The facility risk manager or designee must notify the appropriate state agency as required by state regulations. 5. The administrator or DON must notify the regional vice president and regional clinical director for any potential state or federal reportable events. Documentation: 1. Record the facts surrounding the incident or accident on an incident/accident report. Keep the original occurrence report on file at the facility. 3. Record the relevant facts regarding the resident in the interdisciplinary progress notes: where the resident was found, assessment conducted, care provided, follow-up care provided.

Based on observation, interview and record review, the facility failed to ensure one resident (#52) had orders for the use of oxygen continuously for three (2/28, 3/1, and 3/2) of three days observed for three residents on continuous oxygen. Findings Included: Observation and interview with Resident #52 on 2/28/22 at 10:16 a.m. revealed the resident was wearing oxygen at 2 liters via nasal cannula. The resident stated she never wore oxygen at home unless she was in bed. During the day at the facility if she takes it off the staff say to put it back on. Observation of Resident #52 on 3/1/22 at 8:15 a.m. revealed the resident was wearing oxygen at 2 liters via nasal cannula sitting up in bed. Observation of Resident #52 on 3/2/22 at 9:50 a.m. was wearing oxygen at 2 liters while sitting in her wheel chair. During an interview with Staff A, Licensed Practical Nurse (LPN) on 3/2/22 at 9:51 a.m. she confirmed the resident needed oxygen all the time and should have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] An interview with Staff B, LPN on 3/02/22 at 10:01 a.m. reflected the resident on oxygen all the time but confirmed she did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the electronic medical record revealed Resident #52 was admitted on [DATE], re-admission on 2/2/22 and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of current active physician orders did not reveal any oxygen setting orders. The orders did include to check temperature and oxygen saturation every shift dated 2/3/22. Review of the care plan did not reflect oxygen use for Resident #52. Review of the Minimum Data Set (MDS) Section O, Special Treatments reflected oxygen therapy was not checked as using oxygen during stay. During an interview with the Director of Nursing (DON) on 3/2/22 at 10:07 a.m. she confirmed anyone on oxygen should have an order and confirmed Resident #52 did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the facility policy titled Oxygen Administration, two pages, revised 5/18 revealed: Procedure: 1. Check physician's order, 11. Turn the unit on to the desired flow rate and assess equipment for proper functioning.

Based on record review, observations, interviews, and policy review the facility did not ensure the care plan was implemented for one resident (#17) of 25 residents reviewed for personal hygiene. Findings included: On 11/23/2020 at 8:55 a.m. during the initial tour of the facility, an observation of Resident #17 revealed that he had long fingernails that extended beyond the fingertip with ½ inch of dark debris under the nail. Resident #17 was asked if he wanted his fingernails cleaned and trimmed, his response was that no one had asked him, but was agreeable to have his fingernails trimmed and cleaned. The medical record for Resident #17 was reviewed which revealed that he had been admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. A review of the current Kardex sheet for the CNAs (certified nursing assistant) indicated that the resident was to receive personal hygiene with one person assist and staff were to assist with showers. A review of the care plan with a focus documented as (Resident #17) has ADL (activities of daily living) Self Care Performance Deficit r/t (related to) dx (diagnoses) of heart failure, [DIAGNOSES REDACTED], generalized weakness. Requires assistance with adls, transfer and mobility. Resident requesting showers once a week prefers on Tuesday .initiated on 1/22/16 and revisited on 3/4/19. Interventions included, Personal Hygiene: 1 person assist, initiated on 5/6/20. Observations of Resident#17 were conducted on several occasions as follows: On 11/23/2020 at 8:55 a.m. and 11:07 a.m. Additional observations made on 11/24/2020 at 10:55 a.m. Fingernails remained untrimmed and dirty. A review of the annual MDS (minimum data set) assessment dated [DATE] under Section G - Functional Status, the Activities of Daily Living for Resident #17 were coded for personal hygiene as 3, which indicated extensive assistance and requires a one person assist. Section C - Cognitive Patterns revealed a BIMS (brief interview for mental status) as a 15 indicating the resident was cognitively intact. On 11/24/20 at 10:55 a.m. an interview was held with the Director of Nursing (DON) regarding her expectations for the lack of personal hygiene for Resident #17 in regard to his long/dirty fingernails. She reported that sometimes he has refused, but that he still will have clean nails. She explained that she kept the shower sheets for residents in her office for 30 days. A review of the shower sheets for Resident#17 for the month of November 2020 revealed only three shower sheets (11/2/20, 11/9/20, and 11/12/20) for the resident and none had an indication of refusal from this resident to have his nails trimmed. On 11/24/20 at 11:33 a.m. an interview was conducted with Staff G, CNA. Staff G reported that sometimes the resident refuses and starts to yell if I try to cut his nails, they are hard and long. Staff G was asked if he would document the resident's refusal, and he said on the shower sheet. He was shown three shower sheets for the month on November 2020 that the DON provided and that none had an indication of a refusal. Staff G stated that he had just trimmed the resident's nails today. A review of the facility policy titled, Resident Dignity & Personal Privacy, with a revision date of 4/4/2019, indicated under the title of Procedure: Assist the resident with grooming; groom appropriately and to the resident's desire.

Based on observation, medical record review and staff interviews the facility failed to assist one Resident #(17) with necessary services to maintain good grooming and personal hygiene of 25 sampled residents who were in need of assistance to carry out activities of daily living . Findings included: A review of the facility policy titled, Resident Dignity & Personal Privacy with a revision date of 4/4/2019, indicated under the title Procedure: Assist the resident with grooming; groom appropriately and to the resident's desire. The medical record for Resident #17 was reviewed which revealed that he had been admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. A review of the current Kardex sheet for the CNAs (certified nursing assistant) indicated that the resident was to receive personal hygiene with one person assist and staff were to assist with showers. A review of the annual MDS (minimum data set) assessment dated [DATE] under Section G - Functional Status, the Activities of Daily Living for Resident #17 were coded for personal hygiene as 3, which indicated extensive assistance and requires a one person assist. Section C - Cognitive Patterns revealed a BIMS (brief interview for mental status) as a 15 indicating the resident was cognitively intact. On 11/23/2020 at 8:55 a.m. during the initial tour of the facility, an observation of Resident #17 revealed that he had long fingernails that extended beyond the fingertip with ½ inch of dark debris under the nail. Resident #17 was asked if he wanted his fingernails cleaned and trimmed, his response was that no one had asked him, but was agreeable to have his fingernails trimmed and cleaned. Observations of Resident#17 were conducted on several occasions as follows: On 11/23/2020 at 8:55 a.m. and 11:07 a.m. Additional observations made on 11/24/2020 at 10:55 a.m. Fingernails remained untrimmed and dirty. On 11/24/20 at 10:55 a.m. an interview was held with the Director of Nursing (DON) regarding her expectations for the lack of personal hygiene for Resident #17 in regard to his long/dirty fingernails. She reported that sometimes he has refused, but that he still will have clean nails. She explained that she kept the shower sheets for residents in her office for 30 days. A review of the shower sheets for Resident#17 for the month of November 2020 revealed only three shower sheets (11/2/20, 11/9/20, and 11/12/20) for the resident and none had an indication of refusal from this resident to have his nails trimmed. On 11/24/20 at 11:33 a.m. an interview was conducted with Staff G, CNA. Staff G reported that sometimes the resident refuses and starts to yell if I try to cut his nails, they are hard and long. Staff G was asked if he would document the resident's refusal, and he said on the shower sheet. He was shown three shower sheets for the month on November 2020 that the DON provided and that none had an indication of a refusal. Staff G stated that he had just trimmed the resident's nails today.

Based on record reviews, observations, interviews, policy review, review of the Consumer Product Safety Commission website, and surveyor guidance found at the Agency for Health Care Administration's website, the facility did not ensure safe water temperatures were maintained in one resident bathroom of twenty resident bathrooms and for four residents (#9, #14, #24, and #29) of 25 residents in the facility with the potential to be affected. Findings included: Resident #9 was admitted to the facility with a [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) assessment dated [DATE] reflected a BIMS (brief interview for mental status) summary score of 2, indicating that Resident #9 had impaired cognition. Further review of the assessment showed Resident #9 was dependent on one person for toileting and personal hygiene assistance. Resident #14 was admitted to the facility with a [DIAGNOSES REDACTED]. A review of the MDS assessment dated [DATE] reflected a BIMS summary score of 2, indicating impaired cognition. Further review of the assessment showed Resident #14 required extensive assistance of one person for toilet use and personal hygiene. Resident #24 was admitted to the facility with a [DIAGNOSES REDACTED]. A review of the MDS assessment dated [DATE] reflected a BIMS summary score of 0, indicating severe cognitive impairment. Further review of the assessment reflected extensive assistance for toilet use and personal hygiene of one person. Resident #29 was admitted to the facility with a [DIAGNOSES REDACTED]. Review of the MDS assessment dated [DATE] showed a BIMS summary score of 6, indicating cognitive impairment. Further review showed extensive assistance of two persons for toilet use, and extensive assistance of one person for personal hygiene. A review of the facility map reflected Residents #9, #14, #24, and #29 shared a bathroom. On 11/23/20 at 11:34 a.m. an observation was conducted in Residents' #9, #14, #24, and #29's shared bathroom. The hot water in the bathroom sink was so hot the state surveyor was unable to keep her hand under it. On 11/23/20 at 12:20 p.m. an interview was conducted with the Maintenance Director at the facility. He said he uses a thermometer to check the water temperatures in the bathrooms. If there is a problem he calls a professional servicer to come out. On 11/23/20 at 12:25 p.m. in a follow up interview with the Maintenance Director, he said he checks the water temps (temperature) every Monday, Wednesday, and Friday. On 11/23/20 at 12:28 PM an observation and interview was conducted with the Maintenance Director in the shared bathroom for Residents #9, #14, #24, and #29. After calibrating a thermometer in ice water, the Maintenance Director reported the water temperature should read around 110 to 111 degrees Fahrenheit. The Maintenance Director brought the thermometer into the shared bathroom and placed it under running hot water. The thermometer temperature peaked at 120 degrees Fahrenheit. The Maintenance Director confirmed the thermometer reading was 120 degrees. On 11/23/20 at 12:39 p.m. another interview was conducted with the the Maintenance Director in the boiler room outside of the facility. He said there is a hot water heater with a holding tank. An electrical servicing company provides services to them. The last service was maybe two months ago. Upon observation of the hot water heater system and lines, a blue valve handle was present. The Maintenance Director indicated if he turns the handle clockwise it opens it up more; increasing the temperature, and counter clockwise closes it.; decreasing the water temperature. He said the water is heated and then goes into the holding tank nearby. There wasn't a thermometer present on the holding tank indicating what the temperature was. An immediate audit of all hot water temperatures in resident bathrooms was requested. On 11/23/20 at 1:37 p.m. an interview was conducted with the Nursing Home Administrator (NHA) and the Vice President (VP) of Operations. The NHA said 115 degrees was the maximum temperature the water should be. The Maintenance Director checks the water temperatures three times a week. The NHA said older buildings fluctuate that's why we check the temperatures three times a week. We are constantly adjusting the temperatures. The Maintenance Director said he turns it down. The VP of Operations said today (11/23) is the day he checks them, so it could be a problem that cropped up today. If it comes out of the heater at 120 degrees, it's going to mix with cold water. On 11/23/20 at 1:49 p.m. an observation was conducted in the boiler room with the NHA and VP of Operations. There were two thermometers on the lines near the water heater indicting the temperature was 120 degrees Fahrenheit. The NHA said he couldn't confirm the thermometers near the water heater was the temperature setting. He said he doesn't know where the setting is. The NHA said he was happy they were doing the water temperature checks and confirmed he reviews them periodically. The NHA said the Maintenance Director told him if he opens the blue valve handle the water gets hotter and if he closes it the temperature goes down. On 11/23/20 at 1:55 p.m. the VP of Operations said the Maintenance Director was trained by the Area Director who will be here (facility) in the morning. The VP of Operations said there is a mixer on the hot water system. On 11/23/20 at 2:31 p.m. another interview was conducted with the Maintenance Director. He said he turned the temperature down before he completed the audit because the NHA instructed him too. A review of the policy titled, Monitoring Water Temperatures, dated 1/26/16, reflected that there wasn't any indication of what the hot water temperatures should be. Review of the Surveyor Guidance for Hot Water Temperatures from the Florida Agency for Health Care Administration, dated 10/2011 reflected the following: (page 2-3) The following are some regulatory requirements for hot water temperatures in health care facilities (this is not all inclusive): 42 CFR Part 483.470 only requires that water temperature is safe. The temperature setting in the guidance indicated 105-115 degrees was the acceptable range. On 11/24/20 at 8:58 a.m. an additional interview was conducted with the NHA. He confirmed the facility policy didn't indicate a safe water temperature range. He said the maintenance director knows the temperature can't be set higher than 120 degrees. It's supposed to be 105-115 degrees.

Based on observation, record review and interviews, the facility failed to provide oxygen therapy as per the resident plan of care for two (#7 and #8) of three residents sampled for oxygen care and services. Residents #7 and #8 did not receive accurate oxygen flow rate administration. Findings included: 1. An observation was conducted on 05/30/19 at 9:05 a.m. of Resident #7 in a speciality wheelchair at his bed side, dressed in seasonally appropriate clothing, with oxygen tubing in place via nasal cannula. During an interview with Resident #7 on 05/30/19 at 11:30 a.m., he stated that his oxygen level on his machine should be at 3 liters per minute. An observation conducted on 05/30/19 at 11:30 a.m. of Resident #7's oxygen machine, looking at the ball in the tube, eye level, revealed that the ball was between the 2 and 2.5 line in the flow rate tube. A review of Resident #7's active physician order [REDACTED]. A review of Resident #7's current care plan, last reviewed on 05/09/19, documented a focus area as: Resident #7 has a [DIAGNOSES REDACTED]. At risk for complications, initiated 02/05/18. The interventions included: Give oxygen therapy as ordered by the physician, initiated 02/05/18. An additional observation of Resident #7's oxygen machine was conducted on 05/30/19 at 12:32 p.m. with Staff A, LPN, she reviewed the machine and was observed to turn the knob to have the ball in the tube rise. When asked what level that the machine had been at, she stated at 3. She further stated that when she looked at it from her angle (top and to the side), it looked as if the top of the ball was on the 3 line. At the time of the observation, the surveyor had observed the ball between the 2 and 2.5 line and pointed this out. Read from the front of the machine at eye level. The nurse stated that she would look for instructions for the machine. 2. An observation was conducted of Resident #8, on 05/30/19 at 12:00 p.m. Resident #8 was in her bed with oxygen tubing in place via nasal cannula. During an interview with Resident #8 on 05/30/19 at 12:00 p.m., she confirmed that she received oxygen therapy and that the oxygen flow rate should be 3 liters per minute. An observation conducted of the oxygen machine at the side of the bed revealed at eye level, the ball in the tube, was observed in the middle of the line, 1.5L. A review of Resident #8's active physician order [REDACTED]. A review of Resident #8's current care plan, last reviewed 04/22/19, documented a focus area as: Resident #8 has Oxygen Therapy r/t (related to) [MEDICAL CONDITIONS], Ineffective gas exchange, initiated 04/07/18. The interventions included: Give medications as ordered by physician, initiated 04/07/18. An observation of Resident #8's oxygen machine was conducted on 05/30/19 at 12:30 p.m. with Staff A, Licensed Practical Nurse (LPN). She confirmed that Resident #8's oxygen rate was at 1.5 and she adjusted the machine to have it register the ball in the tube at 2L. An interview conducted with the Staff B, Regional Consultant Registered Nurse, (RN) on 05/30/19 at 1:50 p.m., she provided a copy of the oxygen machine manual for Resident 7's oxygen machine, which indicated that the machine should be read at eye level. In addition to the ball in the tube would be on the line in the middle for the liter of oxygen, i.e., for 3L, the line would be running thru the middle of the ball. She stated that they just conducted an audit of the house, found two of the machines that were running low. She stated that they were going to conduct an in service with the nursing staff. An interview conducted on 05/30/19 at 2:20 p.m. with the representative for the oxygen machine company, Staff C. He stated that his company provides and services the oxygen machines in the building. He stated that when a person reads the machine, the ball should be in the middle of the line and that staff should be at eye level. He stated he would not do the training, but, the building could call and have one of the respiratory therapists come out and conduct the training.

Based on observation, policy review, and staff interview, the facility failed to post the total number and the actual hours worked of the direct care staff on 03/02/19 and on 03/03/19 as evidenced by the staffing list that was displayed at the reception counter (photographic evidence is available) with the date of 3/01/19. Findings included: Upon entry to the facility at approximately 09:00 am on Sunday, 3/03/19, the surveyor did not observe the information required to be posted for nurse staffing information. Staff D, Licensed Practical Nurse (LPN) was unable to provide the location of the posting, and when she was asked whose responsibility it was to post the direct care staffing information on the weekend, she replied that she did not know. She also added that she had never received any directive concerning the posting on the weekend. Staff H, Certified Nurse Aide (CNA) produced a sheet of paper that was lying amongst other papers on the counter of the nursing station (photographic evidence is available). The piece of paper, produced by staff H, CNA was dated 3/01/19 which was the previous Friday and contained the staffing information (photographic evidence is available). An interview on 3/3/19 with the DON revealed that she did not have any explanation for the outdated list. A review of the facility policy entitled Nursing/Scheduling/Posting dated 07/26/16 stated that the posting of the number of Registered Nurses, Licensed Practical Nurses, and Certified Nurse Aides and their scheduled and worked hours are to be posted prominently at the beginning of every shift

Based on resident record review, facility policy and procedure review and staff interviews, it was determined that the facility failed to notify the physician of a change in condition for a fragile, seventy one year old, vulnerable, dependent resident with multiple medical problems being one (#1) of 13 residents reviewed: The facility failed to notify the physician when resident #1 began to exhibit labored breathing and congestion. The investigation revealed resident #1 was in [MEDICAL CONDITION] and had an axillary temperature of 105 degrees Fahrenheit upon the arrival of the paramedics at the facility 4-5 hours after he was initially observed with labored breathing and congestion. The resident required intubation and assisted ventilations while en route to the hospital. The resident arrived at the emergency room with an oral temperature of 107 degrees and was diagnosed with [REDACTED]. Findings include: Review of the Admission Record revealed resident #1 was admitted to the facility on [DATE]. A review of the nursing notes revealed the resident was most recently readmitted via ambulance on 4/6/12 at 5:58 p.m. A review of the Accumulative [DIAGNOSES REDACTED]. Coli) urinary tract infection [MEDICAL CONDITION], urosepsis, [MEDICAL CONDITION], hypokalemia, diastolic heart failure, sacral and lower extremity wounds, [MEDICAL CONDITION], Percutaneous enteral [MEDICAL CONDITION] tube (Peg Tube), dysphagia, [MEDICAL CONDITION] ([MEDICAL CONDITION].) [MEDICAL CONDITION] infection and [MEDICAL CONDITION]. A review of the computerized admission Progress Note completed by a Licensed Practical Nurse (LPN B) revealed the resident was admitted on [DATE] at 5:58 p.m. via stretcher accompanied by paramedics ....meds verified with advanced registered nurse practitioner (ARNP), transcribed, and faxed to pharmacy. A review of the computerized Nursing Admission Assessment, dated 4/6/12, revealed the resident had severely impaired cognitive skills, was totally dependent on staff for care, was receiving all nutrition and hydration from a feeding tube and had a [MEDICAL CONDITION]. It stated the resident had a recorded admission height of 62 inches and a recorded weight of 142.0 pounds. The assessment also stated that the resident was admitted with an open area to the right heel measuring approximately 4.5 centimeters (cm.) in width, an open area to the right great toe a quarter in size and coccyx wound measuring 6 cm. by 8 cm. This was accompanied by three dime to quarter size area [MEDICAL CONDITION]. The left lower front leg had a slightly larger than golf ball diameter lesion with irregular border. A review of the computerized Weights and Vital Summary notes dated 4/9/12 revealed the vital signs recorded at 3:30 p.m. were: blood pressure 118/69, temperature 98.2 degrees Fahrenheit, pulse 70 and respirations 20. It was documented in the handwritten notes by LPN E on 4/9/12 at 9:00 p.m. that resident #1 was resting in bed. Respirations even and unlabored. Tube feeding tolerated well. Contact isolation maintained. Resident in private room with services brought in for [MEDICAL CONDITION]. Review of LPN E ' s Time Detail report revealed that she punched in at 2:32 p.m. and out at 8:00 p.m. The documentation of the 9:00 pm. in the nurses notes on 4/9/12 time is in conflict with the fact that she had punched out and was not in the building. Another handwritten nurse's note by LPN D after this one dated 4/9/12, (with no time), documented: Resident resting in bed. No S/S of distress, no complaint of pain at present. Glucerna 1.5 infusing at 80 cc/hr. Tolerating well. [MEDICAL CONDITION] intact. Remains on contact isolation for [MEDICAL CONDITION]. All services performed in room. Will continue to monitor. Review of the Time Detail report for LPN D revealed she worked 4/9/12 from 7:08 a.m. -7:53p.m. A review of the next nursing note (handwritten) for 4/10/12 (no time documented) by LPN A stated: Resting in bed, respirations labored and resident ' s head of bed up at 45 degrees, resident congested and on contact isolation in a private room and services brought to the room. GT feeding flushes well without difficulties. Placement verified and no residual at this time. Review of the Daily Labor Report and staffing sheet revealed LPN A was scheduled to work on 4/9/12 at 7:00 p.m. until 4/10/12 until 7:00 a.m. Continued review of the record revealed respirations of 20 were documented in the computerized record on 4/10/12 at 4:08 a.m. No additional vital signs were documented and no additional notes could be found regarding an assessment of the resident despite the notation by the 7:00 p.m. to 7:00 a.m. nurse of labored respirations and congestion. There is no documentation in the record of any care that was provided for the resident by this nurse for the labored breathing and the congestion. There was no evidence the physician was contacted regarding the significant change in the resident ' s respiratory condition. A review of the physician's admission orders [REDACTED]. There was an order for [REDACTED]. In an interview with LPN A on 4/24/12 at 3:30 p.m., she stated that she had worked the night of 4/9/12 on the 7:00 p.m. to 7:00 a.m. shift and was assigned to resident #1. She stated she did not give a breathing treatment to the resident and does not remember him being unusually warm. She stated the vital signs were done. The nurse was difficult to understand and seemed to have a hard time understanding the questions and expressing her answers. In a second interview on 4/25/12 at 12:00 p.m. with LPN A., the nurse stated she had noticed resident #1 was congested and had labored breathing at about 4:00-5:00 a.m. The LPN stated she did not give him a breathing treatment because she did not think it would help because he was "too wet". She was unable to describe what she meant by " too wet " and seemed confused about the question. She stated the resident had felt a little warm, but she did not take his vital signs at that time because someone had already taken them earlier in the shift. (Review of the handwritten notes dated 4/10/12 with no time documented revealed vital signs of temperature 97.1 pulse 75, respirations 18 and blood pressure 130/60). The nurse stated she put the head of the bed up and she checked on him frequently. LPN A was unable to say how frequently she checked on the resident and what she was checking him for. She said he had on oxygen at 2 liters per nasal cannula. LPN A stated she did not call the physician because she did not know the resident and was not sure if this was the way he was. She stated she told the oncoming day shift nurse about the resident's condition and left the facility at about 8:00 a.m. The nurse ' s statements and train of thought were fragmented and hard to follow and she did not seem to understand the significance of the situation. In a telephone interview with LPN F on 5/8/12 at 11:47 a.m., it was revealed that she had worked with LPN A on the 4/9/12, 7:00 p.m. to 4/10/12 7:00 a.m. shift. She stated she was not notified or aware of any problems with resident #1. She was not assigned to resident #1 but recalled his door being closed due to isolation precautions. She stated they normally work together on that shift because there are only two nurses in the building. She was surprised to learn of the condition of resident #1 because she did not know anything was wrong until 5/3/12 when interviewed by the DON. LPN F revealed that the resident ' s door was closed further limiting the nurse ' s ability to assess the condition of the resident when he was having difficulty breathing. Continued review of the clinical record revealed the following handwritten nurse note by LPN D 4/10/12 at 7:30 a.m.: congestion noted, increased respirations, blood pressure normal, oxygen saturation level at 87% (it was no specified if the resident was on oxygen or room air). The physician was notified and orders were received to transfer the resident to the hospital. According to the interview with LPN A on 4/25/12, the congestion and labored breathing was observed between 4:00 a.m.-5:00 a.m. Based on this documentation approximately 4 hours had passed before the physician was contacted regarding the resident ' s significant change in condition of respiratory distress. The next nurse ' s note on 4/10/12 at 7:45 a.m. stated the resident was transferred to the hospital. A review of the "Resident Hospital Transfer Form", completed by LPN B prior to transfer dated 4/10/12, no time documented, indicated the resident's temperature was 105 degrees by axilla and the pulse was 100 beats per minute. There was no blood pressure or respirations recorded. The [DIAGNOSES REDACTED]. The reason for transfer was noted as change in level of consciousness and decreased oxygen saturation. Interview with LPN D on 5/3/12 at 1:36 p.m. revealed that she had cared for resident #1 on 4/9/12 on the 7:00 a.m. - 7:00 p.m. shift, the day prior to his transfer to the hospital. On 4/9/12 his temperature was fine and he was sitting up. He showed no signs of distress and his vital signs were stable. She could not recall if he used oxygen and couldn ' t recall giving him any breathing treatments on that shift. LPN D stated nothing of any consequence happened on the day shift on 4/9/12, one day before he was transferred out to the hospital from the facility. Continued interview with LPN D revealed that she came to work on 4/10/12 at about 7:20 a.m. She stated she and LPN A did the narcotics count. Following the narcotic count LPN D and LPN A went on walking rounds. LPN D stated resident #1 sounded congested but nothing severe. The head of the bed was up. After completing walking rounds LPN D went back to resident #1 ' s room by herself to check on him. She stated this was probably around 7:30 - 7:45 a.m. on 4/10/12. LPN D said " I looked at him and could just hear the congestion " , so she went and got the wound care nurse LPN C, and then LPN C went to get the ADON. LPN D stated the other nurses were doing everything. LPN D stated she put the breathing medication into the nebulizer machine but the ADON put the mask on and administered the treatment. After this LPN D was in and out of the room because she needed to start medication pass. She could not recall what time it was when resident #1 left the facility to go to the hospital, and she was not present when they took his vital signs. LPN D was asked about her nurse ' s note dated 4/10/12 at 7:30 a.m. stating the blood pressure was normal. LPN D could not recall what his blood pressure was or who took it. She stated somebody had to have taken the blood pressure for her to have written it down. LPN D also stated she realized now that she didn ' t get to the facility until 7:20 a.m. on 4/10/12 so her times on the documentation in resident #1 ' s clinical record were probably inaccurate. Further interview with LPN D at 2:10 p.m. on 5/3/12 revealed she did not notice resident #1 having any wetness or odor, just congestion. In an interview with LPN C on 5/4/12 at 1:19 p.m., she stated she was the wound care nurse and she went to see resident #1 to evaluate his wounds on the morning of 4/10/12. She stated she usually works 6:00 a.m. - 2:00 p.m. but she thought it was around 7:00 a.m. when she first saw resident #1 on 4/10/12. LPN C said she knew something was going on because she had overheard their shift report, and LPN D had already been in the room to see resident #1. LPN C noticed resident #1 ' s breathing was labored and his respirations were increased. The ADON was walking past so LPN C asked her to come in. She said the ADON was working up top and she (LPN C) was undressing his right leg wound. LPN C stated his legs didn ' t feel warm at all, and she thought they came in and applied oxygen to him around 7:30 a.m. - 7:45 a.m. LPN C checked the resident ' s oxygen saturation level after applying the pulse oximeter and recalled a result which was in the 70 ' s. LPN C did not know who took his vital signs. LPN C stated they turned his tube feeding off and the head of bed was elevated. LPN C said we did do a blood sugar (BS) test on him and it was 200 something. She said she remembers it wasn ' t too high or too low. She thinks LPN D did the BS but was not certain. LPN C could not describe resident #1 ' s color as he was a dark skinned man. LPN C stated he opened his eyes when you called his name, but did not verbally respond. She did not notice if anyone gave him a breathing treatment and she did not recall any odor or indications that the resident was in need of incontinence care. An interview was conducted with the Assistant Director of Nurses (ADON) on 4/24/12 at 2:40 p.m. The ADON stated she was present on 4/10/12 at 7:30 a.m., when resident was transferred to the hospital. She stated the head of the bed was elevated and the resident was experiencing abnormal breath sounds. The ADON stated she gave him a breathing treatment. (Clinical record review revealed no documentation of any administration of breathing treatments). The ADON stated the tube feeding was off and the resident's oxygen saturation level was going up and down. The resident's eyes were open but he was not responding. She stated they took vital signs and he had a temperature but she could not remember what it was. In an interview on 5/3/12 at 12:53 p.m. with LPN B., she stated on the morning of 4/10/12 she heard LPN D saying resident #1 needed to go to the hospital. LPN B stated she went to resident #1 ' s room to assist. She noticed the ADON administering a breathing treatment, he was receiving oxygen, and had a pulse oximeter on his finger which had a reading that was fluctuating " 40, 60, and would go up into the 80 ' s " . LPN B said he had increased respirations, but he was not gasping for air. She said the resident would look at you but did not respond verbally. According to LPN C, in the past this resident would speak in a real soft voice. LPN B recalled asking if anybody got his vitals. One of the C.N.A. ' s came in and took his temperature; however, she could not recall the name of this C.N.A. LPN B recorded the temperature as 105 degrees Fahrenheit per axillary. After that she went to the desk to prepare his transfer forms and called the doctor. LPN B stated she informed the ARNP that the resident was receiving a breathing treatment, had a temperature of 105 with fluctuating oxygen saturations, and was in an unstable condition. LPN B stated she told the ARNP the resident needed to go to the emergency room . She thinks that this occurred before 8:00 a.m. but was not exactly sure of the time. LPN B could not recall what time the ambulance arrived. Interview on 5/3/12 at 10:53a.m., with the ARNP for resident #1 ' s attending physician revealed she has been assigned to this facility for about 2 months, but she was not familiar with this resident. The ARNP thought the nursing facility had called her to verify his admission orders [REDACTED]. The ARNP could not recall if she was contacted on 4/10/12 when resident #1 was transferred to the hospital and stated she needed to check with the doctor ' s answering service first. Subsequent interview with resident #1 ' s ARNP on 5/3/12 at 12:29 p.m. revealed she checked with the doctor ' s answering service and was informed that they did not receive any calls from the facility on 4/10/12. The ARNP stated that the answering service stops accepting calls at 8:00 a.m. so they probably contacted her sometime after 8:00 a.m. on 4/10/12. The ARNP had no recollection of this call. In an interview on 5/4/12 at 1:55 p.m. with the resident ' s attending physician, he stated that the resident had a history of [REDACTED]. He stated that the resident is currently at a long term care hospital on a ventilator. He stated that when the resident went to the hospital on the morning of 4/10/12, his temperature was 107 degrees Fahrenheit and that he was diagnosed with [REDACTED]. He also stated that the resident was intubated in the field so that may have been the cause of the pneumothorax but he could not be sure. He also said he did not know about the weight discrepancies and that the weights may have been different because of how they were obtained. He was not contacted on the morning of 4/10/12. Based on these interviews with physician, ARNP and LPN A ' s interview on 4/25/12 at 12:00 p.m., the resident ' s physician/ARNP was not contacted for a period of about 4 hours after he exhibited a significant change of labored breathing and congestion. In addition, this interview demonstrates that the facility ' s documentation of contacting the physician at 7:30 a.m. and sending the resident out to the hospital at 7:45 a.m. on 4/10/12 was inaccurate. A review of the Emergency Medical Services (EMS) report, dated 4/10/12, revealed the call from the facility was received at 8:38 a.m. on 4/10/12 and the ambulance arrived at the facility at 8:41 a.m. The documented time of transport to the hospital was 9:03 a.m. The Emergency Medical Services (EMS) arrived at the hospital on [DATE] at 9:11 a.m. According to the EMS narrative notes .... " Staff stated that at shift change the patient complained of difficulty breathing. Staff stated that the patient had a temperature 105 degrees F, and that patient was being treated for [REDACTED]. Upon assessment patient found to be in [MEDICAL CONDITION], SPO2 reading was 78% on non rebreather mask, Glasgow Coma Scale (GCS) was a 6 with labored respirations. Secondary revealed skin hot, pink, very dry ... ....pupils sluggish and unequal, lung sounds rhonchi throughout ... facilitated intubation and ventilations were assisted. " A review of the Hospital face sheet revealed a registration time of 4/10/12 at 9:16 a.m. A review the Emergency Physician record dated 4/10/12 revealed the resident had been intubated prior to arrival in the ER, was initially hypotensive with a systolic blood pressure of 70. The patient ' s temperature was 107 F rectally. On physical exam, patient with unequal pupils, sent to CT which revealed chronic changes. Chest x-ray showed the endotracheal tube was in good position however the patient had a right pneumothorax, a chest tube was place immediately and the resident was placed on a ventilator. Review of the hospital emergency department triage report dated 4/10/12 at 9:24 a.m. revealed the resident ' s blood sugar was 300. Review of the hospital emergency department nurse's documentation dated 4/10/12 performed at 9:19 a.m. stated in capitalized letters that the resident was " SOAKED IN URINE THAT APPEARS FOR A PROLONGED PERIOD OF TIME; DIAPER WAS SOAKED IN ENTIRETY, BROWN IN COLOR, STRONG ODOR OF AMMONIA, AND THE BOTTOM SHEET WAS SOAKED AS WELL WITH A HUGE RING AROUND THE PATIENT- APPEARS TO HAVE BEEN THERE FOR A LONG PERIOD OF TIME. WHEN ROLLED, A USED ANGIOCATH WAS STUCK TO THE BACK OF THE PATIENT ' S RIGHT LEG AND HAD A DATE OF 3/16/12 ATTACHED TO CATH " . The entry went on to say that this situation was reported to the charge nurse and the social worker. Interview with the DON on 5/3/12 at approximately 9:30 a.m. revealed they had initiated in servicing and staff education on 4/24/12 which was on-going with all registered and licensed nurses. Review of the in-service materials revealed education was provided in the following areas: Nursing assessment data to include a discussion on the responsibility of assessing a resident on admission, in accordance with the plan of care, when a clinical change in condition occurs and upon discharge. Subjective and objective documentation in accordance with the patient ' s status. Professional standards and services must be provided to residents in accordance with their plan of care with follow up documentation to include interventions of services and notification of any clinical changes. It is the licensed direct care staff member ' s responsibility to utilize professional standard and skills during clinical observation, reporting and documentation. Notifications of clinical changes to the physician and the responsible party. The use of the SBAR assessment tool as a method for communicating with the physician and other allied licensed health care professionals. *Situation - briefly state the problem. Nurse assessment of the situation. *Background - Pertinent patient information in the clinical picture of the patient. *Assessment - What are your assessment and/or observation of the patient clinical status? What interventions do you currently have in place? *Recommendation - What are your recommendations in meeting the patient ' s needs? What do you need to care for the patient? Review of the in-service sign in records on 5/3/12 at approximately 4:30 p.m. revealed 17 of the 19 regularly scheduled nurses had received the in-service training. Interview with the DON revealed one of these nurses had received the training but had not signed the attendance record. The DON contacted one of the nurses by phone and conducted the in-service on 5/3/12 at approximately 4:45 p.m. via telephone and the nurse who had not signed the attendance record was called in to provide her signature. Telephone interviews were conducted with 6 of the 19 regularly scheduled nurses and were representative of all three shifts. All of the nurses were able to verbalize how they would respond when provided with a change in condition scenario. All nurses indicated they would assess the resident, obtain vital signs, check the record for orders, provide emergency treatments if needed, contact the physician for guidance and orders, and document accurately and completely in the clinical record. The nurses also stated that they have been re-in serviced on obtaining a height and weight for a tube fed resident upon admission and communicating this information along with the physician's order [REDACTED]. In addition, all the nurses were able to verbalize how they are monitoring the C.N.A. ' s to ensure proper care and services are being provided. Interview with the administrator on 5/4/12 at approximately 8:45 a.m. revealed she and the DON have decided to terminate the employment of LPN A. In addition, the administrator indicated that they have reviewed the incident involving resident #1 in the quality assurance meeting held on 4/24/12. Review of documentation provided by the administrator on 5/4/12 revealed the following plan was developed from the 4/24/12 QA meeting: *Licensed nurses re-educated on assessment and documentation skills. * No other residents were discharged during the timeframe of 4/6/12 - 4/10/12 *DON or designee will audit discharged charts in a timely manner and will randomly audit nurse documentation. *Results of findings will be discussed and reviewed by QA&A committee to determine systematic effectiveness for further quality improvement. The immediate jeopardy was determined removed on 5/3/12 and the scope and severity was reduced to a D.

Based on staff interview, facility record review, and facility policy review, it was determined that the facility failed to provide the following necessary services which resulted in neglect of an elderly [AGE] year old, vulnerable, dependent resident with multiple serious medical problems for one (#1) of 13 residents reviewed: The facility neglected to provide an assessment or an evaluation of resident #1 when he was observed experiencing labored breathing and congestion to include at a minimum respiratory function, blood sugar test, and vital signs. The facility neglected to provide the breathing medication ordered by the physician to be given if the resident was short of breath when the resident needed it due to documented labored breathing and congestion. The facility neglected to consult with the physician for direction and orders for the care of the resident ' s labored breathing and congestion. The facility neglected to provide timely incontinence and personal care for the resident who had sacral pressure ulcers leaving the resident who could do nothing for himself or even ask for assistance, in a soaked brief for a prolonged period of time, smelling of ammonia and left lying in urine soaked sheets. The facility neglected to administer the physician ordered tube feeding to the resident (who could take nothing by mouth) until approximately 7 hours after admission. The facility neglected to assure that the amount of the tube feeding and water administered to the resident had been evaluated by the dietician based on an accurate weight. The investigation revealed resident #1 was in [MEDICAL CONDITION] and had an axillary temperature of 105 degrees Fahrenheit upon the arrival of the paramedics at the facility 4-5 hours after he was first observed with labored breathing and congestion. The resident required intubation and assisted ventilations while en route to the hospital. The resident arrived at the emergency room with an oral temperature of 107 degrees and was diagnosed with [REDACTED]. Findings include: Review of an Emergency Medical Services (EMS) run report for resident #1 found that the resident arrived at the hospital on [DATE] at 9:11 a.m. According to the EMS narrative notes .... " Staff stated that at shift change the patient (#1) complained of difficulty breathing. Staff stated that the patient had a temperature 105 degrees F, and that patient was being treated for [REDACTED]. Upon assessment patient found to be in [MEDICAL CONDITION], SPO2 reading was 78% on non rebreather mask, Glasgow Coma Scale (GCS) was a 6 with labored respirations. Secondary revealed skin hot, pink, very dry ... ....pupils sluggish and unequal, lung sounds rhonchi throughout ... facilitated intubation and ventilations were assisted. " A review of the Hospital face sheet revealed a registration time of 4/10/12 at 9:16 a.m. A review the Emergency Physician record dated 4/10/12, revealed the resident had been intubated prior to arrival in the ER, was initially hypotensive with a systolic blood pressure of 70. The patient ' s temperature was 107 F rectally. On physical exam, patient with unequal pupils, sent to CT which revealed chronic changes. Chest x-ray showed the endotracheal tube was in good position however the patient had a right pneumothorax, a chest tube was place immediately and the resident was placed on a ventilator. Review of the hospital emergency department triage report dated 4/10/12 at 9:24 a.m. revealed the resident ' s blood sugar was 300. Review of the hospital emergency department nurse's documentation dated 4/10/12 performed at 9:19 a.m. stated in capitalized letters that the resident was " SOAKED IN URINE THAT APPEARS FOR A PROLONGED PERIOD OF TIME; DIAPER WAS SOAKED IN ENTIRETY, BROWN IN COLOR, STRONG ODOR OF AMMONIA, AND THE BOTTOM SHEET WAS SOAKED AS WELL WITH A HUGE RING AROUND THE PATIENT- APPEARS TO HAVE BEEN THERE FOR A LONG PERIOD OF TIME. WHEN ROLLED, A USED ANGIOCATH WAS STUCK TO THE BACK OF THE PATIENT ' S RIGHT LEG AND HAD A DATE OF 3/16/12 ATTACHED TO CATH " . The entry went on to say that this situation was reported to the charge nurse and the social worker. In an interview with the DON on 5/2/12 at 6:15 p.m. and the Administrator who was on speakerphone, they both stated that they had not investigated the care of resident #1 related to the unusually high temperature of 105 degrees. The response from the DON was, " He was very sick, we did what we were supposed to do. The ABCs. ( basics) What more could we have done? " The administrator stated that another state agency had come out to the facility on [DATE] to investigate allegations of neglect. When asked if this event triggered an investigation by the facility, she said no. Review of the facility policy entitled, " Abuse and Neglect Prohibition, " SHC 02 0003.3 and undated revealed the definition of neglect to be failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Listed under the title Investigation 1. It states: " The facility will conduct an investigation of any alleged abuse/neglect or misappropriation of resident property in accordance with state law. " Review of the Admission Record revealed resident #1 was admitted to the facility on [DATE]. A review of the nursing notes revealed the resident was most recently readmitted via ambulance on 4/6/12 at 5:58 p.m. A review of the Accumulative [DIAGNOSES REDACTED]. Coli) urinary tract infection [MEDICAL CONDITION], urosepsis, [MEDICAL CONDITION], hypokalemia, diastolic heart failure, sacral and lower extremity wounds, [MEDICAL CONDITION], Percutaneous enteral [MEDICAL CONDITION] tube (Peg Tube), dysphagia, [MEDICAL CONDITION] ([MEDICAL CONDITION].) [MEDICAL CONDITION] infection and [MEDICAL CONDITION]. A review of the computerized admission Progress Note completed by a Licensed Practical Nurse (LPN B) revealed the resident was admitted on [DATE] at 5:58 p.m. via stretcher accompanied by paramedics ....meds verified with advanced registered nurse practitioner (ARNP), transcribed, and faxed to pharmacy. A review of the computerized Nursing Admission Assessment, dated 4/6/12, revealed the resident had severely impaired cognitive skills, was totally dependent on staff for care, was receiving all nutrition and hydration from a feeding tube and had a [MEDICAL CONDITION]. It stated the resident had a recorded admission height of 62 inches and a recorded weight of 142.0 pounds. The assessment also stated that the resident was admitted with an open area to the right heel measuring approximately 4.5 centimeters (cm.) in width, an open area to the right great toe a quarter in size and coccyx wound measuring 6 cm. by 8 cm. This is accompanied by three dime to quarter size areas [MEDICAL CONDITION]. The left lower front leg had a slightly larger than golf ball diameter lesion with irregular border. A review of the computerized Weights and Vital Summary notes dated 4/9/12 revealed the vital signs recorded at 3:30 p.m. were: blood pressure 118/69, temperature 98.2 degrees Fahrenheit, pulse 70 and respirations 20. It was documented in the handwritten notes by LPN E on 4/9/12 at 9:00 p.m. that resident #1 was resting in bed. Respirations even, unlabored. Tube feeding tolerated well. Contact isolation maintained. Resident in private room with services brought in for [MEDICAL CONDITION]. Review of LPN E ' s Time Detail report revealed that she punched in at 2:32 p.m. and out at 8:00 p.m. The documentation of the 9:00 pm.in the nurses notes on 4/9/12 time is in conflict with the fact that she had punched out and was not in the building. Another handwritten nurse's note by LPN D after this one dated 4/9/12, (with no time), documented: Resident resting in bed. No S/S of distress, no complaint of pain at present. Glucerna 1.5 infusing at 80 cc/hr. Tolerating well. [MEDICAL CONDITION] intact. Remains on contact isolation for [MEDICAL CONDITION]. All services performed in room. Will continue to monitor. Review of the Time Detail report for LPN D revealed she worked 4/9/12 from 7:08 a.m. -7:53p.m. A review of the next nursing note (handwritten) for 4/10/12 (no time documented) by LPN A stated: Resting in bed, respirations labored and resident ' s head of bed up at 45 degrees, resident congested and on contact isolation in a private room and services brought to the room. GT feeding flushes well without difficulties. Placement verified and no residual at this time. Review of the Daily Labor Report and staffing sheet revealed LPN A was scheduled to work on 4/9/12 at 7:00 p.m. until 4/10/12 until 7:00 a.m. Continued review of the record revealed that respirations of 20 were documented in the computerized record on 4/10/12 at 4:08 a.m. No additional vital signs were documented and no additional notes could be found regarding an assessment of the resident despite the notation by the 7:00 p.m. to 7:00 a.m. nurse of labored respirations and congestion. There is no documentation in the record of any care that was provided for the resident by this nurse for the labored breathing and the congestion. There was no evidence the physician was contacted regarding the significant change in the resident ' s respiratory condition. A review of the physician's admission orders [REDACTED]. A review of the April MAR indicated [REDACTED]. The resident's admission physician orders dated 4/6/12 included the following relevant orders: blood sugar tests (finger sticks) at 6:30 a.m., 11:30 a.m., 4:30 p.m., and 9:30 p.m. with [MEDICATION NAME] regular insulin coverage on a sliding scale as follows: less than 151= 0 units, 151-200= 3units, 201-250= 6 units, 251-300= 9 units, 301-350= 12 units, 351-400= 15 units, and 401-450= 18 units. If blood sugar tests greater than 450 give 21 units and call medical doctor. If blood sugar less than 60, give [MEDICATION NAME]. A review of the monthly April Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the nursing schedule and nurse ' s notes revealed that three different nurses failed to follow these physician orders. On 4/10/12 at 6:30 a.m. during the time that the resident was exhibiting labored breathing and congestion, the nurse did not assess the resident ' s blood sugar level. The MAR indicated [REDACTED]. Further review of the admission physician's admission orders [REDACTED]. It stated to flush the feeding tube with 200 ml. of water every shift (every eight hours). It also stated to flush the tube with 50 ml. of water before and after administration of medications. (This resident received medication 4 times a day for a total of an additional 400 ml. of water.) These tube feeding orders originated from the medication list sent from the hospital on [DATE]. This information from the hospital also stated the resident ' s weight was 175.3 pounds (lbs.) and his height was 72 inches. The admission nursing assessment dated [DATE] documented the resident weighed 142 pounds and a height of 62 inches in direct conflict with the data from the hospital. In an interview on 5/3/12 at 10:53a.m., with the ARNP for resident ' s attending physician, she stated they have 10 to 12 ARNPs and one PA. She stated she had been assigned to this facility about 2 months, but she was not familiar with this resident. He was assigned to another ARNP at the hospital. She stated she thought the nursing facility had called her to verify his orders on admission 4/6/12, which was a Friday. She stated their normal procedure is to read off the orders from the hospital ' s medication reconciliation record. She lets them know if things need to be adjusted. She stated she never came in to see this resident because he was only there for 4 days and she normally visits on Thursdays. She stated the nurses would have read her the tube feeding orders but not the resident ' s weight. She could not recall if she asked the Registered Dietician (RD) to assess the resident right away. She said if she were informed of a weight discrepancy from the hospital of 175 lbs. and from the nursing home of 142 pounds, she would ask how the resident was weighed in the hospital and in the facility. She would ask them to reweigh the resident for a couple of days in the same way and have the dietitian look at them. The ARNP stated her expectation would be that the RD would see a resident with a tube feeding within a couple of days of admission or at least be called to let the RD know what the orders and weight are. Then the RD could decide if the orders need to be adjusted. Interview on 5/3/12 at 11:34 a.m. with the restorative C.N.A. responsible for recording weights revealed documentation of a weight completed on 4/7/12 of 145.8 lbs. The C.N.A. revealed she weighed him on the hoyer lift in the morning and checked his height to be 6 feet, 2 inches. She stated she reported this weight to the resident ' s nurse immediately after the resident was weighed. This weight recorded by the restorative CNA revealed a third weight discrepancy in 24 hours. In an interview with LPN B on 5/3/12 at 12:52, she stated she handled resident #1 ' s admission orders [REDACTED]' s attending physician. She said he had a thick bone structure, was tall but she could tell he had lost weight since his previous admission. She stated nobody weighed him while she was there on 4/6/12 and she left at approximately 7:00p.m. The day before resident #1 was admitted this nurse recalled telling the RD that resident #1 was expected to return to the facility. LPN B stated she called the RD on 4/6/12 and read off his tube feeding orders from the hospital. She could not recall the RD asking for a weight, she just remembered her saying something like continue with the hospital orders. Review of resident #1 ' s Interim Admission Care Plan dated 4/9/12 revealed is resident was at risk for nutrition/dehydration problems related to dependency on a PEG tube. The following relevant intervention was listed: Dietary assessment on admission and as needed. Review of the resident ' s record revealed no nutrition assessment or dietary notes had been completed during the resident ' s stay from 4/6/12 - 4/10/12, despite the recording of three different weights with a discrepancy of approximately 30 lbs. and 2 different heights with a discrepancy of 10 inches. If the resident was truly 145.8 lbs. or approximately 66.2 kilograms (kg.), then 30 calories per kg. and 30 ml. per kg of fluid may not have been appropriate for a metabolically stressed resident. Furthermore, review of hospital emergency room nurse ' s notes on 4/10/12 at 12:54 p.m. revealed a fourth weight of 120 lbs. The Accumulative [DIAGNOSES REDACTED]. In an interview with the Director of Nurses (DON) on 5/3/12 at 11:10 a.m., she confirmed there was no dietary assessment in the record during the resident ' s stay. She stated they had recently employed a consultant company to provide RD services. The DON stated that the RD who was working at the facility during the time of resident #1 ' s stay was on a cruise and was not available for an interview. The DON stated in the interview on 5/3/12 at 11:10 a.m. that the RD completed a nutrition risk screening on 4/12/12; however, this resident had been discharged to the hospital 2 days prior to this screening. This nutrition risk screening was reviewed and it was completed 4/12/12 using a resident weight of 175 pounds. This revealed further problems with documentation accuracy, times, and delays impacting the care of the resident. In an interview with the facility ' s current RD consultant on 5/4/12 at 1:35 p.m., she stated she was familiar with long term care, but did not know resident #1. She stated it was the facility ' s procedure to call her when a resident with a tube feeding was admitted . She would ask their diagnoses, history, gender, height, weight, and if they have any issues like pressure ulcers, and if the tube feeding was new for the resident. The RD stated she needs the weight to assess the tube feeding accurately. There are a lot of variables, so she would have to look at each situation. She stated she would get a brief review to get a picture of the situation and then make a recommendation. In an interview on 5/4/12 at 1:30 p.m. with the Administrator, a policy on what would be expected of the dietician regarding assessment of a resident with a tube feeding was requested. She produced a policy about being able to write orders for tube feedings. It did not address expectations regarding how soon an assessment should be done and she stated that was all they had. She brought a job description entitled Registered Dietician and dated 10/1/03 that state in a bulleted list: assesses resident ' s nutritional needs and confers with clinical staff to coordinate patients ' nutritional intake. A review of resident ' s monthly Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s note, dated 4/7/12 at 1:30 a.m. revealed "GT feeding initiated". There was no documentation in the record to indicate why the feeding was not started immediately after confirming the physician's orders on 4/6/12 at 5:58 p.m. per the nursing notes. This was approximately 7 to 8 hours that the resident did not receive any food or water after admission on 4/6/12 at 5:58 p.m. In an interview with the DON on 5/3/12 at 11:10 a.m., she stated they have tube feedings formulas on hand and would have had Glucerna 1.5. She did not know why the tube feeding for resident #1 was not started until 1:30 a.m. 4/7/12 approximately 7 -7/1/2 hours after admission. To reiterate, the nursing note (handwritten) for 4/10/12 (no time documented) by LPN A stated: Resting in bed, respirations labored and resident ' s head of bed up at 45 degrees, resident congested and on contact isolation in a private room and services brought to the room. GT feeding flushes well without difficulties. Placement verified and no residual at this time. Review of the Daily Labor Report and staffing sheet revealed LPN A was scheduled to work on 4/9/12 at 7:00 p.m. until 4/10/12 until 7:00 a.m. In an interview with LPN A on 4/24/12 at 3:30 p.m., she stated that she had worked the night of 4/9/12 on the 7:00 p.m. to 7:00 a.m. shift and was assigned to resident #1. She stated she did not give a breathing treatment to the resident and does not remember him being unusually warm. She stated the vital signs were done. The nurse was difficult to understand and seemed to have a hard time understanding the questions and expressing her answers. In a second interview on 4/25/12 at 12:00 p.m. with LPN A., the nurse stated she had noticed resident #1 was congested and had labored breathing at about 4:00-5:00 a.m. The LPN stated she did not give him a breathing treatment because she did not think it would help because he was "too wet". She was unable to say what she meant and seemed confused about the question. She stated the resident had felt a little warm, but she did not take his vital signs at that time because someone had already taken them earlier in the shift. (Review of the handwritten notes dated 4/10/12 with no time documented revealed vital signs of temperature 97.1 pulse 75, respirations 18 and blood pressure 130/60). The nurse stated she put the head of the bed up and she checked on him frequently. She was unable to say how frequently or what she was checking. She said he had on oxygen at 2 liters per nasal cannula. LPN A stated she did not call the physician because she did not know the resident and was not sure if this was the way he was. She stated she told the oncoming day shift nurse about the resident's condition and left the facility at about 8:00 a.m. The nurse ' s statements and train of thought were fragmented and hard to follow and she did not seem to understand the significance of the situation. In a telephone interview with LPN F on 5/8/12 at 11:47 a.m., it was revealed that she had worked with LPN A on the 4/9/12, 7:00 p.m. to 4/10/12 7:00 a.m. shift. She stated she was not notified or aware of any problems with resident #1. She was not assigned to resident #1 but recalled his door being closed due to isolation precautions. She stated they normally work together on that shift because there are only two nurses in the building. She was surprised to learn of the condition of resident #1 because she did not know anything was wrong until 5/3/12 when interviewed by the DON. LPN F revealed that the resident ' s door was closed further limiting the nurse ' s ability to assess the condition of the resident when he was having difficulty breathing. Review of resident #1 ' s interim care plan dated 4/9/12 stated that the resident would have no complications related to [MEDICAL CONDITION]. Interventions listed were: observe for weakness, dehydration, and fever, administer medications and treatments per physician ' s orders. The nurse did not follow the plan of care when the resident had a significant decline as there is no record that the resident ' s temperature was taken and no record of any breathing treatments provided. Continued review of the clinical record revealed the following handwritten nurse note by LPN D 4/10/12 at 7:30 a.m.: congestion noted, increased respirations, blood pressure normal, oxygen saturation level at 87% (it was not specified if the resident was on oxygen or room air). The physician was notified and orders were received to transfer the resident to the hospital. According to the interview with LPN A on 4/25/12, the congestion and labored breathing was observed between 4:00 a.m.-5:00 a.m. Based on this information it was approximately 4 hours that treatment was delayed. The resident was in contact isolation with the door closed. The next nurse ' s note on 4/10/12 at 7:45 a.m. stated the resident was transferred to the hospital. A review of the "Resident Hospital Transfer Form", completed by LPN B prior to transfer dated 4/10/12, no time documented, indicated the resident's temperature was 105 degrees by axilla and the pulse was 100 beats per minute. There was no blood pressure or respirations recorded. The [DIAGNOSES REDACTED]. The reason for transfer was noted as change in level of consciousness and decreased oxygen saturation. In an interview and review of the Resident Hospital Transfer Form on 4/24/12 at approximately 3:00 p.m. with the Assistant Director of Nursing (ADON), LPN B and LPN D who were working the morning of 4/10/12, they stated the temperature on the transfer form must have been an error and should have been 100.5 degrees. They stated they could not recall who took the blood pressure, but LPN B stated she took resident #1 ' s temperature and filled out the transfer form. An interview was conducted on 4/24/12 at 3:00 p.m. with LPN D assigned to take care of the resident during the 7:00 a.m. to 3:00 p.m. (7-3), shift on 4/10/12. LPN D stated that in the shift to shift report at 7:00 a.m., the night nurse stated she had been giving him breathing treatments because of congestion. This statement is in direct conflict with what LPN A stated to the surveyor in 2 separate interviews in which she stated she did not give a breathing treatment on the night of 4/10/12. There were no signatures on the MAR indicated [REDACTED]. In fact no there were no signatures on the MAR indicated [REDACTED]. Nurse notes documented on this resident contain time discrepancies. In a subsequent interview with LPN D on 5/3/12/ at 1:36 p.m., it was revealed that she had cared for resident #1 on 4/9/12 on the 7:00 a.m. - 7:00 p.m. shift. On 4/9/12 his temperature was fine and he was sitting up. He showed no signs of distress and his vital signs were stable. She could not recall if he used oxygen and couldn ' t recall giving him any breathing treatments on that shift. LPN D stated nothing of any consequence happened on that shift. Continued interview with LPN D revealed that she came to work on 4/10/12 at about 7:20 a.m. She stated she and LPN A did the narcotics count. Following the narcotic count LPN D and LPN A went on walking rounds. LPN D stated resident #1 sounded congested but nothing severe. The head of the bed was up. After completing walking rounds LPN D went back to resident #1 ' s room by herself to check on him. She stated this was probably around 7:30 - 7:45 a.m. She said " I looked at him and could just hear the congestion " , so she went and got the wound care nurse LPN C, then LPN C went to get the ADON. LPN D stated the other nurses were doing everything. LPN D stated she put the breathing medication into the nebulizer machine but the ADON put the mask on and administered the treatment. After this LPN D was in and out of the room because she needed to start medication pass. She could not recall when he went to the hospital and she was not present when they took his vital signs. LPN D was asked about her nurse ' s note dated 4/10/12 at 7:30 a.m. stating the blood pressure was normal. She could not recall what it was or who took it. She stated somebody had to have taken it for her to write it down. LPN D also stated she realized now that she didn ' t get to the facility until 7:20 a.m. on 4/10/12 so her times on the documentation were probably not right. Further interview with LPN D at 2:10 p.m. on 5/3/12 revealed she did not notice any wetness or odors, just congestion. In an interview with LPN C on 5/4/12 at 1:19 p.m., she stated she was the wound care nurse and she went to see resident #1 to evaluate his wounds on the morning of 4/10/12. She stated she usually works 6:00 a.m. - 2:00 p.m. but she thinks she was it was around 7:00 a.m. when she first saw resident #1 on 4/10/12. LPN D had been in before her and LPN C said she knew something was going on because she overheard their shift report. LPN C noticed resident #1 ' s breathing was labored and his respirations were increased. The ADON was walking past so LPN C asked her to come in. She said the ADON was working up top and she was undressing his right leg wound. She said his legs didn ' t feel warm at all. She does not think there was oxygen on him in conflict with interviews with ADON and LPN D. She thinks they came in and put oxygen on him around 7:30 a.m. - 7:45 a.m. She checked the oxygen saturation level after applying the pulse oximeter and recalled it was in the 70 ' s. LPN C did not know who took his vital signs. LPN C stated they turned his tube feeding off and the head of bed was elevated. We did do a blood sugar (BS) test on him and it was 200 something. She said she remembers it wasn ' t too high or too low. She thinks LPN D did the BS but was not certain. LPN C could not describe resident #1 ' s color as he was a dark skinned man. LPN C stated he did open his eyes when you called his name, but did not verbally respond. She didn ' t notice if they gave him a breathing treatment. She does not recall any odor or indications that he was in need of incontinence care. An interview was conducted with the Assistant Director of Nurses (ADON) on 4/24/12 at 2:40 p.m. The ADON stated she was present on 4/10/12 at 7:30 a.m., when resident was transferred to the hospital. She stated the head of the bed was elevated and the resident was experiencing abnormal breath sounds. The ADON stated she gave him a breathing treatment. Yet, there was no documentation of the breathing treatment having been given in the record. The ADON stated the tube feeding was off and the resident's oxygen saturation level was going up and down. The resident's eyes were open but he was not responding. She stated they took vital signs and he had a temperature but she could not remember what it was. In an interview on 5/3/12 at 12:53 p.m. with LPN B., she stated on the morning of 4/10/12 she heard LPN D saying resident #1 needed to go to the hospital. LPN B stated she went to resident #1 ' s room to assist. She noticed the ADON administering a breathing treatment, he was receiving oxygen, and had a pulse oximeter on his finger which had a reading that was fluctuating " 40, 60, and would go up into the 80 ' s " . She said he had increased respirations, but he was not gasping for air. He would look at you but did not respond verbally. In the past, this resident would speak in a real soft voice. She recalled asking if anybody got his vitals. One of the C.N.A. ' s came in and took his temperature; however, she could not recall the name of this C.N.A. LPN B recorded the temperature as 105 degrees Fahrenheit per axillary. After that she went to the desk to prepare his transfer forms and called the doctor. LPN B stated she informed the ARNP that the resident was receiving a breathing treatment, had a temperature of 105 with fluctuating oxygen saturations, and was in an unstable condition. LPN B stated she told the ARNP the resident needed to go to the emergency room . She thinks that this occurred before 8:00 a.m. but was not exactly sure of the time. LPN B could not recall what time the ambulance arrived. In an interview with the resident ' s attending physician on 5/4/12 at 1:55 p.m., he stated that the resident had a history of [REDACTED]. He stated that the resident is at a long term care hospital on a ventilator. He stated that when the resident went to the hospital on [DATE], his temperature was 107 and he was diagnosed with [REDACTED]. He also stated that the resident was intubated in the field so that may have caused the pneumothorax, but he could not be sure. He also said he did not know about the weight discrepancies and that the weights may have been different because of how they were obtained. He was not contacted when the resident first exhibited labored breathing and congestion or on the morning of 4/10/12 when resident #1 was sent to the hospital. A review of the Emergency Medical Services (EMS) report, dated 4/10/12, revealed the call from the facility was received at 8:38 a.m. on 4/10/12 and the ambulance arrived at the facility at 8:41 a.m. The documented time of transport was 9:03 a.m. This was conflicting with the facility ' s documentation of sending the resident out of the building at 7:45 a.m. This would mean an additional hour in delay of treatment from 4:00 -5:00 a.m. to 8:38 a.m. In an interview with the DON on 5/2/12 at 6:15 p.m. and the Administrator who was on speakerphone, they both stated that they had not investigated the care of resident #1 related to the unusua

Based on facility staff interview and medical record review, the facility did not provide nursing services that met professional standards of care. The facility Licensed Practical Nurse (LPN) did not assess an elderly, diabetic resident with labored breathing and congestion including not evaluating respiratory function, blood sugar level, vital signs and other pertinent necessary information to evaluate the resident. The facility LPN did not relay the findings to the physician resulting in a delay in treatment. The facility LPN did not provide necessary physician ordered medication to help alleviate the resident ' s labored breathing. The facility nurses did not provide nursing supervision to assure the provision of incontinence care for a resident with sacral ulcers. The facility nurses did not administer the physician ordered tube feeding to the resident (who could take nothing by mouth) until approximately 7 hours after admission. The facility nurses failed to communicate to the physician an approximate 30 pound weight loss that the resident experienced while out of the facility to assure that the amount of tube feeding and water ordered were based on an accurate weight. These practices were not consistent with professional standards and the nurse practice act which states the LPN administers medications and treatments and provides care to the ill under the direction of the physician and the Registered nurse. The outline for the care for resident #1 was found in the plan of care, the physician orders, and the LPN ' s job description. These practices resulted in physical harm to one (#1) of 13 residents reviewed. The investigation revealed resident #1 was in [MEDICAL CONDITION] and had an axillary temperature of 105 degrees Fahrenheit upon the arrival of the paramedics at the facility 4-5 hours after he was first observed with labored breathing and congestion. The resident required intubation and assisted ventilations while en route to the hospital. The resident arrived at the emergency room with an oral temperature of 107 degrees and was diagnosed with [REDACTED]. These facility practices resulted in the determination of Immediate Jeopardy which was reduced to a D on 5/3/12. Findings include: Professional Standard of Care is defined in Chapter 766.102 as, " the prevailing professional standard of care for a given health care provider shall be that level of care, skill, and treatment which, in light of all relevant surrounding circumstances, is recognized as acceptable and appropriate by reasonably prudent similar health care providers " . 464.001 Short title.--This part may be cited as the "Nurse Practice Act (2) "Board" means the Board of Nursing.(3)(a) "Practice of professional nursing" means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: 1. The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others. 2. The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments. 3. The supervision and teaching of other personnel in the theory and performance of any of the above acts. (b) "Practice of practical nursing" means the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infirm and the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist. The professional nurse and the practical nurse shall be responsible and accountable for making decisions that are based upon the individual's educational preparation and experience in nursing. Review of the Licensed Practical Nurse (LPN) job description signed by LPN A on 2/24/12 states that a licensed practical nurse provides care and treatment in accordance with physician ' s orders. Under essential duties and responsibilities, relevant duties listed are: Collection of data (may be part of an assessment, vital signs, resident ' s complaints, symptoms, etc.). Observation of the residents. (e.g. location, activity, position etc.). Administers and documents medications and treatments. Supervises LPNs and certified nursing assistants with appropriate supervisory LPN training. Communicates with RNs and or physicians regarding pertinent resident observations and information. Documents observations and care in compliance with standards of care and company policy. Review of the Emergency Medical Services (EMS) run report for resident #1 revealed that they arrived at the hospital on [DATE] at 9:11 a.m. According to the EMS narrative notes .... " Staff stated that at shift change the patient complained of difficulty breathing. Staff stated that the patient had a temperature 105 degrees F, and that patient was being treated for [REDACTED]. Upon assessment patient found to be in [MEDICAL CONDITION], SPO2 reading was 78% on non rebreather mask, Glasgow Coma Scale (GCS) was a 6 with labored respirations. Secondary revealed skin hot, pink, very dry ... ....pupils sluggish and unequal, lung sounds rhonchi throughout ... facilitated intubation and ventilations were assisted. " A review of the Hospital face sheet revealed a registration time of 4/10/12 at 9:16 a.m. A review the Emergency Physician record dated 4/10/12 revealed the resident had been intubated prior to arrival in the ER was initially hypotensive with a systolic blood pressure of 70. The patient ' s temperature was 107 F rectally. On physical exam, patient with unequal pupils, sent to CT which revealed chronic changes. Chest x-ray showed the endotracheal tube was in good position however the patient had a right pneumothorax, a chest tube was place immediately and the resident was placed on a ventilator. Review of the hospital emergency department triage report dated 4/10/12 at 9:24 a.m. revealed the resident ' s blood sugar was 300. Review of the hospital emergency department nurse's documentation dated 4/10/12 performed at 9:19 a.m. stated in capitalized letters that the resident was " SOAKED IN URINE THAT APPEARS FOR A PROLONGED PERIOD OF TIME; DIAPER WAS SOAKED IN ENTIRETY, BROWN IN COLOR, STRONG ODOR OF AMMONIA, AND THE BOTTOM SHEET WAS SOAKED AS WELL WITH A HUGE RING AROUND THE PATIENT- APPEARS TO HAVE BEEN THERE FOR A LONG PERIOD OF TIME. WHEN ROLLED, A USED ANGIOCATH WAS STUCK TO THE BACK OF THE PATIENT ' S RIGHT LEG AND HAD A DATE OF 3/16/12 ATTACHED TO CATH " . The entry went on to say that this situation was reported to the charge nurse and the social worker. Review of the facility Admission Record revealed resident #1 was originally admitted to the facility on [DATE]. A review of the nursing notes revealed the resident was most recently readmitted via ambulance on 4/6/12 at 5:58 p.m. A review of the Accumulative [DIAGNOSES REDACTED]. Coli) urinary tract infection [MEDICAL CONDITION], urosepsis, [MEDICAL CONDITION], hypokalemia, diastolic heart failure, sacral and lower extremity wounds, [MEDICAL CONDITION], Percutaneous enteral [MEDICAL CONDITION] tube (Peg Tube), dysphagia, [MEDICAL CONDITION] ([MEDICAL CONDITION].) [MEDICAL CONDITION] infection and [MEDICAL CONDITION]. A review of the computerized admission Progress Note completed by a Licensed Practical Nurse (LPN B) revealed the resident was admitted on [DATE] at 5:58 p.m. via stretcher accompanied by paramedics ....meds verified with advanced registered nurse practitioner (ARNP), transcribed, and faxed to pharmacy. A review of the computerized Nursing Admission Assessment, dated 4/6/12, revealed the resident had severely impaired cognitive skills, was totally dependent on staff for care, was receiving all nutrition and hydration from a feeding tube and had a [MEDICAL CONDITION]. It stated the resident had a recorded admission height of 62 inches and a recorded weight of 142.0 pounds. The assessment also stated that the resident was admitted with an open area to the right heel measuring approximately 4.5 centimeters (cm.) in width, an open area to the right great toe a quarter in size and coccyx wound measuring 6 cm. by 8 cm. This is accompanied by three dime to quarter size areas [MEDICAL CONDITION]. The left lower front leg had a slightly larger than golf ball diameter lesion with irregular border. A review of the computerized Weights and Vitals Summary notes dated 4/9/12 revealed the vital signs recorded at 3:30 p.m. were: blood pressure 118/69, temperature 98.2 degrees Fahrenheit, pulse 70 and respirations 20. It was documented in the handwritten notes by LPN E on 4/9/12 at 9:00 p.m. that resident #1 was resting in bed. Respirations even and unlabored. Tube feeding tolerated well. Contact isolation maintained. Resident in private room with services brought in for [MEDICAL CONDITION]. Review of LPN E ' s Time Detail report revealed that she punched in at 2:32 p.m. and out at 8:00 p.m. The documentation of the 9:00 pm.in the nurses notes on 4/9/12 time is in conflict with the fact that she had punched out and was not in the building. Another handwritten nurse's note by LPN D after this one dated 4/9/12, (with no time), documented: Resident resting in bed. No S/S of distress, no complaint of pain at present. Glucerna 1.5 infusing at 80 cc/hr. Tolerating well. [MEDICAL CONDITION] intact. Remains on contact isolation for [MEDICAL CONDITION]. All services performed in room. Will continue to monitor. Review of the Time Detail report for LPN D revealed she worked 4/9/12 from 7:08 a.m. -7:53p.m. A review of the next nursing note (handwritten) for 4/10/12 (no time documented) by LPN A stated: Resting in bed, respirations labored and resident ' s head of bed up at 45 degrees, resident congested and on contact isolation in a private room and services brought to the room. GT feeding flushes well without difficulties. Placement verified and no residual at this time. Review of the Daily Labor Report and staffing sheet revealed LPN A was scheduled to work on 4/9/12 at 7:00 p.m. until 4/10/12 at 7:00 a.m. Continued review of the record revealed that respirations of 20 were documented in the computerized record on 4/10/12 at 4:08 a.m. No additional vital signs were documented and no additional notes could be found regarding an assessment of the resident despite the notation by the 7:00 p.m. to 7:00 a.m. nurse of labored respirations and congestion. There is no documentation in the record of any care that was provided for the resident by this nurse for the labored breathing and the congestion. There was no evidence the physician was contacted regarding the significant change in the resident ' s respiratory condition. A review of the physician's admission orders [REDACTED]. A review of the April MAR indicated [REDACTED]. The resident's admission physician orders dated 4/6/12 included the following relevant orders: blood sugar tests (finger sticks) at 6:30 a.m., 11:30 a.m., 4:30 p.m., and 9:30 p.m. with [MEDICATION NAME] regular insulin coverage on a sliding scale as follows: less than 151= 0 units, 151-200= 3units, 201-250= 6 units, 251-300= 9 units, 301-350= 12 units, 351-400= 15 units, and 401-450= 18 units. If blood sugar tests greater than 450 give 21 units and call medical doctor. If blood sugar less than 60, give [MEDICATION NAME]. A review of the monthly April Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the nursing schedule and nurse ' s notes revealed that three different nurses failed to follow these physician orders. On 4/10/12 at 6:30 a.m. during the time that the resident was exhibiting labored breathing and congestion, the nurse did not assess the resident ' s blood sugar level. The MAR indicated [REDACTED]. Further review of the admission physician's admission orders [REDACTED]. It stated to flush the feeding tube with 200 ml. of water every shift (every eight hours). It also stated to flush the tube with 50 ml. of water before and after administration of medications. (This resident received medication 4 times a day for a total of an additional 400 ml. of water.) These tube feeding orders originated from the medication list sent from the hospital on [DATE]. This information from the hospital also stated the resident ' s weight was 175.3 pounds (lbs.) and his height was 72 inches. The admission nursing assessment dated [DATE] documented the resident weighed 142 pounds and a height of 62 inches in direct conflict with the data from the hospital. In an interview on 5/3/12 at 10:53a.m., with the ARNP for resident #1 ' s attending physician, she stated she was not familiar with this resident. He was assigned to another ARNP at the hospital. She stated she thought the nursing facility had called her to verify his orders on admission 4/6/12, which was a Friday. She stated their normal procedure is to read off the orders from the hospital ' s medication reconciliation record. She lets them know if things need to be adjusted. She stated she never came in to see this resident because he was only there for 4 days and she normally visits on Thursdays. She stated the nurses would have read her the tube feeding orders but not the resident ' s weight. She said if she were informed of a weight discrepancy from the hospital of 175 lbs. and from the nursing home of 142 pounds, she would ask how the resident was weighed in the hospital and in the facility. She would ask them to reweigh the resident for a couple of days in the same way and have the dietitian look at them. Interview on 5/3/12 at 11:34 a.m. with the restorative C.N.A. responsible for recording weights revealed documentation of a weight completed on 4/7/12 of 145.8 lbs. The C.N.A. revealed she weighed him on the hoyer lift in the morning and checked his height to be 6 feet, 2 inches. She stated she reported this weight to the resident ' s nurse immediately after the resident was weighed. This weight recorded by the restorative CNA revealed a third weight discrepancy in 24 hours. In an interview with LPN B on 5/3/12 at 12:52, she stated she handled resident #1 ' s admission orders [REDACTED]' s attending physician. She said he had a thick bone structure, was tall but she could tell he had lost weight since his previous admission. She stated nobody weighed him while she was there on 4/6/12 and she left at approximately 7:00p.m. If the resident was truly 145.8 lbs. or approximately 66.2 kilograms (kg.), then 30 calories per kg. and 30 ml. per kg of fluid may not have been appropriate for a metabolically stressed resident. Furthermore, review of hospital emergency room nurse ' s notes on 4/10/12 at 12:54 p.m. revealed a fourth weight of 120 lbs. The Accumulative [DIAGNOSES REDACTED]. There is no evidence that the physician and/or the ARNP were made aware of the resident ' s weight loss. A review of resident ' s monthly Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s note, dated 4/7/12 at 1:30 a.m. revealed "GT feeding initiated". There was no documentation in the record to indicate why the feeding was not started immediately after confirming the physician's orders on 4/6/12 at 5:58 p.m. per the nursing notes. This was approximately 7 to 8 hours that the resident did not receive any food or water after admission on 4/6/12 at 5:58 p.m. In an interview with the DON on 5/3/12 at 11:10 a.m., she stated they have tube feeding formulas on hand and would have had Glucerna 1.5. She did not know why the tube feeding for resident #1 was not started until 1:30 a.m. 4/7/12 approximately 7 -7/1/2 hours after admission. Report and staffing sheet revealed LPN A was scheduled to work on 4/9/12 at 7:00 p.m. until 4/10/12 until 7:00 a.m. The nursing note (handwritten) for 4/10/12 (no time documented) by LPN A stated: Resting in bed, respirations labored and resident ' s head of bed up at 45 degrees, resident congested and on contact isolation in a private room and services brought to the room. GT feeding flushes well without difficulties. Placement verified and no residual at this time. In an interview with LPN A on 4/24/12 at 3:30 p.m., she stated that she had worked the night of 4/9/12 on the 7:00 p.m. to 7:00 a.m. shift and was assigned to resident #1. She stated she did not give a breathing treatment to the resident and does not remember him being unusually warm. She stated the vital signs were done. The nurse was difficult to understand and seemed to have a hard time understanding the questions and expressing her answers. In a second interview on 4/25/12 at 12:00 p.m. with LPN A., the nurse stated she had noticed resident #1 was congested and had labored breathing at about 4:00-5:00 a.m. The LPN stated she did not give him a breathing treatment because she did not think it would help because he was "too wet". She was unable to say what she meant and seemed confused about the question. She stated the resident had felt a little warm, but she did not take his vital signs at that time because someone had already taken them earlier in the shift. (Review of the handwritten notes dated 4/10/12 with no time documented revealed vital signs of temperature 97.1 pulse 75, respirations 18 and blood pressure 130/60). The nurse stated she put the head of the bed up and she checked on him frequently. She was unable to say how frequently or what she was checking. She said he had on oxygen at 2 liters per nasal cannula. LPN A stated she did not call the physician because she did not know the resident and was not sure if this was the way he was. She stated she told the oncoming day shift nurse about the resident's condition and left the facility at about 8:00 a.m. The nurse ' s statements and train of thought were fragmented and hard to follow and she did not seem to understand the significance of the situation. In a telephone interview with LPN F on 5/8/12 at 11:47 a.m., it was revealed that she had worked with LPN A on the 4/9/12, 7:00 p.m. to 4/10/12 7:00 a.m. shift. She stated she was not notified or aware of any problems with resident #1. She was not assigned to resident #1 but recalled his door being closed due to isolation precautions. She stated they normally work together on that shift because there are only two nurses in the building. She was surprised to learn of the condition of resident #1 because she did not know anything was wrong until 5/3/12 when interviewed by the DON. The interview with LPN F confirmed that LPN A did not seek assistance from her the night of 4/10/12. LPN F revealed that the resident ' s door was closed further limiting the nurse ' s ability to assess the condition of the resident when he was having difficulty breathing. It was unclear why the door was closed for resident #1 for contact isolation. Review of the Centers for Disease Control (CDC) 2007 Guidelines for Isolation Precautions in Health Care Settings does not list closing the door as a recommendation for a resident on contact precautions and would only be used if a resident was on a form of airborne precautions. Review of resident #1 ' s interim care plan dated 4/9/12 stated that the resident would have no complications related to [MEDICAL CONDITION]. Interventions listed were: observe for weakness, dehydration, and fever, administer medications and treatments per physician ' s orders. The nurse did not follow the plan of care when the resident had a significant decline as there is no record that the resident ' s temperature was taken and no record of any breathing treatments provided including a denial of giving a breathing treatment by LPN A in 2 separate interviews. Review of a handwritten nurse ' s note by LPN D on 4/10/12 at 7:30 a.m. stated: congestion noted, increased respirations, blood pressure normal, oxygen saturation level at 87% (it was not specified if the resident was on oxygen or room air). The physician was notified and orders were received to send the resident to the hospital. According to the interview with LPN A on 4/25/12, the congestion and labored breathing was first observed between 4:00 a.m.-5:00 a.m. Based on this information it was approximately 4 hours that treatment was delayed. The next nurse ' s note on 4/10/12 at 7:45 a.m. stated the resident was transferred to the hospital. A review of the "Resident Hospital Transfer Form", completed by LPN B prior to transfer dated 4/10/12, no time documented, indicated the resident's temperature was 105 degrees by axilla and the pulse was 100 beats per minute. There was no blood pressure or respirations recorded. The [DIAGNOSES REDACTED]. The reason for transfer was noted as change in level of consciousness and decreased oxygen saturation. In an interview and review of the Resident Hospital Transfer Form on 4/24/12 at approximately 3:00 p.m. with the Assistant Director of Nursing (ADON), LPN B and LPN D who were working the morning of 4/10/12, they stated the temperature on the transfer form must have been an error and should have been 100.5 degrees. They stated they could not recall who took the blood pressure, but LPN B stated she took resident #1 ' s temperature and filled out the transfer form. An interview was conducted on 4/24/12 at 3:00 p.m. with LPN D assigned to take care of the resident during the 7:00 a.m. to 3:00 p.m. (7-3), shift on 4/10/12. LPN D stated that in the shift to shift report at 7:00 a.m., the night nurse stated she had been giving him breathing treatments because of congestion. This statement is in direct conflict with what LPN A stated to the surveyor in 2 separate interviews in which she stated she did not give a breathing treatment on the night of 4/10/12. There were no signatures on the MAR indicated [REDACTED]. Nurse notes documented on this resident are very vague and time discrepancies are evident. In a subsequent interview with LPN D on 5/3/12/ at 1:36 p.m., it was revealed that she had cared for resident #1 on 4/9/12 on the 7:00 a.m. - 7:00 p.m. shift. On 4/9/12 his temperature was fine and he was sitting up. He showed no signs of distress and his vital signs were stable. She could not recall if he used oxygen and couldn ' t recall giving him any breathing treatments on that shift. LPN D stated nothing of any consequence happened on that shift. Continued interview with LPN D revealed that she came to work on 4/10/12 at about 7:20 a.m. She stated she and LPN A did the narcotics count. Following the narcotic count LPN D and LPN A went on walking rounds. LPN D stated resident #1 sounded congested but nothing severe. The head of the bed was up. After completing walking rounds LPN D went back to resident #1 ' s room by herself to check on him. She stated this was probably around 7:30 - 7:45 a.m. She said " I looked at him and could just hear the congestion " , so she went and got the wound care nurse LPN C, then LPN C went to get the ADON. LPN D stated the other nurses were doing everything. LPN D stated she put the breathing medication into the nebulizer machine but the ADON put the mask on and administered the treatment. After this LPN D was in and out of the room because she needed to start medication pass. She could not recall when he went to the hospital and she was not present when they took his vital signs. LPN D was asked about her nurse ' s note dated 4/10/12 at 7:30 a.m. stating the blood pressure was normal. She could not recall what it was or who took it. She stated somebody had to have taken it for her to write it down. LPN D also stated she realized now that she didn ' t get to the facility until 7:20 a.m. on 4/10/12 so her times on the documentation were probably not right. Further interview with LPN D at 2:10 p.m. on 5/3/12 revealed she did not notice any wetness or odors, just congestion. In an interview with LPN C on 5/4/12 at 1:19 p.m., she stated she was the wound care nurse and she went to see resident #1 to evaluate his wounds on the morning of 4/10/12. She stated she usually works 6:00 a.m. - 2:00 p.m. but she thinks she was it was around 7:00 a.m. when she first saw resident #1 on 4/10/12. LPN D had been in before her and LPN C said she knew something was going on because she had overheard their shift report. LPN C noticed resident #1 ' s breathing was labored and his respirations were increased. The ADON was walking past so LPN C asked her to come in. She said the ADON was working up top and she was undressing his right leg wound. She said his legs didn ' t feel warm at all. She does not think there was oxygen on him in conflict with interviews with ADON and LPN D. She thinks they came in and put oxygen on him around 7:30 a.m. - 7:45 a.m. She checked the oxygen saturation level after applying the pulse oximeter and recalled it was in the 70 ' s. LPN C did not know who took his vital signs. LPN C stated they turned his tube feeding off and the head of bed was elevated. We did do a blood sugar (BS) test on him and it was 200 something. She said she remembers it wasn ' t too high or too low. She thinks LPN D did the BS but was not certain. LPN C could not describe resident #1 ' s color as he was a dark skinned man. LPN C stated he did open his eyes when you called his name, but did not verbally respond. She didn ' t notice if they gave him a breathing treatment. She does not recall any odor or indications that he was in need of incontinence care. An interview was conducted with the Assistant Director of Nurses (ADON) on 4/24/12 at 2:40 p.m. The ADON stated she was present on 4/10/12 at 7:30 a.m., when resident was transferred to the hospital. She stated the head of the bed was elevated and the resident was experiencing abnormal breath sounds. The ADON stated she gave him a breathing treatment. Yet, there was no documentation of the breathing treatment having been given in the record. The ADON stated the tube feeding was off and the resident's oxygen saturation level was going up and down. The resident's eyes were open but he was not responding. She stated they took vital signs and he had a temperature but she could not remember what it was. In an interview on 5/3/12 at 12:53 p.m. with LPN B., she stated on the morning of 4/10/12 she heard LPN D saying resident #1 needed to go to the hospital. LPN B stated she went to resident #1 ' s room to assist. She noticed the ADON administering a breathing treatment, he was receiving oxygen, and had a pulse oximeter on his finger which had a reading that was fluctuating " 40, 60, and would go up into the 80 ' s " . She said he had increased respirations, but he was not gasping for air. He would look at you but did not respond verbally. In the past, this resident would speak in a real soft voice. She recalled asking if anybody got his vitals. One of the C.N.A.s came in and took his temperature; however, she could not recall the name of this C.N.A. LPN B recorded the temperature as 105 degrees Fahrenheit per axillary. After that she went to the desk to prepare his transfer forms and called the doctor. LPN B stated she informed the ARNP that the resident was receiving a breathing treatment, had a temperature of 105 with fluctuating oxygen saturations, and was in an unstable condition. LPN B stated she told the ARNP the resident needed to go to the emergency room . She thinks that this occurred before 8:00 a.m. but was not exactly sure of the time. LPN B could not recall what time the ambulance arrived. A review of the Emergency Medical Services (EMS) report, dated 4/10/12, revealed the call from the facility was received at 8:38 a.m. on 4/10/12 and the ambulance arrived at the facility at 8:41 a.m. The documented time of transport was 9:03 a.m. This was conflicting with the facility ' s documentation of sending the resident out of the building at 7:45 a.m. This would mean an additional hour in delay of treatment from 4:00 -5:00 a.m. to 8:38 a.m. In an interview with the DON on 5/2/12 at 6:15 p.m. and the Administrator who was on speakerphone, they both stated that they had not investigated the care of resident #1 related to the unusually high temperature of 105 degrees. The response from the DON was, " He was very sick, we did what we were supposed to do. The ABCs. ( basics) What more could we have done? " The administrator stated that another state agency had come out to the facility on [DATE] to investigate allegations of neglect, but stated the investigator stayed only about 45 minutes. When asked if this event triggered an investigation by the facility, she said no. Review of the facility policy entitled Abuse and Neglect Prohibition SHC 02 0003.3 and undated revealed the definition of neglect to be failure to provide goods and services necessary to avoid. Upon surveyor ' s arrival at the facility on 5/3/12 at 9:00 a.m., an interview was conducted with the DON and the Administrator. They said they started their investigation at 5:00 a.m. and contacted by phone or in person all of the staff nurses who worked in the facility on 4/9/12 at 7:00 p.m. through 4/10/12 when the resident was sent to the hospital. Documentation of these interviews revealed the following: LPN A: report received with walking rounds, resident observed to be stable. No respiratory distress. Temperature 97.1, blood pressure 130/60, pulse 75, respirations 18. 5am-7am: later during shift primary nurse observed resident to be congested, respirations increased, oxygen applied and breathing treatment provided on the shift. This documentation provided by the facility on 5/3/12 was in direct conflict with 2 prior surveyor interviews conducted on 4/24/12 and 4/25/12 stating that a breathing treatment was not given and conflicts with clinical record documentation. The DON and the Administrator confirmed in this interview that LPN A ' s recollection of events is inconsistent and has changed during multiple interviews. In an interview on 5/4/12 at 1:55 p.m. with the resident ' s attending physician, he stated that the resident had a history of [REDACTED]. He stated that the resident is at a long term care hospital on a ventilator. He stated that when the resident went to the hospital on 4/10, his temperature was 107 and that he was diagnosed with [REDACTED]. He also stated that the resident was intu

Based on facility staff interview and medical record review, the facility did not follow the care plan interventions for one (#1) of 13 sampled residents including: not assessing an elderly, [AGE] year old, diabetic resident with labored breathing and congestion, not evaluating respiratory function, blood sugar level and vital signs, not communicating the findings to the physician resulting in a delay in treatment. The facility failed to provide physician ordered medication to help alleviate the resident ' s labored breathing as outlined in the care plan when the resident had labored breathing and congestion. The facility did not follow the plan of care for incontinence for a resident with sacral ulcers. The facility did not follow the plan of care for the tube feeding and did not administer the tube feeding to the resident (who could take nothing by mouth) until approximately 7 hours after admission. The facility nurses failed to keep the physician informed as outlined in the plan of care regarding a 30 pound weight loss. The outline for the care for resident #1 was found in the plan of care and the physician orders. These practices resulted in physical harm to the resident. The investigation revealed resident #1 was in [MEDICAL CONDITION] and had an axillary temperature of 105 degrees Fahrenheit upon the arrival of the paramedics at the facility 4-5 hours after he was first observed with labored breathing and congestion. The resident required intubation and assisted ventilations while en route to the hospital. The resident arrived at the emergency room with an oral temperature of 107 degrees and was diagnosed with [REDACTED]. Findings include: Review of the facility Admission Record revealed resident #1, a [AGE] year old, was originally admitted to the facility on [DATE], but, was most recently readmitted via ambulance on 4/6/12 at 5:58 p.m., per nursing notes. The Accumulative [DIAGNOSES REDACTED]. Coli) urinary tract infection [MEDICAL CONDITION], urosepsis, [MEDICAL CONDITION], hypokalemia, diastolic heart failure, sacral and lower extremity wounds, [MEDICAL CONDITION], Percutaneous enteral [MEDICAL CONDITION] tube (Peg Tube), dysphagia, [MEDICAL CONDITION] ([MEDICAL CONDITION].) [MEDICAL CONDITION] infection and [MEDICAL CONDITION]. The computerized admission Progress Note, completed by a Licensed Practical Nurse (LPN B), revealed the resident was admitted on [DATE] at 5:58 p.m. via stretcher accompanied by paramedics ....meds verified with advanced registered nurse practitioner (ARNP), transcribed, and faxed to pharmacy. A 4/6/2012 computerized Nursing Admission Assessment revealed the resident had severely impaired cognitive skills, was totally dependent on staff for care, was receiving all nutrition and hydration from a feeding tube and had a [MEDICAL CONDITION]. It stated the resident had a recorded admission height of 62 inches and a recorded weight of 142.0 pounds. The assessment also stated that the resident was admitted with an open area to the right heel measuring approximately 4.5 centimeters (cm.) in width, an open area to the right great toe a quarter in size and coccyx wound measuring 6 cm. by 8 cm. This is accompanied by three dime to quarter size areas [MEDICAL CONDITION]. The left lower front leg had a slightly larger than golf ball diameter lesion with irregular border. The plan of care with admission date of [DATE] listed relevant interventions under the [DIAGNOSES REDACTED]. Further interventions listed under at risk for dehydration included: monitor vital signs as ordered and notify the physician of significant abnormalities. Interventions listed under contact isolation for [MEDICAL CONDITION] infection were: monitor for weakness, fever, give medications and treatments per physician's order [REDACTED]. Review of the nursing note (handwritten) for 4/10/12 (no time documented) by LPN A stated: Resting in bed, respirations labored and resident ' s head of bed up at 45 degrees, resident congested and on contact isolation in a private room and services brought to the room. GT feeding flushes well without difficulties. Placement verified and no residual at this time. Review of the Daily Labor Report and staffing sheet revealed LPN A was scheduled to work on 4/9/12 at 7:00 p.m. until 4/10/12 at 7:00 a.m. Continued review of the record revealed that respirations of 20 were documented in the computerized record on 4/10/12 at 4:08 a.m. No additional vital signs were documented and no additional notes could be found regarding an assessment of the resident despite the notation by the 7:00 p.m. to 7:00 a.m. nurse of labored respirations and congestion. There is no documentation in the record of any care that was provided for the resident by this nurse for the labored breathing and the congestion. There was no evidence the physician was contacted regarding the significant change in the resident ' s respiratory condition. A review of the physician's admission orders [REDACTED]. A review of the April MAR indicated [REDACTED]. The care plan interventions were not followed. Resident #1 ' s admission physician orders, dated 4/6/12, included the following relevant orders: blood sugar tests (finger sticks) at 6:30 a.m., 11:30 a.m., 4:30 p.m., and 9:30 p.m. with [MEDICATION NAME] regular insulin coverage on a sliding scale as follows: less than 151= 0 units, 151-200= 3units, 201-250= 6 units, 251-300= 9 units, 301-350= 12 units, 351-400= 15 units, and 401-450= 18 units. If blood sugar tests greater than 450 give 21 units and call medical doctor. If blood sugar less than 60, give [MEDICATION NAME]. A review of the monthly April Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the nursing schedule and nurse ' s notes revealed that three different nurses failed to follow these physician orders [REDACTED]. On 4/10/12 at 6:30 a.m. during the time that the resident was exhibiting labored breathing and congestion, the nurse did not assess the resident ' s blood sugar level. The MAR indicated [REDACTED]. The care plan for admitted d 4/6/12 stated that the resident was at risk for hypo and [MEDICAL CONDITION] and to monitor lab values as ordered and follow up with the physician. These interventions were not followed. Further review of the admission physician's admission orders [REDACTED]. It stated to flush the feeding tube with 200 ml. of water every shift (every eight hours). It also stated to flush the tube with 50 ml. of water before and after administration of medications. The medication list originating from the hospital, dated 4/6/12, stated the resident ' s weight was 175.3 pounds (lbs.) and his height was 72 inches. The admission nursing assessment, dated 4/6/12, documented the resident weighed 142 pounds and a height of 62 inches in direct conflict with the data from the hospital. These findings were not communicated to the physician. In an interview on 5/3/12 at 10:53 a.m., with the ARNP for resident #1 ' s attending physician, she stated she thought the nursing facility had called her to verify his orders on admission 4/6/12, which was a Friday. She stated their normal procedure is to read off the orders from the hospital ' s medication reconciliation record. She lets them know if things need to be adjusted. She stated the nurses would have read her the tube feeding orders but not the resident ' s weight. She said if she were informed of a weight discrepancy from the hospital of 175 lbs. and from the nursing home of 142 pounds, she would ask how the resident was weighed in the hospital and in the facility. She would ask them to reweigh the resident for a couple of days in the same way and have the dietitian look at them. Interview on 5/3/12 at 11:34 a.m. with the restorative C.N.A. responsible for recording weights revealed documentation of a weight completed on 4/7/12 of 145.8 lbs. The C.N.A. revealed she weighed him on the hoyer lift in the morning and checked his height to be 6 feet, 2 inches. She stated she reported this weight to the resident ' s nurse immediately after the resident was weighed. This weight recorded by the restorative CNA revealed a third weight discrepancy in 24 hours. In an interview with LPN B on 5/3/12 at 12:52, she stated she handled resident #1 ' s admission orders [REDACTED]' s attending physician. She said he had a thick bone structure, was tall but she could tell he had lost weight since his previous admission. She stated nobody weighed him while she was there on 4/6/12 and she left at approximately 7:00p.m. Review of resident #1 ' s Interim Admission Care Plan, dated 4/9/12, revealed the resident was at risk for nutrition/dehydration problems related to a dependency on a PEG tube. The following relevant intervention was listed: Dietary assessment on admission and as needed. Review of the resident ' s record revealed no nutrition assessment or dietary notes had been completed, yet during the resident ' s stay from 4/6/12 - 4/10/12, despite the recording of three different weights with a discrepancy of approximately 30 lbs. and 2 different heights with a discrepancy of 10 inches. If the resident was truly 145.8 lbs., or approximately 66.2 kilograms (kg.), then 30 calories per kg. and 30 ml. per kg of fluid may not have been appropriate for a metabolically stressed resident. Furthermore, review of hospital emergency room nurse ' s notes on 4/10/12 at 12:54 p.m. revealed a fourth weight of 120 lbs. The care plan was not followed to obtain a dietician assessment. In an interview with the Director of Nurses (DON) on 5/3/12 at 11:10 a.m., she confirmed there was no dietary assessment in the record during the resident ' s stay. She stated they had recently employed a consultant company to provide RD services. The DON stated that the RD who was working at the facility during the time of resident #1 ' s stay was on a cruise and was not available for an interview. There is no evidence that the physician and/or the ARNP were made aware of the resident ' s weight loss. A review of resident ' s monthly Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s note, dated 4/7/12 at 1:30 a.m. revealed "GT feeding initiated". There was no documentation in the record to indicate why the feeding was not started immediately after confirming the physician's orders [REDACTED]. This was approximately 7 to 8 hours that the resident did not receive any food or water after admission on 4/6/12 at 5:58 p.m. The interim care plan, dated 4/9/12, stated to provide peg tube feeding and water per physician's order [REDACTED]. In an interview with the DON on 5/3/12 at 11:10 a.m., she stated they have tube feeding formulas on hand and would have had Glucerna 1.5. She did not know why the tube feeding for resident #1 was not started until 1:30 a.m. 4/7/12 approximately 7 -7/1/2 hours after admission. The plan of care with admission date of [DATE] listed relevant interventions under the [DIAGNOSES REDACTED]. Further interventions listed under at risk for dehydration included: monitor vital signs as ordered and notify the physician of significant abnormalities. Interventions listed under contact isolation for [MEDICAL CONDITION] infection were: monitor for weakness, fever, give medications and treatments per physician's order [REDACTED]. Review of the nursing note (handwritten) for 4/10/12 (no time documented) by LPN A stated: Resting in bed, respirations labored and resident ' s head of bed up at 45 degrees, resident congested and on contact isolation in a private room and services brought to the room. GT feeding flushes well without difficulties. Placement verified and no residual at this time. Review of the Daily Labor Report and staffing sheet revealed LPN A was scheduled to work on 4/9/12 at 7:00 p.m. until 4/10/12 at 7:00 a.m. Continued review of the record revealed that respirations of 20 were documented in the computerized record on 4/10/12 at 4:08 a.m. No additional vital signs were documented and no additional notes could be found regarding an assessment of the resident despite the notation by the 7:00 p.m. to 7:00 a.m. nurse of labored respirations and congestion. There is no documentation in the record of any care that was provided for the resident by this nurse for the labored breathing and the congestion. There was no evidence the physician was contacted regarding the significant change in the resident ' s respiratory condition. A review of the physician's admission orders [REDACTED]. A review of the April MAR indicated [REDACTED]. The care plan interventions were not followed. In an interview with LPN A on 4/24/12 at 3:30 p.m., she stated that she had worked the night of 4/9/12 on the 7:00 p.m. to 7:00 a.m. shift and was assigned to resident #1. She stated she did not give a breathing treatment to the resident and does not remember him being unusually warm. She stated the vital signs were done. In a second interview on 4/25/12 at 12:00 p.m. with LPN A., the nurse stated she had noticed resident #1 was congested and had labored breathing at about 4:00-5:00 a.m. The LPN stated she did not give him a breathing treatment because she did not think it would help because he was "too wet". She was unable to say what she meant and seemed confused about the question. She stated the resident had felt a little warm, but she did not take his vital signs at that time because someone had already taken them earlier in the shift. (Review of the handwritten notes dated 4/10/12 with no time documented revealed vital signs of temperature 97.1 pulse 75, respirations 18 and blood pressure 130/60). The nurse stated she put the head of the bed up and she checked on him frequently. She was unable to say how frequently or what she was checking. She said he had on oxygen at 2 liters per nasal cannula. LPN A stated she did not call the physician because she did not know the resident and was not sure if this was the way he was. She stated she told the oncoming day shift nurse about the resident's condition and left the facility at about 8:00 a.m. The nurse ' s statements were fragmented and hard to follow and she did not seem to understand the significance of the situation. In a telephone interview with LPN F on 5/8/12 at 11:47 a.m., it was revealed that she had worked with LPN A on the 4/9/12, 7:00 p.m. to 4/10/12 7:00 a.m. shift. She stated she was not notified or aware of any problems with resident #1. She recalled his door being closed due to isolation precautions. She was surprised to learn of the condition of resident #1 because she did not know anything was wrong until 5/3/12 when interviewed by the DON. The interview with LPN F confirmed that LPN A did not seek assistance from her the night of 4/10/12. LPN F revealed that the resident ' s door was closed further limiting the nurse ' s ability to assess the condition of the resident when he was having difficulty breathing. It was unclear why the door was closed for resident #1 for contact isolation. Review of the Centers for Disease Control (CDC) 2007 Guidelines for Isolation Precautions in Health Care Settings does not list closing the door as a recommendation for a resident on contact precautions and would only be used if a resident was on a form of airborne precautions. Review of resident #1 ' s interim care plan dated 4/9/12 stated that the resident would have no complications related to [MEDICAL CONDITION]. Interventions listed were: observe for weakness, dehydration, and fever, administer medications and treatments per physician's order [REDACTED]. The nurse did not follow the plan of care when the resident had a significant decline as there is no record that the resident ' s temperature was taken and no record of any breathing treatments provided including a denial of giving a breathing treatment by LPN A in 2 separate interviews. Review of a handwritten nurse ' s note by LPN D on 4/10/12 at 7:30 a.m. stated: congestion noted, increased respirations, blood pressure normal, oxygen saturation level at 87% (it was not specified if the resident was on oxygen or room air). The physician was notified and orders were received to send the resident to the hospital. According to the interview with LPN A on 4/25/12, the congestion and labored breathing was first observed between 4:00 a.m.-5:00 a.m. Based on this information it was approximately 4 hours that treatment was delayed. The next nurse ' s note on 4/10/12 at 7:45 a.m. stated the resident was transferred to the hospital. A review of the "Resident Hospital Transfer Form", completed by LPN B prior to transfer dated 4/10/12, no time documented, indicated the resident's temperature was 105 degrees by axilla and the pulse was 100 beats per minute. There was no blood pressure or respirations recorded. The [DIAGNOSES REDACTED]. The reason for transfer was noted as change in level of consciousness and decreased oxygen saturation. An interview was conducted on 4/24/12 at 3:00 p.m. with LPN D assigned to take care of the resident during the 7:00 a.m. to 3:00 p.m. (7-3), shift on 4/10/12. LPN D stated that in the shift to shift report at 7:00 a.m., the night nurse stated she had been giving him breathing treatments because of congestion. This statement is in direct conflict with what LPN A stated to the surveyor in 2 separate interviews in which she stated she did not give a breathing treatment on the night of 4/10/12. There were no signatures on the MAR indicated [REDACTED]. Nurse notes documented on this resident include time discrepancies. In a subsequent interview with LPN D on 5/3/12/ at 1:36 p.m., it was revealed that she had cared for resident #1 on 4/9/12 on the 7:00 a.m. - 7:00 p.m. shift. On 4/9/12 his temperature was fine and he was sitting up. He showed no signs of distress and his vital signs were stable. She could not recall if he used oxygen and couldn ' t recall giving him any breathing treatments on that shift. LPN D stated nothing of any consequence happened on that shift. Continued interview with LPN D revealed that she came to work on 4/10/12 at about 7:20 a.m. She stated she and LPN A did the narcotics count. Following the narcotic count LPN D and LPN A went on walking rounds. LPN D stated resident #1 sounded congested but nothing severe. The head of the bed was up. After completing walking rounds LPN D went back to resident #1 ' s room by herself to check on him. She stated this was probably around 7:30 - 7:45 a.m. She said " I looked at him and could just hear the congestion " , so she went and got the wound care nurse LPN C, and then LPN C went to get the ADON. LPN D stated the other nurses were doing everything. LPN D stated she put the breathing medication into the nebulizer machine but the ADON put the mask on and administered the treatment. After this LPN D was in and out of the room because she needed to start medication pass. She could not recall when he went to the hospital and she was not present when they took his vital signs. LPN D was asked about her nurse ' s note dated 4/10/12 at 7:30 a.m. stating the blood pressure was normal. She could not recall what it was or who took it. She stated somebody had to have taken it for her to write it down. LPN D also stated she realized now that she didn ' t get to the facility until 7:20 a.m. on 4/10/12 so her times on the documentation were probably not right. Further interview with LPN D at 2:10 p.m. on 5/3/12 revealed she did not notice any wetness or odors, just congestion. In an interview with LPN C on 5/4/12 at 1:19 p.m., she stated she was the wound care nurse and she went to see resident #1 to evaluate his wounds on the morning of 4/10/12. She stated she usually works 6:00 a.m. - 2:00 p.m. but she thinks she was it was around 7:00 a.m. when she first saw resident #1 on 4/10/12. LPN D had been in before her and LPN C said she knew something was going on because she had overheard their shift report. LPN C noticed resident #1 ' s breathing was labored and his respirations were increased. The ADON was walking past so LPN C asked her to come in. She said the ADON was working up top and she was undressing his right leg wound. She said his legs didn ' t feel warm at all. She does not think there was oxygen on him in conflict with interviews with ADON and LPN D. She thinks they came in and put oxygen on him around 7:30 a.m. - 7:45 a.m. She checked the oxygen saturation level after applying the pulse oximeter and recalled it was in the 70 ' s. LPN C did not know who took his vital signs. LPN C stated they turned his tube feeding off and the head of bed was elevated. We did do a blood sugar (BS) test on him and it was 200 something. She said she remembers it wasn ' t too high or too low. She thinks LPN D did the BS but was not certain. LPN C could not describe resident #1 ' s color as he was a dark skinned man. LPN C stated he did open his eyes when you called his name, but did not verbally respond. She didn ' t notice if they gave him a breathing treatment. She does not recall any odor or indications that he was in need of incontinence care. An interview was conducted with the Assistant Director of Nurses (ADON) on 4/24/12 at 2:40 p.m. The ADON stated she was present on 4/10/12 at 7:30 a.m., when resident was transferred to the hospital. She stated the head of the bed was elevated and the resident was experiencing abnormal breath sounds. The ADON stated she gave him a breathing treatment. Yet, there was no documentation of the breathing treatment having been given in the record. The ADON stated the tube feeding was off and the resident's oxygen saturation level was going up and down. The resident's eyes were open but he was not responding. She stated they took vital signs and he had a temperature but she could not remember what it was. In an interview on 5/3/12 at 12:53 p.m. with LPN B., she stated on the morning of 4/10/12 she heard LPN D saying resident #1 needed to go to the hospital. LPN B stated she went to resident #1 ' s room to assist. She noticed the ADON administering a breathing treatment, he was receiving oxygen, and had a pulse oximeter on his finger which had a reading that was fluctuating " 40, 60, and would go up into the 80 ' s " . She said he had increased respirations, but he was not gasping for air. He would look at you but did not respond verbally. In the past, this resident would speak in a real soft voice. She recalled asking if anybody got his vitals. One of the C.N.A.s came in and took his temperature; however, she could not recall the name of this C.N.A. LPN B recorded the temperature as 105 degrees Fahrenheit per axillary. After that she went to the desk to prepare his transfer forms and called the doctor. LPN B stated she informed the ARNP that the resident was receiving a breathing treatment, had a temperature of 105 with fluctuating oxygen saturations, and was in an unstable condition. LPN B stated she told the ARNP the resident needed to go to the emergency room . She thinks that this occurred before 8:00 a.m. but was not exactly sure of the time. LPN B could not recall what time the ambulance arrived. Review of the Emergency Medical Services (EMS) run report for resident #1 revealed that they arrived at the hospital on [DATE] at 9:11 a.m. According to the EMS narrative notes .... " Staff stated that at shift change the patient complained of difficulty breathing. Staff stated that the patient had a temperature 105 degrees F, and that patient was being treated for [REDACTED]. Upon assessment patient found to be in [MEDICAL CONDITION], SPO2 reading was 78% on non rebreather mask, Glasgow Coma Scale (GCS) was a 6 with labored respirations. Secondary revealed skin hot, pink, very dry ... ....pupils sluggish and unequal, lung sounds rhonchi throughout ... facilitated intubation and ventilations were assisted. " A review of the Hospital face sheet revealed a registration time of 4/10/12 at 9:16 a.m. A review the Emergency Physician record dated 4/10/12 revealed the resident, who had been intubated prior to arrival in the ER, was initially hypotensive with a systolic blood pressure of 70. The patient ' s temperature was 107 F rectally. On physical exam, patient with unequal pupils, sent to CT which revealed chronic changes. Chest x-ray showed the endotracheal tube was in good position however the patient had a right pneumothorax, a chest tube was place immediately and the resident was placed on a ventilator. Review of the resident ' s interim care plan, dated 4/9/12, found reference to impaired skin integrity with interventions including: Keep clean and dry after each incontinence episode. The care plan for incontinence was not followed as evidenced by the report from the emergency department. Review of the hospital emergency department nurse's documentation, dated 4/10/12, performed at 9:19 a.m. stated in capitalized letters that the resident was " SOAKED IN URINE THAT APPEARS FOR A PROLONGED PERIOD OF TIME; DIAPER WAS SOAKED IN ENTIRETY, BROWN IN COLOR, STRONG ODOR OF AMMONIA, AND THE BOTTOM SHEET WAS SOAKED AS WELL WITH A HUGE RING AROUND THE PATIENT- APPEARS TO HAVE BEEN THERE FOR A LONG PERIOD OF TIME. WHEN ROLLED, A USED ANGIOCATH WAS STUCK TO THE BACK OF THE PATIENT ' S RIGHT LEG AND HAD A DATE OF 3/16/12 ATTACHED TO CATH " . The entry went on to say that this situation was reported to the charge nurse and the social worker. A review of the Emergency Medical Services (EMS) report, dated 4/10/12, revealed the call from the facility was received at 8:38 a.m. on 4/10/12 and the ambulance arrived at the facility at 8:41 a.m. The documented time of transport was 9:03 a.m. This was conflicting with the facility ' s documentation of sending the resident out of the building at 7:45 a.m. This would mean an additional hour in delay of treatment from 4:00 -5:00 a.m. to 8:38 a.m. In an interview with the DON on 5/2/12 at 6:15 p.m. and the Administrator who was on speakerphone, they both stated that they had not investigated the care of resident #1 related to the unusually high temperature of 105 degrees. The response from the DON was, " He was very sick, we did what we were supposed to do. The ABCs. ( basics) What more could we have done? " Upon surveyor ' s arrival at the facility on 5/3/12 at 9:00 a.m., an interview was conducted with the DON and the Administrator. They said they started their investigation at 5:00 a.m. and contacted by phone or in person all of the staff nurses who worked in the facility on 4/9/12 at 7:00 p.m. through 4/10/12 when the resident was sent to the hospital. Documentation of these interviews revealed the following: LPN A: report received with walking rounds, resident observed to be stable. No respiratory distress. Temperature 97.1, blood pressure 130/60, pulse 75, respirations 18. 5am-7am: later during shift primary nurse observed resident to be congested, respirations increased, oxygen applied and breathing treatment provided on the shift. This documentation provided by the facility on 5/3/12 was in direct conflict with 2 prior surveyor interviews conducted on 4/24/12 and 4/25/12 stating that a breathing treatment was not given and conflicts with clinical record documentation. The DON and the Administrator confirmed in this interview that LPN A ' s recollection of events is inconsistent and has changed during multiple interviews. In an interview on 5/4/12 at 1:55 p.m. with the resident ' s attending physician, he stated that the resident had a history of [REDACTED]. He stated that the resident is at a long term care hospital on a ventilator. He stated that when the resident went to the hospital on 4/10, his temperature was 107 and that he was diagnosed with [REDACTED]. He also stated that the resident was intubated in the field so that may have caused the pneumothorax but he could not be sure. He also said he did not know about the weight discrepancies and that the weights may have been different because of how they were obtained. He was not contacted on the morning of 4/10/12. In an interview with the DON on 5/3/12 at approximately 9:30 a.m. revealed they had initiated in servicing and staff education on 4/24/12 which was on-going with all registered and licensed nurses. Review of the in-service materials revealed education was provided in the following areas: Nursing assessment data to include a discussion on the responsibility of assessing a resident on admission, in accordance with the plan of care, when a clinical change in condition occurs and upon discharge. Subjective and objective documentation in accordance with the patient ' s status. Professional standards and services must be provided to residents in accordance with their plan of care with follow up documentation to include interventions of services and notification of any clinical changes. It is the licensed direct care staff member ' s responsibility to utilize professional standard and skills during clinical observation, reporting and documentation. Notifications of clinical changes to the physician and the responsible party. The use of the SBAR assessment tool as a method for communicating with the physician and other allied licensed health care professionals. *Situation - briefly state the problem. Nurse assessment of the situation. *Background - Pertinent patient information in the clinical picture of the patient. *Assessment - What are your assessment and/or observation of the patient clinical status? What interventions do you currently have in place? *Recommendation - What are your recommendations in meeting the patient ' s needs? What do you need to care for the patient? Review of the in-service sign in records on 5/3/12 at approximately 4:30 p.m. revealed 17 of the 19 regularly scheduled nurses had received the in-service training. Interview with the DON revealed one of these nurses had received the training but had not signed the attendan

Based on staff interview and facility record review, it was determined that the facility failed to monitor, assess, provide necessary care and services, and follow physician's order [REDACTED]. The facility did not perform physician ordered blood sugar testing and provide insulin if needed on the resident who was diabetic. This practice involved three different nurses who did not follow the orders and check the resident ' s blood sugar when due on their shift. The nurses did not notify the dietician or the physician of an approximate 30 pound weight loss on admission for resident #1 who had dysphagia (unable to swallow safely) and could not consume anything by mouth. Resident #1 was completely dependent on the staff for all food and water which was given to him through a feeding tube and was not initiated for 7-8 hours after admission. The facility did not assess the resident ' s respiratory function and take vital signs including a temperature for resident #1 (who had a [MEDICAL CONDITION] infection) when the resident exhibited signs and symptoms of a declining condition including congestion and labored breathing. The facility did not administer medication that may have relieved some of the resident ' s breathing distress and was ordered by the physician to be given if the resident was short of breath. The facility did not call the physician when the resident (who was readmitted with multiple medical problems and was known to the staff from a prior admission) first exhibited labored breathing and congestion to obtain orders on how to provide care and prevent a significant decline in condition. The facility did not provide incontinence care to the resident who had a sacral wound leaving the resident soaked in an ammonia smelling brief and sheets. The investigation revealed resident #1 was in [MEDICAL CONDITION] upon the arrival of paramedics to the facility and required intubation and assisted ventilations while en route to the hospital. The resident arrived at the emergency room with a temperature of 107 degrees, required a chest tube to be inserted as a result of a pneumothorax, became dependent for breathing on a ventilator and was diagnosed with [REDACTED]. Findings include: Review of the Admission Record revealed resident #1 was a [AGE] year old male, well known to the facility from a prior admission on 10/24/11. A review of the nursing notes revealed the resident was most recently readmitted via ambulance on 4/6/12 at 5:58 p.m. A review of the Accumulative [DIAGNOSES REDACTED]. Coli) urinary tract infection [MEDICAL CONDITION], urosepsis, [MEDICAL CONDITION], hypokalemia, diastolic heart failure, sacral and lower extremity wounds, [MEDICAL CONDITION], Percutaneous enteral [MEDICAL CONDITION] tube (Peg Tube), dysphagia, [MEDICAL CONDITION] ([MEDICAL CONDITION].) [MEDICAL CONDITION] infection and [MEDICAL CONDITION]. A review of the computerized admission Progress Note completed by a Licensed Practical Nurse (LPN B) revealed this resident was admitted on [DATE] at 5:58 p.m. via stretcher accompanied by paramedics ....meds verified with advanced registered nurse practitioner (ARNP), transcribed, and faxed to pharmacy. A review of the computerized Nursing Admission assessment dated [DATE] revealed the resident had severely impaired cognitive skills, was totally dependent on staff for care, was receiving all nutrition and hydration from a feeding tube and had a [MEDICAL CONDITION]. It stated the resident had a recorded admission height of 62 inches and a recorded weight of 142.0 pounds. The assessment also stated that the resident was admitted with an open area to the right heel measuring approximately 4.5 centimeters (cm.) in width, an open area to the right great toe a quarter in size and coccyx wound measuring 6 cm. by 8 cm. This was accompanied by three dime to quarter size areas [MEDICAL CONDITION]. The left lower front leg had a slightly larger than golf ball size diameter size lesion with irregular border. The resident's admission physician orders [REDACTED].= 0 units, 151-200= 3units, 201-250= 6 units, 251-300= 9 units, 301-350= 12 units, 351-400= 15 units, and 401-450= 18 units. If blood sugar tests greater than 450 give 21 units and call medical doctor. If blood sugar less than 60, give [MEDICATION NAME]. A review of the monthly April Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the nursing schedule and nurse ' s notes revealed that three different nurses failed to follow these physician orders. On 4/10/12 at 6:30 a.m. during the time resident #1 was exhibiting labored breathing and congestion, the nurse did not assess the resident ' s blood sugar level. The MAR indicated [REDACTED]. Further review of the admission physician's admission orders [REDACTED]. It stated to flush the feeding tube with 200 ml. of water every shift (every eight hours). It also stated to flush the tube with 50 ml. of water before and after administration of medications. (This resident received medication 4 times a day for a total of an additional 400 ml. of water.) These tube feeding orders originated from the medication list sent from the hospital on [DATE]. This information from the discharge medication list dated 4/6/12 from the hospital also stated the resident ' s weight was 175.3 pounds (lbs.) and his height was 72 inches. The admission nursing assessment dated [DATE] documented the resident weighed 142 pounds and a height of 62 inches in direct conflict with the data from the hospital. In an interview on 5/3/12 at 10:53a.m., with the ARNP for resident ' s attending physician, she stated they have 10 to 12 ARNPs and one PA. She stated she had been assigned to this facility about 2 months, but she was not familiar with this resident. He was assigned to another ARNP at the hospital. She stated she thought the nursing facility had called her to verify his orders on admission 4/6/12, which was a Friday. She stated their normal procedure is to read off the orders from the hospital ' s medication reconciliation record. She lets them know if things need to be adjusted. She stated she never came in to see this resident because he was only there for 5 days and she normally visits on Thursdays. She stated the nurses would have read her the tube feeding orders but not the resident ' s weight. She could not recall if she asked the Registered Dietician (RD) to assess the resident right away. She said if she were informed of a weight discrepancy from the hospital of 175 lbs. and from the nursing home of 142 pounds, she would ask how the resident was weighed in the hospital and in the facility. She would ask them to reweigh the resident for a couple of days in the same way and have the dietitian look at them. The ARNP stated her expectation would be that the RD would see a resident with a tube feeding within a couple of days of admission or at least be called to let the RD know what the orders and weight are. Then the RD could decide if the orders need to be adjusted. Interview on 5/3/12 at 11:34 a.m. with the restorative C.N.A. responsible for recording weights revealed documentation of a weight completed on 4/7/12 of 145.8 lbs. The C.N.A. revealed she weighed him on the hoyer lift in the morning and checked his height to be 6 feet, 2 inches. She stated she reported this weight to the resident ' s nurse immediately after the resident was weighed. This weight recorded by the restorative CNA revealed a third weight discrepancy in 24 hours. In an interview with LPN B on 5/3/12 at 12:52, she stated she handled resident #1 ' s admission orders [REDACTED]' s attending physician. She said he had a thick bone structure, was tall but she could tell he had lost weight since his previous admission. She stated nobody weighed him while she was there on 4/6/12 and she left at approximately 7:00 p.m. The day before resident #1 was admitted this nurse recalled telling the RD that resident #1 was expected to return to the facility. LPN B stated she called the RD on 4/6/12 and read off his tube feeding orders from the hospital. She could not recall the RD asking for a weight, she just remembered her saying something like continue with the hospital orders. Review of resident #1 ' s Interim Admission Care Plan dated 4/9/12 revealed Resident #1 was at risk for nutrition/dehydration problems related to a dependency on a PEG tube. The following relevant intervention was listed: Dietary assessment on admission and as needed. Review of the resident ' s record revealed no nutrition assessment or dietary notes had been completed during the resident ' s stay from 4/6/12 - 4/10/12, despite the recording of three different weights with a discrepancy of approximately 30 lbs. and 2 different heights with a discrepancy of 10 inches. If the resident was truly 145.8 lbs., or approximately 66.2 kilograms (kg.), then 30 calories per kg. and 30 ml. per kg of fluid may not have been appropriate for a metabolically stressed resident. Furthermore, review of hospital emergency room nurse ' s notes on 4/10/12 at 12:54 p.m. revealed a fourth weight of 120 lbs. The Accumulative [DIAGNOSES REDACTED]. In an interview with the Director of Nurses (DON) on 5/3/12 at 11:10 a.m., she confirmed there was no dietary assessment in the record during the resident ' s stay. She stated they had recently employed a consultant company to provide RD services. The DON stated that the RD who was working at the facility during the time of resident #1 ' s stay was on a cruise and was not available for an interview. The DON stated in the interview on 5/3/12 at 11:10 a.m. that the RD completed a nutrition risk screening on 4/12/12; however, this resident had been discharged to the hospital 2 days prior to this screening. This nutrition risk screening was reviewed and it was completed 4/12/12 using a resident weight of 175 pounds. This revealed further problems with documentation accuracy, times, and delays impacting the care of the resident. In an interview with the facility ' s current RD consultant on 5/4/12 at 1:35 p.m., she stated she was familiar with long term care, but did not know resident #1. She stated it was the facility ' s procedure to call her when a resident with a tube feeding was admitted . She would ask their diagnoses, history, gender, height, weight, and if they have any issues like pressure ulcers, and if the tube feeding was new for the resident. The RD stated she needs the weight to assess the tube feeding accurately. There are a lot of variables, so she would have to look at each situation. She stated she would get a brief review to get a picture of the situation and then make a recommendation. In an interview on 5/4/12 at 1:30 p.m. with the Administrator, a policy on what would be expected of the dietician regarding assessment of a resident with a tube feeding was requested. She produced a policy about being able to write orders for tube feedings. It did not address expectations regarding how soon an assessment should be done and she stated that was all they had. She brought a job description entitled Registered Dietician and dated 10/1/03 that stated in a bulleted list: assesses resident ' s nutritional needs and confers with clinical staff to coordinate patients ' nutritional intake. A review of resident ' s monthly Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s note, dated 4/7/12 at 1:30 a.m. revealed "GT feeding initiated". There was no documentation in the record to indicate why the feeding was not started immediately after confirming the physician's orders [REDACTED]. This was approximately 7 to 8 hours that the resident did not receive any food or water after admission on 4/6/12 at 5:58 p.m. In an interview with the DON on 5/3/12 at 11:10 a.m., she stated they have tube feedings formulas on hand and would have had Glucerna 1.5. She did not know why the tube feeding for resident #1 was not started until 1:30 a.m. 4/7/12. A review of the computerized Weights and Vital Summary notes dated 4/9/12 revealed the vital signs at 3:30 p.m. were blood pressure 118/69, temperature 98.2 degrees Fahrenheit, pulse 70 and respirations 20. It was documented in the handwritten notes by LPN E on 4/9/12 at 9:00 p.m. that resident #1was resting in bed. Respirations even and unlabored. Tube feeding tolerated well. Contact isolation maintained. Resident in private room with services brought in for [MEDICAL CONDITION]. Review of LPN E ' s Time Detail report revealed that she punched in at 2:32 p.m. and out at 8:00 p.m. Another handwritten nurse's note by LPN D after this one dated 4/9/12, (with no time), documented: Resident resting in bed. No S/S of distress, no complaint of pain at present. Glucerna 1.5 infusing at 80 cc/hr. Tolerating well. [MEDICAL CONDITION] intact. Remains on contact isolation for [MEDICAL CONDITION]. All services performed in room. Will continue to monitor. Review of the Time Detail report for LPN D revealed she worked 4/9/12 from 7:08 a.m. -7:53p.m. A review of the next nursing note (handwritten) for 4/10/12 (no time documented) by LPN A stated: Resting in bed, respirations labored and resident ' s head of bed up at 45 degrees, resident congested and on contact isolation in a private room and services brought to the room. GT feeding flushes well without difficulties. Placement verified and no residual at this time. Review of the Daily Labor Report and staffing sheet revealed LPN A was scheduled to work on 4/9/12 at 7:00 p.m. until 4/10/12 until 7:00 a.m. Continued review of the record revealed that respirations of 20 were documented in the computerized record on 4/10/12 at 4:08 a.m. No additional vital signs were documented and no additional notes could be found regarding an assessment of the resident despite the notation by the 7:00 p.m. to 7:00 a.m. nurse of labored respirations and congestion. There is no documentation in the record of any care that was provided for the resident by this nurse for the labored breathing and the congestion. There was no evidence the physician was contacted regarding the significant change in the resident ' s respiratory condition. In an interview on 5/4/12 at 1:55 p.m. with the resident ' s attending physician, he stated that the resident had a history of [REDACTED]. He stated that when the resident went to the hospital on [DATE], his temperature was 107 and he was diagnosed with [REDACTED]. He also stated that the resident was intubated in the field so that may have caused the pneumothorax but he could not be sure. He also said he did not know about the weight discrepancies and that the weights may have been different because of how they were obtained. He stated he was not contacted on 4/10/12. A review of the physician's admission orders [REDACTED]. A review of the April MAR indicated [REDACTED]. In an interview with LPN A on 4/24/12 at 3:30 p.m., she stated that she had worked the night of 4/9/12 on the 7:00 p.m. to 7:00 a.m. shift and was assigned to resident #1. She stated she did not give a breathing treatment to the resident and does not remember him being unusually warm. She stated the vital signs were done. The nurse was difficult to understand and seemed to have a hard time understanding the questions and expressing her answers. In a second interview on 4/25/12 at 12:00 p.m. with LPN A., the nurse stated she had noticed resident #1 was congested and had labored breathing at about 4:00-5:00 a.m. The LPN stated she did not give him a breathing treatment because she did not think it would help because he was "too wet". She was unable to say what she meant and seemed confused about the question. She stated the resident had felt a little warm, but she did not take his vital signs at that time because someone had already taken them earlier in the shift. (Review of the handwritten notes dated 4/10/12 with no time documented revealed vital signs of temperature 97.1 pulse 75, respirations 18 and blood pressure 130/60). The nurse stated she put the head of the bed up and she checked on him frequently. She was unable to say how frequently or what she was checking. She said he had on oxygen at 2 liters per nasal cannula. LPN A stated she did not call the physician because she did not know the resident and was not sure if this was the way he was. She stated she told the oncoming day shift nurse about the resident's condition and left the facility at about 8:00 a.m. The nurse ' s statements and train of thought were fragmented and hard to follow and she did not seem to understand the significance of the situation. In a telephone interview with LPN F on 5/8/12 at 11:47 a.m., it was revealed that she had worked with LPN A on the 4/9/12, 7:00 p.m. to 4/10/12 7:00 a.m. shift. She stated she was not notified or aware of any problems with resident #1. She was not assigned to resident #1 but recalled his door being closed due to isolation precautions. She stated they normally work together on that shift because there are only two nurses in the building. She was surprised to learn of the condition of resident #1 because she did not know anything was wrong until 5/3/12 when interviewed by the DON. LPN F revealed that the resident ' s door was closed further limiting the nurse ' s ability to assess the condition of the resident when he was having difficulty breathing. Review of resident #1 ' s interim care plan dated 4/9/12 stated that the resident would have no complications related to [MEDICAL CONDITION]. Interventions listed were: observe for weakness, dehydration, and fever, administer medications and treatments per physician's order [REDACTED]. Continued review of the clinical record revealed the following handwritten nurse note by LPN D 4/10/12 at 7:30 a.m.: congestion noted, increased respirations, blood pressure normal, oxygen saturation level at 87% (it was no specified if the resident was on oxygen or room air). The physician was notified and orders were received to transfer the resident to the hospital. The nurse ' s note prior to this one that documented the resident was congested and had labored breathing did not document when this first started. In the interview with LPN A on 4/25/12, she stated that she thought it was between 4:00 to 5:00 a.m., indicating there was an approximate 4 to 4/1/2 hour delay in treatment for [REDACTED]. The next nurse ' s note on 4/10/12 at 7:45 a.m. stated the resident was transferred to the hospital. A review of the "Resident Hospital Transfer Form", completed by LPN B prior to transfer dated 4/10/12, no time documented, indicated the resident's temperature was 105 degrees by axilla and the pulse was 100 beats per minute. There was no blood pressure or respirations recorded. The [DIAGNOSES REDACTED]. The reason for transfer was noted as change in level of consciousness and decreased oxygen saturation. In an interview and review of the Resident Hospital Transfer Form on 4/24/12 at approximately 3:00 p.m. with the Assistant Director of Nursing (ADON), LPN B and LPN D who were working the morning of 4/10/12, they stated the temperature on the transfer form must have been an error and should have been 100.5 degrees. They stated they could not recall who took the blood pressure, but LPN B stated she took resident #1 ' s temperature and filled out the transfer form. An interview was conducted on 4/24/12 at 3:00 p.m. with LPN D assigned to take care of the resident during the 7:00 a.m. to 3:00 p.m. (7-3), shift on 4/10/12. LPN D stated that in the shift to shift report at 7:00 a.m., the night nurse stated she had been giving him breathing treatments because of congestion. This statement is in direct conflict with what LPN A stated to the surveyor in 2 separate interviews in which she stated she did not give a breathing treatment on the night of 4/10/12. There were no signatures on the MAR indicated [REDACTED]. In fact no there were no signatures on the MAR indicated [REDACTED]. Nurse notes documented on this resident are very vague and time discrepancies are evident. In a subsequent interview with LPN D on 5/3/12/ at 1:36 p.m., it was revealed that she had cared for resident #1 on 4/9/12 on the 7:00 a.m. - 7:00 p.m. shift. On 4/9/12 his temperature was fine and he was sitting up. He showed no signs of distress and his vital signs were stable. She could not recall if he used oxygen and couldn ' t recall giving him any breathing treatments on that shift. LPN D stated nothing of any consequence happened on that shift. Continued interview with LPN D revealed that she came to work on 4/10/12 at about 7:20 a.m. She stated she and LPN A did the narcotics count. Following the narcotic count LPN D and LPN A went on walking rounds. LPN D stated resident #1 sounded congested but nothing severe. The head of the bed was up. After completing walking rounds LPN D went back to resident #1 ' s room by herself to check on him. She stated this was probably around 7:30 - 7:45 a.m. She said " I looked at him and could just hear the congestion " , so she went and got the wound care nurse LPN C, then LPN C went to get the ADON. LPN D stated the other nurses were doing everything. LPN D stated she put the breathing medication into the nebulizer machine but the ADON put the mask on and administered the treatment. After this LPN D was in and out of the room because she needed to start medication pass. She could not recall when he went to the hospital and she was not present when they took his vital signs. LPN D was asked about her nurse ' s note dated 4/10/12 at 7:30 a.m. stating the blood pressure was normal. She could not recall what it was or who took it. She stated somebody had to have taken it for her to write it down. LPN D also stated she realized now that she didn ' t get to the facility until 7:20 a.m. on 4/10/12 so her times on the documentation were probably not right. Further interview with LPN D at 2:10 p.m. on 5/3/12 revealed she did not notice any wetness or odors, just congestion. In an interview with LPN C on 5/4/12 at 1:19 p.m., she stated she was the wound care nurse and she went to see resident #1 to evaluate his wounds on the morning of 4/10/12. She stated she usually works 6:00 a.m. - 2:00 p.m. but she thought it was around 7:00 a.m. when she first saw resident #1 on 4/10/12. LPN D had been in before her and LPN C said she knew something was going on because she overheard their shift report. LPN C noticed resident #1 ' s breathing was labored and his respirations were increased. The ADON was walking past so LPN C asked her to come in. She said the ADON was working up top and she was undressing his right leg wound. She said his legs didn ' t feel warm at all. She did not think there was oxygen on him in conflict with interviews with ADON and LPN D. She thought they came in and put oxygen on him around 7:30 a.m. - 7:45 a.m. She checked the oxygen saturation level after applying the pulse oximeter and recalled it was in the 70 ' s. LPN C did not know who took his vital signs. LPN C stated they turned his tube feeding off and the head of bed was elevated. We did do a blood sugar (BS) test on him and it was 200 something. She said she remembers it wasn ' t too high or too low. She thought LPN D did the BS but was not certain. LPN C could not describe resident #1 ' s color as he was a dark skinned man. LPN C stated he did open his eyes when you called his name, but did not verbally respond. She didn ' t notice if they gave him a breathing treatment. She does not recall any odor or indications that he was in need of incontinence care. An interview was conducted with the Assistant Director of Nurses (ADON) on 4/24/12 at 2:40 p.m. The ADON stated she was present on 4/10/12 at 7:30 a.m., when resident was transferred to the hospital. She stated the head of the bed was elevated and the resident was experiencing abnormal breath sounds. The ADON stated she gave him a breathing treatment. Yet, there was no documentation of the breathing treatment having been given in the record. The ADON stated the tube feeding was off and the resident's oxygen saturation level was going up and down. The resident's eyes were open but he was not responding. She stated they took vital signs and he had a temperature but she could not remember what it was. In an interview on 5/3/12 at 12:53 p.m. with LPN B., she stated on the morning of 4/10/12 she heard LPN D saying resident #1 needed to go to the hospital. LPN B stated she went to resident #1 ' s room to assist. She noticed the ADON administering a breathing treatment, he was receiving oxygen, and had a pulse oximeter on his finger which had a reading that was fluctuating " 40, 60, and would go up into the 80 ' s " . She said he had increased respirations, but he was not gasping for air. He would look at you but did not respond verbally. In the past, this resident would speak in a real soft voice. She recalled asking if anybody got his vitals. One of the C.N.A. ' s came in and took his temperature; however, she could not recall the name of this C.N.A. LPN B recorded the temperature as 105 degrees Fahrenheit per axillary. After that she went to the desk to prepare his transfer forms and called the doctor. LPN B stated she informed the ARNP that the resident was receiving a breathing treatment, had a temperature of 105 with fluctuating oxygen saturations, and was in an unstable condition. LPN B stated she told the ARNP the resident needed to go to the emergency room . She thinks that this occurred before 8:00 a.m. but was not exactly sure of the time. LPN B could not recall what time the ambulance arrived. A review of the Emergency Medical Services (EMS) report, dated 4/10/12, revealed the call from the facility was received at 8:38 a.m. on 4/10/12 and the ambulance arrived at the facility at 8:41 a.m. The documented time of transport was 9:03 a.m. This was conflicting with the facility ' s documentation of sending the resident out of the building at 7:45 a.m. LPN A stated in interview that the resident exhibited labored breathing and congestion sometime between 4:00-5:00 a.m. Based on the EMS documentation that stated they arrived 8:41 a.m., this resident did not receive any documented care and services for approximately 4-5 hours after it was discovered that he had a significant change in condition. The EMS arrived at the hospital at 9:11 a.m. According to the EMS narrative notes .... " Staff stated that at shift change the patient complained of difficulty breathing. Staff stated that the patient had a temperature 105 degrees F, and that patient was being treated for [REDACTED]. Upon assessment patient found to be in [MEDICAL CONDITION], SPO2 reading was 78% on non rebreather mask, Glasgow Coma Scale (GCS) was a 6 with labored respirations. Secondary revealed skin hot, pink, very dry ... ....pupils sluggish and unequal, lung sounds rhonchi throughout ... facilitated intubation and ventilations were assisted. " A review of the Hospital face sheet revealed a registration time of 4/10/12 at 9:16 a.m. A review the Emergency Physician record dated 4/10/12, revealed the resident had been intubated prior to arrival in the ER, was initially hypotensive with a systolic blood pressure of 70. The patient ' s temperature was 107 F rectally. On physical exam, patient with unequal pupils, sent to CT which revealed chronic changes. Chest x-ray showed the endotracheal tube was in good position however the patient had a right pneumothorax, a chest tube was place immediately and the resident was placed on a ventilator. Review of the hospital emergency department triage report dated 4/10/12 at 9:24 a.m. revealed the resident ' s blood sugar was 300. The hospital emergency department nurse's documentation dated 4/10/12 performed at 9:19 a.m. stated in capitalized letters that the resident was " SOAKED IN URINE THAT APPEARS FOR A PROLONGED PERIOD OF TIME; DIAPER WAS SOAKED IN ENTIRETY, BROWN IN COLOR, STRONG ODOR OF AMMONIA, AND THE BOTTOM SHEET WAS SOAKED AS WELL WITH A HUGE RING AROUND THE PATIENT- APPEARS TO HAVE BEEN THERE FOR A LONG PERIOD OF TIME. WHEN ROLLED A USED ANGIOCATH WAS STUCK TO THE BACK OF THE PATIENT ' S RIGHT LEG AND HAD A DATE OF 3/16/12 ATTACHED TO CATH " . The entry went on to say that this situation was reported to the charge nurse and the social worker. In an interview with the DON on 5/2/12 at 6:15 p.m. and the Administrator who was on speakerphone, she stated the nurse who worked 7:00 p.m-7:00 a.m. on 4/10/12 had been suspended for not documenting appropriately. They both stated that they had not investigated the care of resident #1. The surveyor informed the facility of the resident ' s physical stated upon arrival in the emergency roiagnom on [DATE]. The response from the DON was, " He was very sick, we did what we were supposed to do. The ABCs. (basics) What more could we have done? " The surveyor asked if they had investigated the fact that he had a 105 degree temperature in the facility and the response was. " I thought we figured out that it was 100.5, not 105. The surveyor told them that the EMS documented that the facility nurse told them that the resident ' s temperature was 105. The administrator stated that another state agency had come out to the facility on [DATE] to investigate allegations of neglect. When asked if this event triggered an investigation by the facility, she said no. Upon surveyor ' s arrival at the facility on 5/3/12 at 9:00 a.m., an interview was conducted with the DON and the Administrator. They stated they came in at 5:00 a.m. and contacted by phone or in person all of the staff the nurses who worked in the facility on 4/9/12 at 7:00 p.m. through 4/10/12 when the resident was sent to the hospital. Docum

Based on staff interview and facility medical record review, it was determined that the facility failed to provide a medicated respiratory inhalation treatment to an elderly ([AGE] year old), frail dependent resident when the resident exhibited signs and symptoms of congestion and labored breathing for one (#1) of 13 sampled residents reviewed. The facility did not assess the resident ' s respiratory function including evaluating the resident ' s blood oxygen saturation level and taking vital signs when the resident first exhibited signs and symptoms of respiratory distress. The facility did not administer the medication that was ordered by the physician that may have relieved some of the resident ' s breathing distress. The facility left the resident, who was in isolation for an infection and having difficulty breathing, with the door to his private room closed. The facility did not call the physician when the resident (who was readmitted with multiple medical problems and was known to the staff from a prior admission) first exhibited labored breathing and congestion to obtain orders on how to provide care and prevent a significant decline in condition resulting in the following harm to the resident. The investigation revealed resident #1 was in [MEDICAL CONDITION] upon the arrival of paramedics to the facility approximately 4 hours after he started experiencing difficulty breathing and required intubation and assisted ventilations while en route to the hospital. The resident arrived at the emergency room and required a chest tube to be inserted as a result of a pneumothorax, became dependent for breathing on a ventilator and was diagnosed with [REDACTED]. Findings include: A review of the computerized admission Progress Note completed by a Licensed Practical Nurse (LPN B) revealed resident #1 was admitted to the facility on [DATE] at 5:58 p.m. via stretcher accompanied by paramedics ....meds verified with advanced registered nurse practitioner (ARNP), transcribed, and faxed to pharmacy. A review of the computerized Nursing Admission assessment dated [DATE] revealed the resident had severely impaired cognitive skills, was totally dependent on staff for care, was receiving all nutrition and hydration from a feeding tube and had a [MEDICAL CONDITION]. Review of the Admission Record revealed resident #1 was a [AGE] year old male well known to the facility from a prior admission on 10/24/11. A review of the Accumulative [DIAGNOSES REDACTED]. Coli) urinary tract infection [MEDICAL CONDITION], urosepsis, [MEDICAL CONDITION], hypokalemia, diastolic heart failure, sacral and lower extremity wounds, [MEDICAL CONDITION], Percutaneous enteral [MEDICAL CONDITION] tube (Peg Tube), dysphagia, [MEDICAL CONDITION] ([MEDICAL CONDITION].) [MEDICAL CONDITION] infection and [MEDICAL CONDITION]. In an interview on 5/3/12 at 10:53a.m., with the ARNP for the resident ' s attending physician, she stated she had been assigned to this facility about 2 months, but she was not familiar with this resident. He was assigned to another ARNP at the hospital. She stated she thought the nursing facility had called her to verify his orders on admission 4/6/12, which was a Friday. She stated their normal procedure is to read off the orders from the hospital ' s medication reconciliation record. She lets them know if things need to be adjusted. She stated she never came in to see this resident because he was only there for 4 days and she normally visits on Thursdays. In an interview with LPN B on 5/3/12 at 12:52, she stated she handled resident #1 ' s admission orders [REDACTED]' s attending physician. A review of the computerized Weights and Vital Summary notes dated 4/9/12 revealed the vital signs at 3:30 p.m. were blood pressure 118/69, temperature 98.2 degrees Fahrenheit, pulse 70 and respirations 20. It was documented in the handwritten notes by LPN E on 4/9/12 at 9:00 p.m. that resident #1 was resting in bed. Respirations even and unlabored. Tube feeding tolerated well. Contact isolation maintained. Resident in private room with services brought in for [MEDICAL CONDITION]. Review of LPN E ' s Time Detail report revealed that she punched in at 2:32 p.m. and out at 8:00 p.m. Another handwritten nurse's note by LPN D after this one dated 4/9/12, (with no time), documented: Resident resting in bed. No S/S of distress, no complaints of pain at present. Glucerna 1.5 infusing at 80 cc/hr. Tolerating well. [MEDICAL CONDITION] intact. Remains on contact isolation for [MEDICAL CONDITION]. All services performed in room. Will continue to monitor. Review of the Time Detail report for LPN D revealed she worked 4/9/12 from 7:08 a.m. -7:53p.m. A review of the next handwritten nursing note dated 4/10/12 revealed there was no time recorded of when the resident became congested and had labored breathing. The note was written by LPN A and stated: " 4/10/12 Resting in bed, respirations labored and resident ' s head of bed up at 45 degrees, resident congested and on contact isolation in a private room and services brought to the room. GT feeding flushes well without difficulties. Placement verified and no residual at this time. " Review of the Daily Labor Report and staffing sheet revealed LPN A was scheduled to work on 4/9/12 at 7:00 p.m. until 4/10/12 until 7:00 a.m. Continued review of the record revealed that respirations of 20 were documented in the computerized record on 4/10/12 at 4:08 a.m. No additional vital signs were documented and no additional notes could be found regarding an assessment of the resident ' s respiratory function despite the notation by the 7:00 p.m. to 7:00 a.m. nurse of labored respirations and congestion. A review of the physician's admission orders [REDACTED]. A review of the April MAR indicated [REDACTED]. There was no documentation in the record of any care that was provided for the resident ' s labored breathing and congestion. There was no evidence the physician was contacted regarding the significant change in the resident ' s respiratory condition. In an interview with LPN A on 4/24/12 at 3:30 p.m., she stated that she had worked the night of 4/9/12 on the 7:00 p.m. to 7:00 a.m. shift and was assigned to resident #1. She stated she did not give a breathing treatment to the resident. She stated the vital signs were done. In a second interview on 4/25/12 at 12:00 p.m. with LPN A., the nurse stated she noticed resident #1 was congested and had labored breathing at about 4:00-5:00 a.m. The LPN stated she did not give him a breathing treatment because she did not think it would help because he was "too wet". She was unable to say what she meant and seemed confused about the question. She stated the resident had felt a little warm, but she did not take his vital signs at that time because someone had already taken them earlier in the shift. (Review of the handwritten notes dated 4/10/12 with no time documented, revealed vital signs of temperature 97.1 pulse 75, respirations 18 and blood pressure 130/60). The nurse stated she put the head of the bed up and she checked on him frequently. She was unable to say how frequently or what she was checking. She said he had on oxygen at 2 liters per nasal cannula. LPN A stated she did not call the physician because she did not know the resident and was not sure if this was the way he was. She stated she told the oncoming day shift nurse about the resident's condition and left the facility at about 8:00 a.m. The nurse ' s statements and train of thought were fragmented and hard to follow and she did not seem to understand the significance of the situation. In a telephone interview with LPN F on 5/8/12 at 11:47 a.m., it was revealed that she had worked with LPN A on the 4/9/12, 7:00 p.m. to 4/10/12 7:00 a.m. shift. She stated she was not notified or aware of any problems with resident #1. She was not assigned to resident #1 but recalled his door being closed due to isolation precautions. She stated they normally work together on that shift because there are only two nurses in the building. She was surprised to learn of the condition of resident #1 because she did not know anything was wrong until 5/3/12 when interviewed by the DON. The interview with LPN F confirmed that LPN A did not seek assistance from her the night of 4/10/12. LPN F revealed that the resident ' s door was closed further limiting the nurse ' s ability to assess the condition of the resident when he was having difficulty breathing. It was unclear why the door was closed for resident #1 for contact isolation. Review of the Centers for Disease Control (CDC) 2007 Guidelines for Isolation Precautions in Health Care Settings does not list closing the door as a recommendation for a resident on contact precautions and would only be used if a resident was on a form of airborne precautions. Continued review of the clinical record revealed the following handwritten nurse note by LPN D 4/10/12 at 7:30 a.m.: congestion noted, increased respirations, blood pressure normal, oxygen saturation level at 87% (it was no specified if the resident was on oxygen or room air). The physician was notified and orders were received to transfer the resident to the hospital. LPN A stated in the interview on 4/25/12 that she noticed his labored breathing and congestion between 4:00 to 5:00 a.m., indicating there was an approximate 4 to 4/1/2 hour delay in treatment for [REDACTED]. The next nurse ' s note on 4/10/12 at 7:45 a.m. stated the resident was transferred to the hospital. A review of the "Resident Hospital Transfer Form", completed by LPN B prior to transfer dated 4/10/12, no time documented, indicated the resident's temperature was 105 degrees by axilla and the pulse was 100 beats per minute. There was no blood pressure or respirations recorded. The [DIAGNOSES REDACTED]. The reason for transfer was noted as change in level of consciousness and decreased oxygen saturation. An interview was conducted on 4/24/12 at 3:00 p.m. with LPN D assigned to take care of the resident during the 7:00 a.m. to 3:00 p.m. (7-3), shift on 4/10/12. LPN D stated that in the shift to shift report at 7:00 a.m., the night nurse stated she had been giving him breathing treatments because of congestion. This statement is in direct conflict with what LPN A stated to the surveyor in 2 separate interviews in which she stated she did not give a breathing treatment on the night of 4/10/12. There were no signatures on the MAR indicated [REDACTED]. In fact no there were no signatures on the MAR indicated [REDACTED]. In a subsequent interview with LPN D on 5/3/12/ at 1:36 p.m., it was revealed that she had cared for resident #1 on 4/9/12 on the 7:00 a.m. - 7:00 p.m. shift. On 4/9/12, he showed no signs of distress and his vital signs were stable. She could not recall if he used oxygen and couldn ' t recall giving him any breathing treatments on that shift. LPN D stated nothing of any consequence happened on that shift. Continued interview with LPN D revealed that she came to work on 4/10/12 at about 7:20 a.m. She stated she and LPN A did the narcotics count. Following the narcotic count LPN D and LPN A went on walking rounds. LPN D stated resident #1 sounded congested but nothing severe. The head of the bed was up. After completing walking rounds LPN D went back to resident #1 ' s room by herself to check on him. She stated this was probably around 7:30 - 7:45 a.m. She said " I looked at him and could just hear the congestion " , so she went and got the wound care nurse LPN C, then LPN C went to get the ADON. LPN D stated the other nurses were doing everything. LPN D stated she put the breathing medication into the nebulizer machine but the ADON put the mask on and administered the treatment. After this LPN D was in and out of the room because she needed to start medication pass. LPN D also stated she realized now that she didn ' t get to the facility until 7:20 a.m. on 4/10/12 so her times on the documentation were probably not right. In an interview with LPN C on 5/4/12 at 1:19 p.m., she stated she was the wound care nurse and she went to see resident #1 to evaluate his wounds on the morning of 4/10/12. She stated she thought it was around 7:00 a.m. when she first saw resident #1 on 4/10/12. LPN D had been in before her and LPN C said she knew something was going on because she overheard their shift report. LPN C noticed resident #1 ' s breathing was labored and his respirations were increased. The ADON was walking past so LPN C asked her to come in. She did not think there was oxygen on him in conflict with interviews with ADON and LPN D. She thought they came in and put oxygen on him around 7:30 a.m. - 7:45 a.m. She checked the oxygen saturation level after applying the pulse oximeter and recalled it was in the 70 ' s. LPN C did not know who took his vital signs. LPN C stated they turned his tube feeding off and the head of bed was elevated. LPN C could not describe resident #1 ' s color as he was a dark skinned man. LPN C stated he did open his eyes when you called his name, but did not verbally respond. She didn ' t notice if they gave him a breathing treatment. An interview was conducted with the Assistant Director of Nurses (ADON) on 4/24/12 at 2:40 p.m. The ADON stated she was present on 4/10/12 at 7:30 a.m., when resident was transferred to the hospital. She stated the head of the bed was elevated and the resident was experiencing abnormal breath sounds. The ADON stated she gave him a breathing treatment. Yet, there was no documentation of the breathing treatment having been given in the record. The ADON stated the tube feeding was off and the resident's oxygen saturation level was going up and down. The resident's eyes were open but he was not responding. She stated they took vital signs and he had a temperature but she could not remember what it was. In an interview on 5/3/12 at 12:53 p.m. with LPN B., she stated on the morning of 4/10/12 she heard LPN D saying resident #1 needed to go to the hospital. LPN B stated she went to resident #1 ' s room to assist. She noticed the ADON administering a breathing treatment, he was receiving oxygen, and had a pulse oximeter on his finger which had a reading that was fluctuating " 40, 60, and would go up into the 80 ' s " . She said he had increased respirations, but he was not gasping for air. He would look at you but did not respond verbally. In the past, this resident would speak in a real soft voice. She recalled asking if anybody got his vitals. One of the C.N.A. ' s came in and took his temperature; however, she could not recall the name of this C.N.A. LPN B recorded the temperature as 105 degrees Fahrenheit per axillary. After that she went to the desk to prepare his transfer forms and called the doctor. LPN B stated she informed the ARNP that the resident was receiving a breathing treatment, had a temperature of 105 with fluctuating oxygen saturations, and was in an unstable condition. LPN B stated she told the ARNP the resident needed to go to the emergency room . She thinks that this occurred before 8:00 a.m. but was not exactly sure of the time. LPN B could not recall what time the ambulance arrived. A review of the Emergency Medical Services (EMS) report, dated 4/10/12, revealed the call from the facility was received at 8:38 a.m. on 4/10/12 and the ambulance arrived at the facility at 8:41 a.m. The documented time of transport was 9:03 a.m. This was conflicting with the facility ' s documentation of sending the resident out of the building at 7:45 a.m. LPN A stated in interview that the resident exhibited labored breathing and congestion sometime between 4:00-5:00 a.m. Based on the EMS documentation that stated they arrived 8:41 a.m., this resident did not receive any documented care and services for approximately 4-5 hours after it was discovered that he had a significant change in condition. The EMS arrived at the hospital at 9:11 a.m. According to the EMS narrative notes .... " Staff stated that at shift change the patient complained of difficulty breathing. Staff stated that the patient had a temperature 105 degrees F, and that patient was being treated for [REDACTED]. Upon assessment patient found to be in [MEDICAL CONDITION], SPO2 reading was 78% on non rebreather mask, Glasgow Coma Scale (GCS) was a 6 with labored respirations. Secondary revealed skin hot, pink, very dry ... ....pupils sluggish and unequal, lung sounds rhonchi throughout ... facilitated intubation and ventilations were assisted. " A review of the Hospital face sheet revealed a registration time of 4/10/12 at 9:16 a.m. A review the Emergency Physician record dated 4/10/12 revealed the resident had been intubated prior to arrival in the ER, was initially hypotensive with a systolic blood pressure of 70. The patient ' s temperature was 107 F rectally. On physical exam, patient with unequal pupils, sent to CT which revealed chronic changes. Chest x-ray showed the endotracheal tube was in good position however the patient had a right pneumothorax, a chest tube was place immediately and the resident was placed on a ventilator. Review of the hospital emergency department triage report dated 4/10/12 at 9:24 a.m. revealed the resident ' s blood sugar was 300. In an interview with the DON on 5/2/12 at 6:15 p.m. and the Administrator who was on speakerphone, she stated the nurse who worked 7:00 p.m-7:00 a.m. on 4/10/12 had been suspended for not documenting appropriately. They both stated that they had not investigated the care of resident #1. The surveyor informed the facility of the resident ' s condition upon arrival in the emergency roiagnom on [DATE]. The response from the DON was, " He was very sick, we did what we were supposed to do. The ABCs. ( basics) What more could we have done? " The surveyor asked if they had investigated the fact that he had a 105 degree temperature in the facility and the response was. " I thought we figured out that it was 100.5, not 105 " . The surveyor told them that the EMS documented that the facility nurse told them that the resident ' s temperature was 105. The administrator stated that another state agency had come out to the facility on [DATE] to investigate allegations of neglect. When asked if this event triggered an investigation by the facility, she said no. Upon surveyor ' s arrival at the facility on 5/3/12 at 9:00 a.m., an interview was conducted with the DON and the Administrator. They stated they came in at 5:00 a.m. and contacted by phone or in person all of the staff the nurses who worked in the facility on 4/9/12 at 7:00 p.m. through 4/10/12 when the resident was sent to the hospital. Documentation of these interviews revealed the following: LPN A: report received with walking rounds, resident observed to be stable. No respiratory distress. Temperature 97.1 blood pressure 130/60, pulse 75, respirations 18. 5am-7am: later during shift primary nurse observed resident to be congested, respirations increased, oxygen applied and breathing treatment provided on the shift. This documentation provided by the facility on 5/3/12 was in direct conflict with 2 prior surveyor interviews conducted on 4/24/12 and 4/25/12, and clinical record documentation. Continued interview with the DON and the Administrator on 5/3/12 at about 9:00 a.m. confirmed that LPN A ' s recollection of events is inconsistent and has changed during multiple interviews. In an interview on 5/4/12 at 1:55 p.m. with the resident ' s attending physician, he stated that the resident had a history of [REDACTED]. He stated that the resident is at a long term care hospital on a ventilator. He stated that when the resident went to the hospital on [DATE], his temperature was 107 and that he was diagnosed with [REDACTED]. He also stated that the resident was intubated in the field so that may have caused the pneumothorax but he could not be sure. He was not contacted on the morning of 4/10/12. Interview with the DON on 5/3/12 at approximately 9:30 a.m. revealed they had initiated in servicing and staff education on 4/24/12 which was on-going with all registered and licensed nurses. Review of the in-service materials revealed education was provided in the following areas: Nursing assessment data to include a discussion on the responsibility of assessing a resident on admission, in accordance with the plan of care, when a clinical change in condition occurs and upon discharge. Subjective and objective documentation in accordance with the patient ' s status. Professional standards and services must be provided to residents in accordance with their plan of care with follow up documentation to include interventions of services and notification of any clinical changes. It is the licensed direct care staff member ' s responsibility to utilize professional standard and skills during clinical observation, reporting and documentation. Notifications of clinical changes to the physician and the responsible party. The use of the SBAR assessment tool as a method for communicating with the physician and other allied licensed health care professionals. *Situation - briefly state the problem. Nurse assessment of the situation. *Background - Pertinent patient information in the clinical picture of the patient.*Assessment - What are your assessment and/or observation of the patient clinical status? What interventions do you currently have in place? *Recommendation - What are your recommendations in meeting the patient ' s needs? What do you need to care for the patient? Review of the in-service sign in records on 5/3/12 at approximately 4:30 p.m. revealed 17 of the 19 regularly scheduled nurses had received the in-service training. Interview with the DON revealed one of these nurses had received the training but had not signed the attendance record. The DON contacted one of the nurses by phone and conducted the in-service on 5/3/12 at approximately 4:45 p.m. via telephone and the nurse who had not signed the attendance record was called in to provide her signature. Review of the Plan of action dated 5/4/12 revealed that re-education was provided to licensed direct care staff members on following physician orders [REDACTED]. Upon nursing observation, physician will be notified and informed of clinical changes to determine if further measures needed Telephone interviews were conducted with 6 of the 19 regularly scheduled nurses and were representative of all three shifts. All of the nurses were able to verbalize how they would respond when provided with a change in condition scenario. All nurses indicated they would assess the resident, obtain vital signs, check the record for orders, provide emergency treatments if needed, contact the physician for guidance and orders, and document accurately and completely in the clinical record. The nurses also stated that they have been re-in serviced on obtaining a height and weight for a tube fed resident upon admission and communicating this information along with the physician's order [REDACTED]. In addition, all the nurses were able to verbalize how they are monitoring the C.N.A. ' s to ensure proper care and services are being provided. Interview with the administrator on 5/4/12 at approximately 8:45 a.m. revealed she and the DON have decided to terminate the employment of LPN A. In addition, the administrator indicated that they have reviewed the incident involving resident #1 in the quality assurance meeting held on 4/24/12. Review of documentation provided by the administrator on 5/4/12 revealed the following plan was developed from the 4/24/12 QA meeting:*Licensed nurses re-educated on assessment and documentation skills.* No other residents were discharged during the timeframe of 4/6/12 - 4/10/12 *DON or designee will audit discharged charts in a timely manner and will randomly audit nurse documentation. *Results of findings will be discussed and reviewed by QA&A committee to determine systematic effectiveness for further quality improvement. The immediate jeopardy was determined removed on 5/3/12 and the scope and severity was reduced to a D.

Based on staff interview and record reviews including facility policies and procedures, the facility administrator failed to provide effective resource management to promote and ensure the highest practicable physical well-being for one of 13 sampled residents (#1) who was readmitted and physically compromised. Administration failed to provide administrative oversight to ensure care and services were provided to resident #1 during the four day period of residence (4/6-4/10/12) including failure of staff to assess the clinical condition and obtain vital signs for a resident who exhibited significant labored breathing and audible congestion; failure to administer medication ordered to be given in the event of shortness of breath; failure to inform the physician and a family member in a timely manner of a significant change in the resident's condition; failure to monitor blood glucose levels and provide insulin if needed per physician's order [REDACTED]. The investigation revealed resident #1 was not breathing adequately and required intubation while en route to the hospital from the facility. The resident arrived at the emergency room with a temperature of 107 degrees, required a chest tube to be inserted as a result of a pneumothorax and had to be admitted to the hospital and placed on a ventilator with a [DIAGNOSES REDACTED]. Following verification of the corrective measures instituted by the facility, immediate jeopardy was removed on May 3, 2012 and the scope and severity was reduced to a D. Findings include: A copy of the job description for the position of Administrator with an effective and revised date of 10/3/03 and signed by the administrator on 5/1/09 revealed the following relevant information: SUMMARY The incumbent is responsible for the overall management of a facility. Plans, develops, directs, monitors, and supports all operational, administrative, clinical, human resources, customer service and fiscal activities for the facility ' s programs and services. ESSENTIAL DUTIES AND RESPONSIBILITIES ... Ensures the quality and appropriateness of resident/patient care meets or exceeds company and regulatory standards. Ensures compliance with applicable legal, regulatory, accreditation and reimbursement guidelines and standards. Recruits, hires, provides orientation/training, and retains a sufficient number of qualified staff to carry out facility programs and services. Ensures employee performance meets or exceeds expectations ... Makes sure facility is a safe, clean, comfortable, and appealing environment for residents, patients, visitors and staff in accordance with company guidelines. Ensures all required records are maintained and submitted, as appropriate, in an accurate and timely manner. Review of the Admission Record for resident #1 revealed this was a [AGE] year old male well known to the facility from a prior admission on 10/24/11. A review of the nursing notes revealed the resident was most recently readmitted via ambulance on 4/6/12 at 5:58 p.m. A review of the Accumulative [DIAGNOSES REDACTED]. Coli) urinary tract infection [MEDICAL CONDITION], urosepsis, [MEDICAL CONDITION], hypokalemia, diastolic heart failure, sacral and lower extremity wounds, [MEDICAL CONDITION], Percutaneous enteral [MEDICAL CONDITION] tube (Peg Tube), dysphagia, [MEDICAL CONDITION] ([MEDICAL CONDITION].) [MEDICAL CONDITION] infection and [MEDICAL CONDITION]. A review of the computerized admission Progress Note completed by a Licensed Practical Nurse (LPN B) revealed this resident was admitted on [DATE] at 5:58 p.m. via stretcher accompanied by paramedics ....meds verified with advanced registered nurse practitioner (ARNP), transcribed, and faxed to pharmacy. A review of the computerized Nursing Admission assessment dated [DATE] revealed the resident had severely impaired cognitive skills, was totally dependent on staff for care, was receiving all nutrition and hydration from a feeding tube and had a [MEDICAL CONDITION]. It stated the resident had a recorded admission height of 62 inches and a recorded weight of 142.0 pounds. The assessment also stated that the resident was admitted with an open area to the right heel measuring approximately 4.5 centimeters (cm.) in width, an open area to the right great toe a quarter in size and coccyx wound measuring 6 cm. by 8 cm. This is accompanied by three dime to quarter size areas [MEDICAL CONDITION]. The left lower front leg had a slightly larger than golf ball diameter lesion with irregular border. The resident's admission physician orders [REDACTED].= 0 units, 151-200= 3units, 201-250= 6 units, 251-300= 9 units, 301-350= 12 units, 351-400= 15 units, and 401-450= 18 units. If blood sugar tests greater than 450 give 21 units and call medical doctor. If blood sugar less than 60, give [MEDICATION NAME]. A review of the monthly April Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the nursing schedule and nurse ' s notes revealed that three different nurses failed to follow these physician orders. Interview on 4/25/12 at 12:00 p.m. with LPN A., the nurse who was responsible for the care and treatment for [REDACTED].#1 was congested and had labored breathing at about 4:00-5:00 a.m. on 4/10/12. Review of resident #1 ' s April 2012 MAR indicated [REDACTED]' s orders. The MAR indicated [REDACTED]. Continued interview with LPN A on 4/25/12 at 12:00 p.m. revealed she was checking on resident #1 frequently due to the congestion and labored breathing; however, she was unable to say how frequently she checked on the resident and what she was checking on. Further review of the admission physician's admission orders [REDACTED]. It stated to flush the feeding tube with 200 ml. of water every shift (every eight hours). It also stated to flush the tube with 50 ml. of water before and after administration of medications. (This resident received medication 4 times a day for a total of an additional 400 ml. of water.) These tube feeding orders originated from the medication list sent from the hospital on [DATE]. This information from the hospital also stated the resident ' s weight was 175.3 pounds (lbs.) and his height was 72 inches. The admission nursing assessment dated [DATE] documented the resident weighed 142 pounds and a height of 62 inches in direct conflict with the data from the hospital. In an interview on 5/3/12 at 10:53a.m., with the ARNP for resident ' s attending physician, she stated they have 10 to 12 ARNPs and one PA. She stated she had been assigned to this facility about 2 months, but she was not familiar with this resident. He was assigned to another ARNP at the hospital. She stated she thought the nursing facility had called her to verify his orders on admission 4/6/12, which was a Friday. She stated their normal procedure is to read off the orders from the hospital ' s medication reconciliation record. She lets them know if things need to be adjusted. She stated she never came in to see this resident because he was only there for 4 days and she normally visits on Thursdays. She stated the nurses would have read her the tube feeding orders but not the resident ' s weight. She could not recall if she asked the Registered Dietician (RD) to assess the resident right away. She said if she were informed of a weight discrepancy from the hospital of 175 lbs. and from the nursing home of 142 pounds, she would ask how the resident was weighed in the hospital and in the facility. She would ask them to reweigh the resident for a couple of days in the same way and have the dietitian look at them. The ARNP stated her expectation would be that the RD would see a resident with a tube feeding within a couple of days of admission or at least be called to let the RD know what the orders and weight are. Then the RD could decide if the orders need to be adjusted. Interview on 5/3/12 at 11:34 a.m. with the restorative C.N.A. responsible for recording weights revealed documentation of a weight completed on 4/7/12 of 145.8 lbs. The C.N.A. revealed she weighed him on the hoyer lift in the morning and checked his height to be 6 feet, 2 inches. She stated she reported this weight to the resident ' s nurse immediately after the resident was weighed. This weight recorded by the restorative CNA revealed a third weight discrepancy in 24 hours. In an interview with LPN B on 5/3/12 at 12:52, she stated she handled resident #1 ' s admission orders [REDACTED]' s attending physician. She said he had a thick bone structure, was tall but she could tell he had lost weight since his previous admission. She stated nobody weighed him while she was there on 4/6/12 and she left at approximately 7:00p.m. The day before resident #1 was admitted this nurse recalled telling the RD that resident #1 was expected to return to the facility. LPN B stated she called the RD on 4/6/12 and read off his tube feeding orders from the hospital. She could not recall the RD asking for a weight, she just remembered her saying something like continue with the hospital orders. Review of resident #1 ' s Interim Admission Care Plan, dated 4/9/12, revealed the resident was at risk for nutrition/dehydration problems related to a dependency on a PEG tube. The following relevant intervention was listed: Dietary assessment on admission and as needed. Review of the resident ' s record revealed no nutrition assessment or dietary notes had been completed during the resident ' s stay from 4/6/12 - 4/10/12, despite the recording of three different weights with a discrepancy of approximately 30 lbs. and 2 different height with a discrepancy of 10 inches. If the resident was truly 145.8 lbs. or approximately 66.2 kilograms (kg.), then 30 calories per kg. and 30 ml. per kg of fluid may not have been appropriate for a metabolically stressed resident. Furthermore, review of hospital emergency room nurse ' s notes on 4/10/12 at 12:54 p.m. revealed a fourth weight of 120 lbs. The Accumulative [DIAGNOSES REDACTED]. In an interview with the Director of Nurses (DON) on 5/3/12 at 11:10 a.m., she confirmed there was no dietary assessment in the record during the resident ' s stay. She stated they had recently employed a consultant company to provide RD services. The DON stated that the RD who was working at the facility during the time of resident #1 ' s stay was on a cruise and was not available for an interview. The DON stated in the interview on 5/3/12 at 11:10 a.m. that the RD completed a nutrition risk screening on 4/12/12; however, this resident had been discharged to the hospital 2 days prior to this screening. This nutrition risk screening was reviewed and it was completed 4/12/12 using a resident weight of 175 pounds. This revealed further problems with documentation accuracy, times, and delays impacting the care of the resident. In an interview with the facility ' s current RD consultant on 5/4/12 at 1:35 p.m., she stated she was familiar with long term care, but did not know resident #1. She stated it was the facility ' s procedure to call her when a resident with a tube feeding was admitted . She would ask their diagnoses, history, gender, height, weight, and if they have any issues like pressure ulcers, and if the tube feeding was new for the resident. The RD stated she needs the weight to assess the tube feeding accurately. There are a lot of variables, so she would have to look at each situation. She stated she would get a brief review to get a picture of the situation and then make a recommendation. In an interview on 5/4/12 at 1:30 p.m. with the Administrator, a policy on what would be expected of the dietician regarding assessment of a resident with a tube feeding was requested. She produced a policy about being able to write orders for tube feedings. It did not address expectations regarding how soon an assessment should be done and she stated that was all they had. She brought a job description entitled Registered Dietician and dated 10/1/03 that state in a bulleted list: assesses resident ' s nutritional needs and confers with clinical staff to coordinate patients ' nutritional intake. A review of resident ' s monthly Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s note, dated 4/7/12 at 1:30 a.m. revealed "GT feeding initiated". There was no documentation in the record to indicate why the feeding was not started immediately after confirming the physician's orders [REDACTED]. This was approximately 7 to 8 hours that the resident did not receive any food or water after admission on 4/6/12 at 5:58 p.m. In an interview with the DON on 5/3/12 at 11:10 a.m., she stated they have tube feedings formulas on hand and would have had Glucerna 1.5. She did not know why the tube feeding for resident #1 was not started until 1:30 a.m. 4/7/12. A review of the computerized Weights and Vital Summary notes dated 4/9/12 at 3:30 p.m. revealed a blood pressure of 118/69, temperature of 98.2 degrees Fahrenheit, pulse of 70 and respirations 20. Documentation in the handwritten notes by LPN E on 4/9/12 at 9:00 p.m. revealed resident #1 was resting in bed. Respirations even and unlabored. Tube feeding tolerated well. Contact isolation maintained. Resident in private room with services brought in for [MEDICAL CONDITION]. Review of LPN E ' s Time Detail report revealed that she clocked out on 4/9/12 at 8:00 p.m., one hour prior to the time she documented in the 4/9/12 notes. The next handwritten nurse's note dated 4/9/12, (with no time), was completed by LPN D. This note documented : Resident resting in bed. No S/S of distress, no complaint of pain at present. Glucerna 1.5 infusing at 80 cc/hr. Tolerating well. [MEDICAL CONDITION] intact. Remains on contact isolation for [MEDICAL CONDITION]. All services performed in room. Will continue to monitor. Review of the Time Detail report for LPN D revealed she worked 4/9/12 from 7:08 a.m. -7:53p.m. A review of the next nursing note (handwritten) for 4/10/12 (no time documented) by LPN A stated: Resting in bed, respirations labored and resident ' s head of bed up at 45 degrees, resident congested and on contact isolation in a private room and services brought to the room. GT feeding flushes well without difficulties. Placement verified and no residual at this time. Review of the Daily Labor Report and staffing sheet revealed LPN A was scheduled to work on 4/9/12 at 7:00 p.m. until 4/10/12 until 7:00 a.m. Continued review of the record revealed that respirations of 20 were documented in the computerized record on 4/10/12 at 4:08 a.m. No additional vital signs were documented and no additional notes could be found regarding an assessment of the resident despite the notation by the 7:00 p.m. to 7:00 a.m. nurse of labored respirations and congestion. There is no documentation in the record of any care that was provided for the resident by this nurse for the labored breathing and the congestion. There was no evidence the physician or the family was contacted regarding the significant change in the resident ' s respiratory condition. A review of the physician's admission orders [REDACTED]. A review of the April MAR indicated [REDACTED]. In an interview with LPN A on 4/24/12 at 3:30 p.m., she stated that she had worked the night of 4/9/12 on the 7:00 p.m. to 7:00 a.m. shift and was assigned to resident #1. She stated she did not give a breathing treatment to the resident and does not remember him being unusually warm. She stated the vital signs were done. The nurse was difficult to understand and seemed to have a hard time understanding the questions and expressing her answers. In a second interview on 4/25/12 at 12:00 p.m. with LPN A., the nurse stated she had noticed resident #1 was congested and had labored breathing at about 4:00-5:00 a.m. on 4/10/12. The LPN stated she did not give him a breathing treatment because she did not think it would help because he was "too wet". She was unable to say what she meant and seemed confused about the question. She stated the resident had felt a little warm, but she did not take his vital signs at that time because someone had already taken them earlier in the shift. (Review of the handwritten notes dated 4/10/12 with no time documented revealed the following vital signs: temperature 97.1 pulse 75, respirations 18 and blood pressure 130/60). The nurse stated she put the head of the bed up and she checked on him frequently. She was unable to say how frequently or what she was checking. She said he had on oxygen at 2 liters per nasal cannula (this resident had no orders for oxygen). LPN A stated she did not call the physician because she did not know the resident and was not sure if this was the way he was. She stated she told the oncoming day shift nurse about the resident's condition and left the facility at about 8:00 a.m. The nurse ' s statements and train of thought were fragmented and hard to follow and she did not seem to understand the significance of the situation. In a telephone interview with LPN F on 5/8/12 at 11:47 a.m., it was revealed that she had worked with LPN A on the 4/9/12, 7:00 p.m. to 4/10/12 7:00 a.m. shift. She stated she was not notified or aware of any problems with resident #1. She was not assigned to resident #1 but recalled his door being closed due to isolation precautions. She stated they normally work together on that shift because there are only two nurses in the building. She was surprised to learn of the deteriorating condition of resident #1 on her shift because she did not know anything was wrong until 5/3/12 when interviewed by the DON. LPN F revealed that the resident ' s door was closed during the shift further limiting the nurse ' s ability to assess the condition of the resident when he was having difficulty breathing. Review of resident #1 ' s interim care plan dated 4/9/12 stated that the resident would have no complications related to [MEDICAL CONDITION]. Interventions listed were: observe for weakness, dehydration, and fever, administer medications and treatments per physician's order [REDACTED]. The nurse did not follow the plan of care to record the resident ' s temperature and record/administer breathing treatments when the resident had a significant decline as evidenced by labored breathing and congestion. Continued review of the clinical record revealed the following handwritten nurses note by LPN D on 4/10/12 at 7:30 a.m.: congestion noted, increased respirations, blood pressure normal, oxygen saturation level at 87% (it was not specified if the resident was on oxygen or room air). The physician was notified and orders were received to transfer the resident to the hospital. The next nurse ' s note on 4/10/12 at 7:45 a.m. stated the resident was transferred to the hospital. A review of the "Resident Hospital Transfer Form", completed by LPN B prior to transfer dated 4/10/12 with no time documented, indicated the resident's temperature was 105 degrees by axilla and the pulse was 100 beats per minute. There was no blood pressure or respirations recorded. The [DIAGNOSES REDACTED]. The reason for transfer was noted as change in level of consciousness and decreased oxygen saturation. In an interview and review of the Resident Hospital Transfer Form on 4/24/12 at approximately 3:00 p.m. with the Assistant Director of Nursing (ADON), LPN B and LPN D who were working the morning of 4/10/12, they stated the temperature on the transfer form must have been an error and should have been 100.5 degrees. They stated they could not recall who took the blood pressure, but LPN B stated she took resident #1 ' s temperature and filled out the transfer form. An interview was conducted on 4/24/12 at 3:00 p.m. with LPN D assigned to take care of the resident during the 7:00 a.m. to 3:00 p.m. (7-3), shift on 4/10/12. LPN D stated that in the shift to shift report at 7:00 a.m., the night nurse stated she had been giving him breathing treatments because of congestion. This statement is in direct conflict with what LPN A stated to the surveyor in 2 separate interviews. During both of these interviews with LPN A she stated she did not give a breathing treatment on the night of 4/9/10 - morning of 4/10/12. There were no signatures on the MAR indicated [REDACTED]' s stay from 4/6/12 - 4/10/12. Nurses notes documented on this resident are very vague and time discrepancies are evident. In a subsequent interview with LPN D on 5/3/12 at 1:36 p.m., it was revealed that she had cared for resident #1 on 4/9/12 on the 7:00 a.m. - 7:00 p.m. shift. On 4/9/12 his temperature was fine and he was sitting up. He showed no signs of distress and his vital signs were stable. She could not recall if he used oxygen and couldn ' t recall giving him any breathing treatments on that shift. LPN D stated nothing of any consequence happened on that shift. Continued interview with LPN D revealed that she came to work on 4/10/12 at about 7:20 a.m. She stated she and LPN A did the narcotics count. Following the narcotic count LPN D and LPN A went on walking rounds. LPN D stated resident #1 sounded congested but nothing severe. The head of the bed was up. After completing walking rounds LPN D went back to resident #1 ' s room by herself to check on him. She stated this was probably around 7:30 - 7:45 a.m. She said " I looked at him and could just hear the congestion " , so she went and got the wound care nurse LPN C. LPN C then went to get the ADON. LPN D stated the other nurses were doing everything. LPN D stated she put the breathing medication into the nebulizer machine but the ADON put the mask on and administered the treatment. After this LPN D was in and out of the room because she needed to start medication pass. She could not recall when he went to the hospital and she was not present when they took his vital signs. LPN D was asked about her nurse ' s note dated 4/10/12 at 7:30 a.m. stating the blood pressure was normal. She could not recall what the blood pressure was or who took it. She stated somebody had to have taken it for her to write it down. LPN D also stated she realized now that she didn ' t get to the facility until 7:20 a.m. on 4/10/12 so her times on the documentation for 4/10/12 were probably not right. Further interview with LPN D at 2:10 p.m. on 5/3/12 revealed she did not notice any wetness or odors for resident #1, just congestion. In an interview with LPN C on 5/4/12 at 1:19 p.m., she stated she was the wound care nurse and she went to see resident #1 to evaluate his wounds on the morning of 4/10/12. She stated she usually works 6:00 a.m. - 2:00 p.m. but she thought it was around 7:00 a.m. when she first saw resident #1 on 4/10/12. LPN D had been in before her and LPN C said she knew something was going on because she had overheard their shift report. LPN C stated she noticed resident #1 ' s breathing was labored and his respirations were increased. The ADON was walking past so LPN C asked her to come in. She said the ADON was working up top and she was undressing his right leg wound. She said his legs didn ' t feel warm at all. LPN C did not think there was oxygen on him when she came in the room around 7:00 a.m. (this is in conflict with interviews from the ADON and LPN D). LPN C thought they came in and put oxygen on him around 7:30 a.m. - 7:45 a.m. She checked the oxygen saturation level after applying the pulse oximeter and recalled it was in the 70 ' s. LPN C did not know who took his vital signs. LPN C stated they turned his tube feeding off and the head of bed was elevated. We did do a blood sugar (BS) test on him and it was 200 something. She said she remembers it wasn ' t too high or too low. She thought LPN D did the BS but was not certain. LPN C could not describe resident #1 ' s color as he was a dark skinned man. LPN C stated he did open his eyes when you called his name, but did not verbally respond. She didn ' t notice if they gave him a breathing treatment. She does not recall any odor or indications that he was in need of incontinence care. An interview was conducted with the Assistant Director of Nurses (ADON) on 4/24/12 at 2:40 p.m. The ADON stated she was present on 4/10/12 at 7:30 a.m., when resident #1 was transferred to the hospital. She stated the head of the bed was elevated and the resident was experiencing abnormal breath sounds. The ADON stated she gave him a breathing treatment, yet there was no documentation of the breathing treatment having been given in the record. The ADON stated the tube feeding was off and the resident's oxygen saturation level was going up and down. The resident's eyes were open but he was not responding. She stated they took vital signs and he had a temperature but she could not remember what it was. In an interview on 5/3/12 at 12:53 p.m. with LPN B., she stated on the morning of 4/10/12 she heard LPN D saying resident #1 needed to go to the hospital. LPN B stated she went to resident #1 ' s room to assist. She noticed the ADON administering a breathing treatment, he was receiving oxygen, and had a pulse oximeter on his finger which had a reading that was fluctuating " 40, 60, and would go up into the 80 ' s " . She said he had increased respirations, but he was not gasping for air. He would look at you but did not respond verbally. In the past, this resident would speak in a real soft voice. She recalled asking if anybody got his vitals. One of the C.N.A. ' s came in and took his temperature; however, she could not recall the name of this C.N.A. LPN B recorded the temperature as 105 degrees Fahrenheit per axillary. After that she went to the desk to prepare his transfer forms and called the doctor. LPN B stated she informed the ARNP that the resident was receiving a breathing treatment, had a temperature of 105 with fluctuating oxygen saturations, and was in an unstable condition. LPN B stated she told the ARNP the resident needed to go to the emergency room . She thinks that this occurred before 8:00 a.m. but was not exactly sure of the time. LPN B could not recall what time the ambulance arrived. A review of the Emergency Medical Services (EMS) report, dated 4/10/12, revealed the call from the facility was received at 8:38 a.m. on 4/10/12 and the ambulance arrived at the facility at 8:41 a.m. The documented time of transport was 9:03 a.m. This was conflicting with the facility ' s documentation of sending the resident out of the building at 7:45 a.m. In addition, LPN A stated in an interview the resident exhibited labored breathing and congestion sometime between 4:00 a.m. and 5:00 a.m. on 4/10/12. Based on the EMS documentation, this resident did not receive any documented care and services by facility personnel for approximately 4 - 5 hours after discovery of a significant change. The EMS arrived at the hospital at 9:11 a.m. According to the EMS narrative notes .... " Staff stated that at shift change the patient complained of difficulty breathing. Staff stated that the patient had a temperature 105 degrees F, and that patient was being treated for [REDACTED]. Upon assessment patient found to be in [MEDICAL CONDITION], SPO2 reading was 78% on non rebreather mask, Glasgow Coma Scale (GCS) was a 6 with labored respirations. Secondary revealed skin hot, pink, very dry ... ....pupils sluggish and unequal, lung sounds rhonchi throughout ... facilitated intubation and ventilations were assisted. " A review of the Hospital face sheet revealed a registration time of 4/10/12 at 9:16 a.m. A review the Emergency Physician record dated 4/10/12, revealed the resident had been intubated prior to arrival in the ER, was initially hypotensive with a systolic blood pressure of 70. The patient ' s temperature was 107 F rectally. On physical exam, patient with unequal pupils, sent to CT which revealed chronic changes. Chest x-ray showed the endotracheal tube was in good position however the patient had a right pneumothorax, a chest tube was place immediately and the resident was placed on a ventilator. Review of the hospital emergency department triage report dated 4/10/12 at 9:24 a.m. revealed the resident ' s blood sugar was 300. The hospital emergency department nurse's documentation dated 4/10/12 performed at 9:19 a.m. stated in capitalized letters that the resident was " SOAKED IN URINE THAT APPEARS FOR A PROLONGED PERIOD OF TIME; DIAPER WAS SOAKED IN ENTIRETY, BROWN IN COLOR, STRONG ODOR OF AMMONIA, AND THE BOTTOM SHEET WAS SOAKED AS WELL WITH A HUGE RING AROUND THE PATIENT- APPEARS TO HAVE BEEN THERE FOR A LONG PERIOD OF TIME. WHEN ROLLED A USED ANGIOCATH WAS STUCK TO THE BACK OF THE PATIENT ' S RIGHT LEG AND HAD A DATE OF 3/16/12 ATTACHED TO CATH " . The entry went on to say that this situation was reported to the charge nurse and the social worker. In an interview with the DON on 5/2/12 at 6:15 p.m. and the Administrator who was on speakerphone, she stated the nurse who worked 7:00 p.m-7:00 a.m. on 4/10/12 had been suspended for not documenting appropriately. They both stated that they had not investigated the care of resident #1. The surveyor informed the facility of the resident ' s physical stated upon arrival in the emergency roiagnom on [DATE]. The response from the DON was, " He was very sick, we did what we were supposed to do. The ABCs. ( basics) What more could we have done? " The surveyor asked if they had investigated the fact that he had a 105 degree temperature in the facility and the response was. " I thought we figured out that it was 100.5, not 105. The surveyor told them that the EMS documented that the facility nurse told them that the resident ' s temperature was 105. The administrator stated that another state agency had