Every finding on record at Purcell Care Center

Based on record review and interview, the facility failed to ensure supervision to prevent an elopement for 1 (#1) of 3 sampled residents reviewed for elopement. The ADON identified eight residents at risk for elopement.Findings:On 09/22/25 Residents #2 and #3, identified by the facility as elopement risks, were observed throughout the day. Neither resident showed any elopement behaviors. New elopement assessments were completed for both residents on 09/12/25.An undated facility policy titled Wandering and Elopements read in part, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents.Res #1 with known exit seeking behaviors eloped from the facility on 09/12/25 and was located down the road from the facility in a residential neighborhood. An undated medical diagnosis list showed Res #1 admitted to the facility with diagnoses which included Alzheimer's and age-related decline.A quarterly assessment, dated 06/13/25, showed the resident's brief interview for mental status score was a 6, which indicated severe cognitive impairment.A progress note, dated 09/10/25 at 10:48 a.m., showed Res #1 showed elopement behaviors and tried to follow a hospice volunteer out the door. Res #1 was placed on every 15 minutes checks.A progress note, dated 09/12/25 at 1:43 p.m., showed Res #1 was observed to be missing from the facility at 11:57 a.m. The note showed certified nurse aide #1, assigned to the hall, reported seeing the resident sitting in the common area at 10:30 a.m. Staff immediately began searching the interior and the perimeter of the facility. At approximately 12:18 p.m. the facility received a call from the local police department indicating they found the resident down the road. Two staff members went to pick them up in the facility van and returned them to the facility. Upon arrival at the facility the resident was immediately placed on 1:1 and a head-to-toe assessment was completed by the charge nurse with no injuries identified. Res #1 stated I waited until someone was going out the door and I followed them out, it's that easy.An in-service, dated 09/12/25, showed all staff were in-serviced on the missing resident's policy and procedures and residents at risk for elopement.A care plan, dated 09/12/25, showed it had been reviewed/revised on:07/30/25 because Res #1 had attempted to elope several times. Interventions put in place were distract by offering pleasant diversions, structed activities, food, conversation, television and book. Identify pattern of wandering- purposeful, aimless, or escapist and intervene as appropriate. Provide structured activities- walking inside and outside reorientation strategies including signs, pictures and memory boxes.09/10/25 Res #1 was let out the door by a volunteer and stayed in sight of the volunteer until staff intervened, and Res #1 was ready to go back inside. Res #1 was placed on every 15-minute checks until further notice.09/12/25 Res #1 left the facility unassisted. Res #1 was placed on 1:1 until further notice and referrals were sent to inpatient psych and memory care.A final incident report form, dated 09/16/25, showed all staff were in-serviced related to missing resident policy, referrals had been sent to behavioral health facilities and memory care facilities for possible admission were reviewed, facility census checks initiated every two hours facility wide until further notice. New assessments were completed for all residents at risk for elopement on 09/12/25 with eight residents identified to be at risk for elopement.A progress note, dated 09/19/25, showed Res #1 was discharged to an inpatient psychiatric facility for evaluation and treatment.On 09/23/25 at 12:09 p.m., the activities director stated they had received in-service related to elopement policies and procedures and what residents were at risk for elopement.On 09/23/25 at 12:11p.m., LPN #1 stated they had received in-service related to elopement policies and procedures and what residents were at risk for elopement.On 09/23/25, CMA #1 stated they received an in-service over policy and procedures of elopement and what residents were at risk for elopement.Quality assurance weekly audits of wandering and elopement risk for 09/16/25 and 09/22/25 were reviewed. On 09/22/25 at 3:00 p.m., the ADON stated Res #1 was taken off every 15-minute checks at 8:00 a.m. on 09/12/25 because they had shown no exit seeking behaviors for the last two days. The ADON reported Res #1 began to get verbally and physically aggressive with staff that was performing 1:1 with them.

Based on record review and interview, the facility failed to ensure medications were administered according to physician orders for 1 (#1) of 6 residents sampled for timely administration of medications. The administrator identified 67 residents in the facility. Findings: An undated administration document showed medication pass for three times a day was from 7:00 a.m. to 11:00 a.m., 2:00 p.m. to 4:00 p.m., and 7:00 p.m. to 10:00 p.m. A policy titled Administering Medications, revised 04/2019, read in part, Medications are administered in a safe and timely manner, and as prescribed .Medications are administered in accordance with the prescribed orders, including any time frame. An order summary report, dated 06/16/25, for Resident #1 showed: a. Metoprolol Succinate Extended Release (an antihypertensive), dated 10/01/23, 25mg in the morning for hypertension; b. Miralax (an osmotic laxative), dated 10/01/23, 17gm in the morning for constipation; c. Lisinopril (an ace inhibitor), dated 10/01/23, 20mg two times daily for HTN; d. Tramadol (an opioid), dated 11/03/23, 50mg three times daily for pain; e. Pepcid (a H2 blocker), dated 10/01/23, 40mg in the morning for indigestion; f. Hydralazine (a vasodilator), dated 10/01/23, 25mg three times a day for HTN; g. Colace (a laxative), dated 10/01/23, 100mg in the morning for constipation; h. Claritin (an antihistamine), dated 10/01/23, 10mg in the morning for allergies; i. Estrace (estrogen), dated 10/01/23, 0.5mg in the morning for hormonal supplement; j. Norvasc (a calcium channel blocker), dated 08/21/24, 5mg in the morning for HTN; k. Allopurinol (xanthine oxidase inhibitors), dated 07/16/24, 100mg in the morning for gout; l. Mirtazapine (an antidepressant), dated 12/23/24, 7.5mg in the evening for weight loss; m. Aricept (an acetylcholinesterase inhibitor), dated 02/12/25, 5mg in the evening for dementia; n. Clonidine (a hypotensive agent), dated 02/12/25, 0.1mg in the evening for HTN; o. Trazodone (a serotonin antagonist), dated 10/01/23, 50mg in the evening for insomnia; p. Hydrochlorothiazide (a diuretic), dated 10/01/23, 25mg in the morning for HTN; and q. Singulair (leukotriene receptor antagonist), 10mg in the evening for chronic obstructive pulmonary disease. A Medication Admin [administration] Audit Report, dated 04/01/25 through 06/12/25, showed: a. Miralax, Norvasc, and Allopurinol were given on 04/08/25 at 11:38 a.m.; b. Pepcid, Hydralazine, Hydrochlorothiazide, Colace, and Estrace were given on 04/08/25 at 11:39 a.m.; c. Metoprolol, Lisinopril, Tramadol, and Claritin were given on 04/08/25 at 11:40 a.m.; d. Allopurinol, Clonidine, Colace, and Lisinopril were given on 04/09/25 at 10:11 p.m.; e. Mirtazapine, Aricept, Hydralazine, Tramadol, and Trazodone were given on 04/09/25 at 10:12 p.m.; f. Norvasc, Allopurinol, Colace, and Miralax were given on 04/19/25 at 11:08 a.m.; g. Pepcid, Hydralazine, Estrace, Hydrochlorothiazide, and Claritin were given on 04/19/25 at 11:09 a.m.; h. Clonidine, Aricept, Allupurinol, Colace, and Hydralazine was given on 05/02/25 at 10:10 p.m.; i. Mirtazapine, Aricept, Hydralazine, Tramadol, Lisinopril, Singulair, and Trazodone were given on 05/02/25 at 10:11 p.m.; j. Hydralazine and Tramadol were given on 05/13/25 at 5:10 p.m.; k. Norvasc, Miralax, Estrace Claritin, and Hydrochlorothiazide were given on 05/27/25 at 11:26 a.m.; l. Metoprolol was given on 05/27/25 at 11:28 a.m.; and m. Hydralazine, Lisinopril, Pepcid, Colace, Tramadol, and Allopurinol were given on 05/27/25 at 11:29 a.m. On 06/16/25 at 1:00 p.m. the director of nursing reported the medications should have been given during the appropriate blocked times.

Based on observation, record review, and interview, the facility failed to ensure discontinued medications were discarded in a timely manner from the refrigerator for three (#25, 27, and #36) of three sampled residents reviewed for medication labeling and storage. The administrator identified 60 residents resided in the facility. Findings: 1. Resident #25's physician's orders documented Trulicity (blood sugar medication) 4.5/0.5ml was discontinued on 05/13/24 and Dupixent (interleukin inhibitor) 300mg/2ml was discontinued on 04/10/24. 2. Resident #27's physician's orders documented formoterol nebulizer solution 20/2ml was discontinued on 07/12/24. 3. Resident #36's physician's orders documented Trulicity 1.5/0.5ml was discontinued on 03/08/24. On 11/04/24 at 11:30 a.m., items in the refrigerator in the medication room were reviewed with LPN #1. The following was observed: a. five unopened injector pens of Trulicity 1.5/0.5ml labeled for Resident #36, b. one unopened injector pen of Trulicity 4.5/0.5ml labeled for Resident #25, c. four unopened injector pens of Dupixent 300mg/2ml labeled for Resident #25, and d. fifty two ampules of formoterol nebulizer solution 20/2ml labeled for Resident #27. On 11/04/24 at 11:40 a.m., LPN #1 was asked the policy for discarding discontinued medications. They stated discontinued medications should be immediately removed from the refrigerator and discarded according to facility policy. LPN #1 acknowledged facility policy had not been followed.

Based on record review and interview, the facility failed to report an allegation of abuse within two hours for two (#1 and #2) of three sampled residents reviewed for abuse. The DON identified 54 residents resided in the facility. Findings: An abuse policy, dated 08/12/22, documented allegations of abuse must be reported within two hours. A progress note, dated 09/01/24 at 4:00 p.m., documented Res #1 had reported to staff Res #2 had been sexually inappropriate toward them. An initial incident report submitted to OSDH was dated as received 09/03/24 at 3:25 p.m. On 09/05/24 at 2:48 p.m., the administrator stated the incident report was submitted late.

Based on record review and interview, the facility failed to notify the physician of abnormal blood pressures for two (#3 and #5) of five sampled residents reviewed for changes in condition. The administrator identified 37 residents resided in the facility. Findings: 1. A facility Blood Pressure, Measuring policy, reviewed September 2010, documented in part .Hypertension is usually defined as blood pressure over 140/90 mm/Hg .Hypertension should be reported to the physician .Hypotension is defined as blood pressure less than 100/60 mm/Hg .Hypotension should be reported to the physician . Res #3 had diagnoses which included vascular dementia and secondary hypertension. A physician order, dated 10/01/23, documented to administer clonidine 0.1 mg by mouth three times per day, hold medication and notify physician of systolic blood pressure below 100. A MAR for December 2023 documented: a. 12/29/23 at 7:00 a.m. Res #3's blood pressure was 153/101, b. 12/29/23 at 2:00 p.m., Res #3's blood pressure was 153/101, c. 12/30/23 at 7:00 a.m., Res #3's blood pressure was 153/101, d. 12/30/23 at 2:00 p.m., Res #3's blood pressure was 153/101. The progress notes were reviewed and did not document the physician was notified of the abnormal blood pressures. There was no documentation the blood pressure was rechecked. On 01/09/24 at 10:38 a.m., CMA #1 stated abnormal blood pressures should be reported to the nurse. On 01/09/24 at 10:40 a.m., RN #1 stated when abnormal blood pressures are reported the nurse should recheck the reading and if they are still abnormal the physician should be notified. They stated a progress note should be documented with the notification and any orders received. On 01/09/24 at 10:45 a.m., Corporate RN #1 reviewed the progress notes and stated there was no documentation the physician was notified of the abnormal blood pressure readings. stated the physician should have been notified. 2. Res #5 had diagnoses which included secondary hypertension. A physician order, dated 11/09/23, documented to administer lisinopril 20 mg by mouth at bedtime for secondary hypertension, hold if systolic blood pressure below 100. A physician order, dated 11/09/23, documented to administer lisinopril-hctz 20-25 mg by mouth in the morning, hold if systolic blood pressure below 100. A MAR for December 2023 documented: a. 12/14/23 at 9:00 p.m., Res #5's blood pressure was 76/57, b. 12/15/23 at 9:00 p.m., Res #5's blood pressure was 76/57, c. 12/19/23 at 9:00 p.m., Res #5's blood pressure was 74/56, d. 12/21/23 at 9:00 p.m., Res #5's blood pressure was 84/59. The progress notes were reviewed and did not document the physician was notified of the abnormal blood pressures. There was no documentation the blood pressure was rechecked by a nurse. On 01/09/24 at 10:38 a.m., CMA #1 stated abnormal blood pressures should be reported to the nurse. On 01/09/24 at 10:40 a.m., RN #1 stated when abnormal blood pressures are reported the nurse should recheck the reading and if they are still abnormal the physician should be notified. They stated a progress note should be documented with the notification and any orders received. On 01/09/24 at 10:45 a.m., Corporate RN #1 reviewed the progress notes and stated there was no documentation the physician was notified of the abnormal blood pressure readings. They stated the physician should have been notified.

Based on record review and interview, the facility failed to administer medications according to physician order for two (#3 and #5) of five sampled residents reviewed for changes in condition. The administrator identified 37 residents resided in the facility. Findings: 1. A facility Administering Mediations procedure, revised April 2019, documented in part .Medications are administered in accordance with prescriber orders .If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose .The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next one . Res #3 had diagnoses which included vascular dementia, history of TIA, tremors, and secondary hypertension. A physician order, dated 10/01/23, documented to administer clonidine 0.1 mg by mouth three times per day, hold medication and notify physician of systolic blood pressure below 100. A physician order, dated 10/01/23, documented to administer benztropine mesylate 2 mg twice daily for tremors. A physician order, dated 10/01/23, documented to administer apixaban 2.5 mg twice per day for TIA. A physician order, dated 10/01/23, documented to administer medroxyprogesterone acetate 10 mg twice daily for sexual behaviors. A physician order, dated 10/01/23, documented to administer riluzole 50 mg twice daily for mood. A physician order, dated 10/01/23, documented to administer risperidone 0.25 mg twice daily for mood. A physician order, dated 10/01/23, documented to administer acetaminophen 650 mg twice daily for pain. A physician order, dated 10/01/23, documented to administer gabapentin 600 mg three times per day for nerve pain. A physician order, dated 10/01/23, documented to administer tramadol 50 mg three times per day for pain. A MAR for December 2023 documented: a. the benztropine administration was blank three of 62 opportunities, b. the apixaban administration was blank three of 62 opportunities, c. the medroxyprogesterone administration was blank three of 62 opportunities, d. the riluzole administration was blank three of 62 opportunities, e. the risperidone administration was blank three of 62 opportunities, f. the acetaminophen administration was blank three of 62 opportunities, g. the clonidine administration was blank four of 93 opportunities, h. the gabapentin administration was blank four of 93 opportunities, and i. the tramadol administration was blank four of 93 opportunities. A MAR for 01/01/24 through 01/08/24 documented clonidine was administered when systolic blood pressure was below 100, three of seven opportunities. 2. Res #5 had diagnoses which included secondary hypertension. A physician order, dated 11/09/23, documented to administer lisinopril 20 mg by mouth at bedtime for secondary hypertension, hold if systolic blood pressure below 100. A physician order, dated 11/09/23, documented to administer lisinopril-hctz 20-25 mg by mouth in the morning, hold if systolic blood pressure below 100. A MAR for December 2023 documented: a. lisinopril was administered when systolic blood pressure was below 100, four of six opportunities, b. lisinopril-hctz was administered when systolic blood pressure was below 100, two of five opportunities On 01/08/23 at 2:46 p.m., the administrator stated there were no outages in the charting system to explain the blanks on the MAR. On 01/08/23 at 3:00 p.m., Corporate RN #1 was made aware of the blanks on the MAR. They stated if it was not documented it was not done. On 01/09/23 at 10:38 a.m., CMA #1 stated the parameters on the order determine when to hold a medication. They stated they would notify the nurse if the medication had to be held. They stated the blanks on the MAR were where it was not documented as given.

Based on observation, record review, and interview, the facility failed to administer insulin according to physician orders for two (#10 and #26) and failed to notify the physician for FSBS outside of ordered parameters for one (#26) of six residents sampled for medications. The ADON identified seven residents who received insulin. Findings: 1. Res #10 had diagnoses which included diabetes. A physician order, dated 06/22/23, documented to administer insulin deglu[DATE] units subcutaneously one time a day at 6:30 a.m. for DM. The order documented to notify PCP if FSBS is less than 60 or greater than 400 and document in progress notes, do not hold. A MAR for August 2023 documented the resident received their insulin greater than one hour after the ordered administration time one of 31 opportunities. A MAR for 09/01/23 through 09/05/23, documented the resident received their insulin greater than one hour after the ordered administration time for one of five opportunities, and greater than one hour before the ordered administration time for one of five opportunities. A physician order, dated 09/06/23, documented to administer insulin deglu[DATE] units subcutaneously one time a day at 6:30 a.m. for diabetes. The order documented to notify PCP if FSBS is less than 60 or greater than 400 and document in progress notes, do not hold. A MAR for September 09/06/23 through 09/15/23, documented the resident received their insulin greater than one hour after the ordered administration time for two of nine opportunities. 2. Res #26 had diagnoses which included diabetes. A physician order, dated 05/25/23, documented to administer insulin aspart according to sliding scale before meals at 6:30 a.m., 11:00 a.m., 4:00 p.m., and 8:00 p.m. The sliding scale documented for a FSBS of 151-400 to administer 5 units, and for a FSBS from 401-450 to administer 8 units. The order documented to notify the PCP for FSBS less than 60 or greater then 450 and document in progress notes, hold if FSBS below 150. A physician order, dated 05/25/23, documented to administer insulin glargine 30 units two times per day at 6:00 a.m. and 8:00 p.m. for diabetes. The order documented to notify the PCP for FSBS less than 60 or greater than 450, do not hold. A FSBS record, dated 07/17/23 at 12:08 p.m., documented Res #26's FSBS was 518. There was not a progress note documenting the physician was notified. A FSBS record, dated 07/26/23 at 4:24 p.m., documented Res #26's FSBS was 478. There was no progress note documenting the physician was notified. A MAR for 07/01/23 through 07/27/23, documented the resident received their insulin glargine 6:00 a.m. dose greater than one hour after the ordered administration time seven of 27 opportunities. The 8:00 p.m. dose was documented as administered greater than one hour after the scheduled administration time 14 of 26 opportunities. A MAR for 07/01/23 through 07/31/23, documented the resident received their sliding scale insulin greater than one hour after the ordered administration time 24 out of 124 opportunities. The sliding scale was documented as administered greater than one our before the ordered administration time one out of 124 opportunities. A physician order, dated 07/27/23, documented to administer insulin glargine 34 units once per day in the morning at 6:00 a.m. for diabetes. The order documented to notify the PCP if FSBS is less than 60 or greater than 450, do not hold. A physician order, dated 07/27/23, documented to administer insulin glargine 30 units once per day in the evening at 8:00 p.m. for diabetes. The order documented to notify the PCP if FSBS is less than 60 or greater than 450, do not hold. A MAR for 07/27/23 through 07/31/23, documented Res #26 received their 8:00 p.m. dose of insulin glargine greater than one hour after the ordered administration time for three of nine opportunities. A FSBS record, dated 08/09/23 at 11:37 a.m., documented Res #26's FSBS was 498. There was no progress note documenting the physician was notified. A FSBS record, dated 08/10/23 at 11:58 a.m., documented Res #26's FSBS was 470. There was no progress note documenting the physician was notified. A FSBS record, dated 08/22/23 at 12:07 p.m., documented Res #26's FSBS was 477. There was no progress note documenting the physician was notified. A MAR for 08/01/23 through 08/31/23, documented Res #26 received their 6:00 a.m. dose of insulin glargine greater than one hour after the scheduled time five of 31 opportunities. The 8:00 p.m. dose was documented as administered greater than one hour after the scheduled time for 14 of 31 opportunities. A MAR for 08/01/23 through 08/31/23, documented Res #26 received their sliding scale insulin aspart greater than one hour after the scheduled time 35 of 124 opportunities. A FSBS record, dated 09/05/23 at 5:53 a.m., documented Res #26's FSBS was 50. There was no progress note documenting the physician was notified. A FSBS record, dated 09/09/23 at 5:33 a.m., documented Res #26's FSBS was 44. There was no progress note documenting the physician was notified. A FSBS record, dated 09/11/23 at 12:18 a.m., documented Res #26's FSBS was 457. There was no progress note documenting the physician was notified. A MAR for 09/01/23 through 09/15/23, documented Res #26 received their insulin glargine 6:00 a.m. dose greater than one hour after the scheduled time four of 15 opportunities. The 8:00 p.m. dose was documented as given greater than an hour after the scheduled time five of 15 opportunities. A MAR for 09/01/23 through 09/15/23, documented Res #26 received their insulin aspart sliding scale greater than one hour after the scheduled time 13 of 44 opportunities. On 09/14/23 at 12:44 p.m., Res #26 stated their blood sugars were very brittle and fluctuated from high to low easily. They stated they sometimes have to wait multiple hours for their insulin injection. On 09/15/23 at 11:15 a.m., the DON stated the physician should be notified according to the orders for any FSBS out of ordered parameters. They stated the physician had requested to be notified via fax, but the staff are able to text him if it is a weekend or after hours. On 09/15/23 at 12:34 p.m., the DON stated insulin should be given within one hour before or after the ordered administration time. They stated they were unsure why the noted late administrations were not given according to protocol. They stated the staff are instructed to use the punch, initial, give, method to administer medications. On 09/15/23 at 3:17 p.m., the DON stated the physician needs to be notified of FSBS readings out of the ordered parameters.

Based on observation and interview, the facility failed to ensure infection control practices were followed during insulin administration. The ADON identified seven residents in the facility received insulin. Findings: On 09/15/23 at 10:40 a.m., LPN #1 was observed during insulin administration. Several insulin pre-filled metered dose syringes were observed stored in the top drawer of the medication cart on top of each other. The pens were labeled with several different resident's names. The pre-filled syringes were not individually packaged or wrapped. The LPN was observed taking a bottle of test strips into the room to perform a FSBS. The nurse was not observed sanitizing the bottle of test strips before returning it to the top drawer of the medication cart. On 09/15/23 at 10:49 a.m., LPN #1 was observed entering a residents room for insulin administration. The LPN was observed taking the same bottle of test strips into the room to perform a FSBS. The nurse was not observed sanitizing the test strip bottle before taking it into the room or after leaving the resident's room. The bottle was placed into the top drawer of the medication cart. On 09/15/23 at 10:58 a.m., LPN #1 was observed taking the same bottle of test strips out of the medication cart and taking it with them into a different resident's room. The bottle was not observed to be sanitized before or after entering this resident's room. On 09/15/23 at 11:08 a.m., LPN #1 was asked if the bottle of test strips was cleaned prior to taking it into different resident's room. They stated it was not. The LPN was asked about the storage of the insulin pens. They stated if one of the pens had blood on it there could be potential cross contamination to the other patient's insulin pens. On 09/15/23 at 11:15 the DON was made aware of the above findings. They stated the insulin pens should have been stored in individual plastic bags. They stated regarding the test strips they would prefer the nurse only take what was needed to perform the finger stick into the room and not the whole bottle of test strips.

Based on record review and interview, the facility failed to ensure assessments accurately documented the status of residents for one (#26) of 16 sampled residents whose assessments were reviewed. The Resident Census and Conditions of Residents form, dated 09/14/23, documented 45 residents resided in the facility. Findings: Resident #23 had diagnoses which included depression, anxiety, and bipolar disorder. A State of Oklahoma Health Care Authority PASRR II evaluation, dated 01/12/22, documented the resident had a serious mental illness as defined by the Centers of Medicare and Medicaid Services. An annual assessment, dated 08/16/23, documented the resident was cognitively intact and required assistance with activities of daily living. The assessment documented the resident did not have a serious mental illness. On 09/19/23 at 11:33 a.m., the MDS coordinator was asked if the assessment was coded correctly concerning the PASRR II evaluation. They stated it was not.

Based on record review, observation, and interview, the facility failed to follow a physician order for a therapeutic diet and follow the menu for one (#5) of three residents sampled for food preferences. The Resident Census and Conditions of Residents form documented 11 residents on mechanically altered diets. Findings: Res #5 had diagnoses which included mouth and facial pain, dementia, and blindness. A physician order, dated 06/15/22, documented reduced concentrated sweets diet, mechanical soft texture, regular liquids, serve in bowls. A quarterly MDS assessment, dated 07/22/22. documented Res #5 was moderately impaired cognitively, required a mechanically altered diet, and required supervision for eating. On 12/20/22 at 11:45 a.m., the menu for the day was observed posted on the wall by the serving window. The menu documented lunch for the day was baked pork chops, black eyed peas, fried squash, corn bread, margarine, fruit fluff, and coffee or tea. On 12/20/22 at 12:40 p.m., Res #5 was observed in the dining room being served a tray containing corn dogs, peaches, and black eye peas. Res #5 was not served a vegetable or cornbread. Res #5 stated he thought they were having pork chops. CNA #3 was observed going to the serving window and asked for a pork chop for resident #5. CNA #3 was observed returning to Res #5 and stated he could not have the pork chops because he had a mechanical soft diet. Observed CNA #3 walk away from resident without assisting him to cut up the corn dogs. Res #5 was observed to eat the corn dogs without assist and had difficulty biting and chewing the corn dogs. On 12/20/22 at 12:56 p.m., the DON stated the corn dogs were not a mechanically soft food. On 12/20/22 at 12:58 p.m., the DM stated she considered corn dogs to be a mechanically soft diet. On 12/20/22 at 1:13 p.m., the DM stated in regards to serving the corn dogs, I know I messed up. When asked if the resident should have been served the corn dogs she stated, No. She stated they did not have enough pork chops to make for Res #5 because they had ran out by the time he had asked for them. She stated she could have made the pork chops mechanically soft if she had any left. On 12/20/22 at 2:30 p.m., Res #5 stated he did not get served what he wanted for lunch and he wanted the pork chops.

Based on record review and interview, the facility failed to have a weekend RN for eight hours a day. The Resident Census and Conditions of Residents report documented 30 residents lived in the facility. Findings: The daily staffing schedule for May 2022, did not document RN coverage on the weekends. On 05/05/22 at 11:00 a.m., the interim DON reported the facility had not had a weekend RN since 03/16/22.

Based on record review and interview, the facility failed to include the recommendations from the PASRR Level II evaluation report into a resident's assessment and care planning for one (#22) of five residents reviewed for PASRR screening. The Resident Census and Conditions of Residents report documented 26 residents receiving psychoactive medications. Findings: Res #22's PASRR II evaluation, dated 08/30/16, documented the resident experiences a serious mental illness as defined by CMS. The evaluation documented to refer the resident to outpatient mental health services of his choice for ''Less than Specialized Mental Health Services. The evaluation documented the services should include: a. nursing facility training in health-care management, b. supportive counseling in the part of the nursing facility staff, c. nursing facility should obtain psychiatric records to clarify history, d. a guardian for decisions regarding health and safety, and e. minimum of an annual psychiatric evaluation and [CONDITION(S)] medication review. Res #22 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An annual MDS assessment, dated 10/13/21, documented the resident was cognitively intact and independent with ADLs. The assessment documented the resident had not been evaluated by the Level II PASRR and determined to have a serious mental illness. The resident's care plan did not include the PASRR II recommendations. On 05/04/22 at 5:06 p.m., the MDS coordinator stated she was not aware the resident had PASRR II evaluation.

Based on record review and interview, the facility failed to administer medication as ordered for one (#2) of three residents reviewed for medication administration and/or medication misappropriation. The administrator identified 29 residents who resided in the facility. Findings: Resident #2 was admitted to the facility on [DATE]. A physician order, dated 02/27/21, documented the resident was to have triamincinolone [MEDICATION(S)] cream 0.1% applied to affected areas topically three times a day. The February 2021 TAR documented the resident had the triamincinolone cream applied on 02/28/21 at 8:00 a.m. and 2:00 p.m. as ordered and scheduled. The cream was also scheduled to be applied at 8:00 p.m., which was left blank with no reason documented as to why it was not applied. The March and April 2021 TARs did not document that the triamincinolone cream was to be applied or was applied three times a day routinely as ordered through 04/12/21 when the order was changed to as needed. A physician order, dated 04/12/21, documented to discontinued the routine application of triamincinolone cream three times a day and ordered it to be applied three times a day as needed. From 02/27/21 through 04/12/21, when the triamincinolone cream should have been applied three times a day according to orders, it was not applied as ordered for 127 out of 129 opportunities. On 12/27/21 at 3:30 p.m., the interim DON was asked about the triamincinolone cream ordered to be applied routinely three times a day on 02/27/21. After looking at the order in the electronic clinical record, she stated it was ordered to be applied routinely three times a day on 02/27/21 through 04/12/21 when it was changed to as needed. At 4:00 p.m., the interim DON stated what happened was the March TARs were printed on 02/26/21 and the order was received on 02/27/21. She stated the nurse who took the order should have hand written the order in on the March TAR, however she did not, and the cream was not applied as ordered.

Based on record review and staff interview, it was determined the facility failed to ensure physicians' orders were obtained to conduct COVID-19 testing for three (#1, 2 and #3) of three sampled residents reviewed for infection control related to COVID-19. The facility identified 38 residents who resided in the facility. Findings: The CDC (Centers for Disease Control and Prevention) guidance titled, Symptoms of Coronavirus, dated 05/13/20, documented: People with COVID-19 have had a wide range of symptoms reported - ranging from mild symptoms to severe illness .People with these symptoms may have COVID-19: .Fever or chills .Cough .Shortness of breath or difficulty breathing .Fatigue .Muscle or body aches .Headache .New loss of taste or smell .Sore throat .Congestion or runny nose .Nausea or vomiting .Diarrhea . Influenza (Flu) and COVID-19 are both contagious respiratory illnesses, but they are caused by [MEDICAL CONDITION] .Because some of the symptoms of flu and COVID-19 are similar, it may be hard to tell the difference between them based on symptoms alone, and testing may be needed to help confirm a diagnosis . Resident #1 had COVID-19 testing conducted on 12/15 and 12/24/20 due to the facility being in an outbreak. There were no physician's orders to conduct the tests. Resident #2 had COVID-19 testing conducted on 12/15, 12/21 and 12/24/20 due to the facility being in an outbreak. There were no physician's orders to conduct the tests. Resident #3 had COVID-19 testing conducted on 12/15 and 12/22/20 due to the facility being in an outbreak. There were no physician's orders to conduct the tests. On 12/29/20 at 2:40 p.m., the regional nurse was asked for physician's orders for COVID-19 tests conducted on residents #1, 2 and #3. She stated she did not remember seeing any. She went to the electronic records to look for physician's orders for resident #1. She was asked if there was an order for [REDACTED]. She continued to look for orders for residents #2 and #3. She stated, That's going to be a no for the other two.

Based on observation, record review and staff interviews, it was determined the facility failed to maintain Center of Disease Control and Prevention (CDC) guidelines to aide in the prevention and spread of COVID-19 by failing to ensure: ~ staff utilized appropriate personal protective equipment (PPE) for residents in quaratine and ~ staff practiced proper hand hygiene, ~ recommended quarantine time for one (#1) of three sampled residents reviewed for infection control, ~ COVID-19 testing was conducted for symptomatic residents for two (#1 and #3) of three sampled residents reviewed for infection control and ~ residents were screened for signs and symptoms of COVID-19 for three (#1, 2, and #3) of three sampled residents reviewed for infection control. The facility identified 38 residents resided in the facility and 13 residents with COVID-19. Findings: The CDC guidance titled, Responding to Coronavirus (COVID-19) in Nursing Homes, dated 04/30/20, documented: All facilities should adhere to current CDC infection prevention and control recommendations, including universal source control measures .screening of residents and HCP (health care personal) . Cleaning your hands reduces: · The spread of potentially deadly germs to patients · The risk of healthcare provider colonization or infection caused by germs acquired from the patient · Alcohol-based hand sanitizers are the most effective products for reducing the number of germs on the hands of healthcare providers. · Alcohol-based hand sanitizers are the preferred method for cleaning your hands in most clinical situations. · Wash your hands with soap and water whenever they are visibly dirty, before eating, and after using the restroom. During Routine Patient Care: Use an Alcohol-Based Hand Sanitizer Wash with Soap and Water Immediately before touching a patient When hands are visibly soiled Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices After caring for a person with known or suspected infectious diarrhea Before moving from work on a soiled body site to a clean body site on the same patient After known or suspected exposure to spores (e.g. B. anthracis,[DIAGNOSES REDACTED]icile outbreaks) After touching a patient or the patient ' s immediate environment After contact with blood, body fluids or contaminated surfaces Immediately after glove removal

Based on observation, interview, and record review, it was determined the facility failed to maintain an infection control program and implement measures to provide a safe environment to help prevent the development and transmission of COVID-19 for three (#2, 9, and #13) of four residents sampled for infection control. The facility failed to ensure: a) cloth masks were not worn by direct care staff, b) hand hygiene was performed between encounters with residents, and c) face shields were worn while caring for residents on the COVID-19 unit. The administrator (adm) reported seven residents were COVID-19 positive and 33 residents resided in the facility. Findings: A CDC document, titled Preparing for COVID-19 in Nursing Homes documented, .Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings .HCP who enter the room of a patient with known or suspected COVID-19 should adhere to Standard Precautions and use .eye protection . Hand Hygiene .HCP should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE . HCP should wear a facemask at all times while they are in the facility. When available, facemasks are generally preferred over cloth face coverings for HCP as facemasks offer both source control and protection for the wearer against exposure to splashes and sprays of infectious material from others. On 06/03/20 at 8:40 AM, CMA #1 was observed on North hallway with a cloth mask which was positioned below her nose. The CMA was asked at that time if she had been told she needed to wear a surgical mask. She stated she had not been told to wear a surgical mask. On 06/03/20 at 9:00 AM, CMA #1 was observed behind nurse station on North/South hall with cloth mask below her nose. Another staff member was heard telling her to pull up her mask at that time. On 06/03/20 at 9:21 AM, CMA #1 was observed on the South hall preparing crushed medications and then took them in a cup to resident #2. The CMA was observed to feed the resident the crushed medications with a spoon. The CMA exited the room, went back to the cart, looked through the medication records, and proceeded to prepare the next resident's medication. Hand hygiene was not observed during this observation. On 06/03/20 at 9:36 AM, CNA #1 was observed on the COVID unit without a face shield. The CNA stated she did not wear a face shield because it would fog up. On 06/03/20 at 9:59 AM, CMA #1 was observed to lock and leave her medication cart, which was parked at the beginning of the South hall, and walk the length of the hallway into the last room on the right. The CMA handed a cup of medications to resident #13. The CMA was observed to leave the resident's room, touch the hallway railing about midway down the hall, and then proceeded to the medication cart. The CMA began thumbing through the residents' medication records. The CMA then walked back down the hall to resident #9's doorway and spoke to the resident. The resident's call light was on. The CMA then went back to the medication cart and began to remove medication out of the cart and punch out medications into a cup. The CMA then locked the cart and took the medications into resident #9's room and gave him the cup of medications. The CMA then left the room and touched her masked while walking back to the medication cart. The CMA touched medication records while she looked at the records, then opened the cart and removed cards of medication and began to punch medications for the next resident. Hand hygiene was not observed during this observation. On 06/03/20 at 10:12 AM, CMA #1 was interviewed related to hand hygiene. She said she was trained to perform hand hygiene when hands were dirty. She was then asked if that was the only time. The CMA said hand hygiene was to be performed between residents. She stated she did not like to use the dispensers in the resident rooms, which were located immediately inside the residents' doors. She stated she used the hand gel on the cart. The clear hand gel container on the cart at that time was observed to be empty. The CMA stated she needed to get another container of hand gel. The CMA was informed hand hygiene had not been observed during the observation. The CMA had no reply and did not leave at that time to obtain hand sanitizer. On 06/03/20 at 11:30 AM, the assistant director of nursing (ADON) stated the staff were wearing shields on the COVID unit but had stopped recently since the residents were not having any symptoms. On 06/03/20 at 11:30 AM, the adm stated he had plenty of shields and the staff on the COVID unit should be wearing them. The adm stated the CMA was a new staff member, but had been in-serviced on hand hygiene. He said hand hygiene should always be performed between residents. He stated all staff, except office staff, should wear surgical masks.

Based on observation, record review and interviews, it was determined the facility failed to supervise medication administration for one (#103) of three sampled residents who were reviewed for medication administration. The facility identified all 41 residents in the facility received medications. Findings: Resident #103 had [DIAGNOSES REDACTED]. An admission assessment, dated 12/27/19, documented the resident's cognition was intact. On 02/26/20, at 2:25 p.m., LPN #1 left a full cup of pills on the table in the common area in front of the resident. The resident self-administered all of the medication without staff supervision. At 2:37 p.m. LPN #1 stated she left the cup full of pills on the table for resident #103 to take unsupervised due to being in a hurry. She stated normal protocol for medication administration was to retrieve the medications from the med cart, chart in the MAR and observe the medication being taken. At 2:45 p.m., the DON stated no residents were assessed and able to self administer medications. At 2:53 p.m., the DON stated leaving medications for residents to self-administer unsupervised was not proper protocol.

Based on record review, and interviews, it was determined the facility failed to ensure they notified the resident's hospice service when found unresponsive and obtain an order to release the body for one (#36) of three sampled residents reviewed for discharge. The facility identified six residents who currently resided in the facility and received hospice services. Findings: Resident #36 had [DIAGNOSES REDACTED]. A significant change assessment, dated 12/11/19, documented the resident had a condition that would have a life expectancy of less then six months and received hospice services. A care plan, updated on 12/11/19, documented the resident was on hospice services. The interventions included to notify hospice with a change in condition. A nurse's note, dated 02/09/20 at 11:40 p.m., documented, Patients family here and called me to the room at 22:20 (10:20 p.m.), they stated I think she just stopped breathing I assessed patient, no heart rate, no blood pressure, no pulse, and no respiration. I said yes your right she is gone. and they ask me to turn off the oxygen so I did and told the family I will leave you alone and to call if they need anything . There was no further documentation in the clinical record the facility had contacted the resident's hospice service when she was found unresponsive. There was no additional documentation about the resident's death and the disposition of the body. On 02/26/20 at 9:35 a.m., the resident's daughter stated she had to notify the hospice provider because no one at the facility had. On 02/27/20 at 7:10 a.m., RN #1 stated she did not call hospice because the family called them. She stated she did not document anything further and should have. She further stated she did not know how the funeral home knew to pick up the body, but they did around 12:00 a.m.

Based on record review and interviews, it was determined the facility failed to ensure the assessments were accurate for two (#9 and #10) of 15 sampled residents whose assessments were reviewed for accuracy. The facility identified 39 residents who resided in the facility. Findings: 1. Resident #9 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 10/19/19, was reviewed and the cognitive pattern and mood sections of the assessment were incomplete. 2. Resident #10 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 10/19/19, was reviewed and the cognitive pattern and mood sections of the assessment were incomplete. On 01/08/20 at 2:14 p.m., the MDS coordinator was asked why the sections determining the cognitive status and moods of the residents were not completed on the assessments. She stated the nurse who had conducted the assessments had not come to the facility to evaluate the residents, therefore the nurse could not answer any of those questions. The MDS coordinator stated the assessments had not been done correctly.

Based on observation and interview, it was determined the facility failed to ensure an odor free environment was maintained for one (#9) of 5 rooms observed on A hall. The facility identified 14 rooms on A hall. Findings: On 01/05/20 at 7:14 p.m., and all days of the survey, a strong odor of urine was noted on A hall just outside of room [ROOM NUMBER]. At 9:39 a.m., CNA #1 was asked about the urine odor in room [ROOM NUMBER], She stated that the odor was mostly a urine odor coming from resident #9. She stated the resident soiled herself instead of going to the restroom. The CNA also stated there was another resident two doors down who had a odor from her room, but it's due to her disease process.

On [DATE] at 10:28 a.m., an Immediate Jeopardy (IJ) situation was verified with the Oklahoma State Department of Health (OSDH) regarding the facility's failure to provide cardiopulmonary resuscitation (CPR) to a resident who had no pulse and no blood pressure and who was a full code. At 10:38 a.m., the facility administrator, director of nurses (DON) and the corporate registered nurse (RN) were informed of the IJ situation related to the facility's failure to initiate CPR for a resident. A plan of removal for the IJ situation was requested. On [DATE] at 2:58 p.m., the administrator provided the survey team with an acceptable plan of removal. He stated the plan of removal components had already been completed when the plan of removal was provided. The facility's plan of removal documented the following: Immediate Jeopardy 11:50am 1. All staff will be re-educated regarding location of resident code status and when to initiate CPR. 2. An audit of resident charts has been completed to ensure accuracy of resident code status. 3. A resident list of code status will be kept at the nurse station, crash cart, and supply room 4. Implementation of CPR will be conducted when a resident is a FULL CODE status and when the resident is found to be without a pulse 5. Employees that are unable to be reached will not work until they have been properly in-serviced. On [DATE] and [DATE], interviews were conducted with a total of 12 employees who worked different shifts and in different departments. The employees verified they had been inserviced regarding the components documented in the plan of removal and that they understood the information provided. On [DATE] at 3:18 p.m., the administrator was informed the IJ had been removed as of [DATE] at 3:00 p.m. The deficient practice remained at a level of actual harm, isolated. Based on record review and interview, it was determined the facility failed to initiate CPR for one (#10) of one sampled residents who had no pulse and no blood pressure and was designated as a full code. This resulted in an IJ situation. Findings: The facility's abuse policy documented: .Abuse also includes the deprivation by and individual, (including a caretaker), of goods or services that are necessary to attain or maintain physical, mental and psychosocial well being. This presumed that instances of abuse of all residents, even those in a coma, cause physical harm or pain or mental anguish . The facility's Emergency Procedure - Cardiopulmonary Resuscitation policy and procedure documented: Personnel have completed training on the initiation of Cardiopulmonary Resuscitation (CPR)/Basic Life Support (BLS) in victims of sudden [MEDICAL CONDITION] .[MEDICAL CONDITION] is defined as inadequate cardiac contractions resulting in insufficient blood flow throughout the body (pulselessness) .Victims of [MEDICAL CONDITION] may initially have gasping respirations or may even appear to be having a [MEDICAL CONDITION]. Training in BLS includes recognizing the atypical presentations of SCA (sudden [MEDICAL CONDITION]) .Any unnecessary interruptions in chest compressions (including longer than necessary pauses for rescue breathing) decreases CPR effectiveness .The goal of early delivery of CPR is to try to maintain life until the emergency medical response team arrives to deliver Advanced Life Support (ALS) .If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: a. It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR .exists for that individual; or b. There are obvious signs of irreversible death (e.g. rigor mortis) .Begin CPR if the adult victim is unresponsive and not breathing normally (ignoring occasional gasps) without assessing the victim's pulse .Following initial assessment, begin CPR with chest compressions rather than opening the airway and delivering rescue breathing .All rescuers, trained or not, should provide chest compressions to victims of [MEDICAL CONDITION] . A physician's orders [REDACTED]. Resident #10 was admitted to the facility for skilled nursing services on [DATE]. Her [DIAGNOSES REDACTED]. The clinical record was reviewed. There was a sticker placed on the first tab inside of the residents record which indicated she was a FULL CODE. The admission assessment, dated [DATE], documented the resident had severe cognitive impairment and had received speech therapy, occupational therapy and physical therapy during the 7 days prior to the assessment date. A comprehensive care plan had not been developed for the resident. (She had been in facility 11 days prior to her death.) A nurse's note, dated [DATE] at 8:16 a.m., documented the following: Res (Resident) was in the dining room eating, her head dropped and she was unresponsive. Sternum rub applied nothing. (Resident) was taken to her room and placed on her bed by (certified nurse aides). the ambulance was called, the crash cart was taken to her room. Unable to feel pulse or obtain (blood pressure). (Respirations) were 5, gulps per minute. Eyes were rolled back. Daughter (name withheld) and Dr (name withheld) notified. The note was entered by licensed practical nurse (LPN) #1. There was no documentation in the clinical record which indicated CPR had been initiated on the resident at any time. An emergency medical services (EMS) prehospital care report, dated [DATE], documented the following times for the ambulance response to the facility's call: Time received: 07:56 (a.m.) Responding: 08:01 On scene: 08:04 Patient contact: 08:06 Transport: 08:17 At Destination (hospital): 08:18 Transfer of Care: 08:19 The EMS report documented the complaint reported was [MEDICAL CONDITION]/Death. The EMS report's initial assessment/treatment at 8:06 a.m. documented the resident was apneic, had an absent carotid pulse, and no blood pressure. The EMS report narrative was as follows: Dispatched to Purcell Care Center on an 85 (year old female) who is unresponsive, full code. (Arrived on scene) to find laying semi-fowlers in bed unresponsive and without nursing home staff performing CPR. EMS learned that the patient was in the mess hall eating breakfast when she had an acute change in responsive, became unresponsive, and staff brought her back into her bed. EMS found an absent carotid pulse and CPR was performed .Pt .taken to ambulance .was placed on the cardiac monitor .which revealed asystole. The EMS report documented the resident's primary reason for treatment was [MEDICAL CONDITION], cause unspecified. The report documented the resident's secondary reason for treatment was [MEDICAL CONDITION], unspecified. A nurse's note, dated [DATE] at 9:07 a.m. documented: THIS NURSE NOTIFIED (RESIDENT) WAS (DEAD ON ARRIVAL). On [DATE] at 8:20 a.m., the surveyor went room to room to determine if there was any system in place to determine whether a resident was a full code or a DNR from the resident's room. No notation or coding system was identified. Some of the resident's bedrooms were approximately 40 yards from the nurses' station. At 8:25 a.m., LPN #1 was asked if she recalled who resident #10 was. She stated she did. She was asked if she remembered if the resident was full code or do not resuscitate status. She stated the resident was full code status and I recall that very well. The LPN was asked if CPR was initiated on the resident when she became unresponsive in the dining room and was taken to her room the morning of [DATE]. She stated the resident had started to breathe on her own and showed the surveyor the way the resident was breathing. The example of breathing was gasps. She stated the crash cart was taken to the resident's room and the previous director of nurses (DON), three or four certified nurse aides and herself were present in the room. The LPN was shown the nurse's note, dated [DATE] at 8:16 a.m., and was asked why CPR was not performed when the resident had no pulse. She stated the resident was breathing. The surveyor asked if breathing circulated blood. She stated, No. LPN #1 stated the previous DON was telling her what to do. She stated the DON stayed in the resident's room and she went to the nurses' station to call the ambulance and get the transfer paper work ready. The surveyor asked LPN #1 if she saw CPR administered on the resident. She stated, No. She was asked if CPR should have been started on an unresponsive resident with no pulse and who was full code status. She stated, Yes. On [DATE] at 9:20 a.m., certified medication aide (CMA) #1 was asked how she knew which residents were DNR. She stated the list was in the Medication Administration Record, [REDACTED]. She was asked what the procedure was when a resident was found lying unresponsive on the floor in their room. She stated she would call for help, wait for a nurse to come and, if the resident was a full code, perform CPR. On [DATE] at 9:33 a.m., certified nurse aide (CNA) #4 was asked how she knew which residents were a DNR. She stated there was a list of residents located in the cabinet at the nurses' station. She stated, We just look at the list every day and we know. CNA #4 was asked which residents who resided on hall A were DNRs. She stated, Uh, I can't tell you right now. The surveyor asked what the procedure was when she found an unresponsive resident lying in their room. She stated, I call for help and find out if the resident is a DNR. If they're not, start CPR. On [DATE] at 9:30 a.m., the DON was asked to review the closed clinical record of resident #10 and was asked if the resident was full code status. He pointed to the physician's orders [REDACTED]. The DON was asked if CPR was initiated when the resident became unresponsive in the dining room and was taken to her room and placed in her bed. He read the nurse's note, dated [DATE] at 8:16 a.m., and stated the note did not document that CPR was performed. The DON was asked if CPR should have been performed for a resident who was full code status and who had no pulse. He stated, That's standard protocol. The DON was asked if the facility had conducted any inservices regarding DNRs and full code status since [DATE]. He stated, No. On [DATE] at 11:06 a.m., the surveyor interviewed one of the emergency medical technicians (EMTs) who came to the facility on [DATE] and attended resident #10. He was asked if the facility staff were performing CPR on the resident when he arrived on the scene. He stated, No. The EMT was asked if the resident had a pulse. He stated, No. He further stated the resident had agonal breathing with long pauses. On [DATE] at 1:00 p.m., the former DON was asked if resident #10 was supposed to be a full code. She acknowledged the resident was a full code. The surveyor asked the former DON about the incident in the dining room on [DATE] when resident #10 became unresponsive. The former DON stated the resident was seated in a geri-chair and staff pushed her out of the dining room and down the hallways into the resident's room. She stated she sent LPN #1 for the crash cart. The former DON stated resident #10 had agonal breathing and she put oxygen on her because she knew oxygen wasn't getting to her (resident #10's) brain. She stated the resident's pulse oximeter reading was 0. She was asked approximately how much time went by from the point she obtained the initial pulse oximeter reading, applied oxygen to the resident and EMS arrived. She stated, Probably ,[DATE] minutes. The former DON was asked again why, if she knew the resident was not getting oxygen to her brain, chest compressions were not started. She stated the resident had a faint pulse and agonal breathing. She was asked if the application of oxygen would be effective if the resident had no circulation. She stated, She still had a pulse. She further stated she was just hooking the ambu bag to the oxygen tubing when EMS arrived. The surveyor asked the former DON if she had documented the incident anywhere in the resident's clinical record. She stated, No.

On 10/26/17 at 2:00 p.m., an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to provide adequate supervision to prevent identified residents who were at risk for elopement from eloping. At 2:13 p.m., the Oklahoma State Department of Health (OSDH) verified the existence of the IJ situation. At 2:38 p.m., the Administrator, Director of Nursing (DON), the corporate nurse and the chief executive officer (CEO), were informed an IJ situation existed due to the facility's failure to ensure staff provided supervision of entry/exit doors to prevent the elopement. At 3:50 p.m., an acceptable plan of removal was received from the corporate nurse. The plan of removal documented: 1. Assigned 1:1 staffing 24/7 for (Resident #29) and documented on a Hourly check sheet at the nurse station. 2. Re-inserviced all staff regarding elopement risk. Employees will not return to work until in-serviced. 3. Contacted (name deleted husband) to assist in location of different facility. 4. Completed by 4pm, 10-26-2017 5. The Administrator will ensure proper completion or designee 6. Residents that are at risk are located in an elopement book An audit of residents will be completed and located in the book as needed. Interviews were conducted with facility staff on 10/27/17. After the last staff member was interviewed and was able to verbalize knowledge of the facility's policy for identifying residents at risk for elopement and how to properly monitor doors, the IJ was removed back to 10/26/17 at 4:00 p.m. when the inservices had been completed. The deficient practice remained at am isolated leval with a potentiol for more than minimal harm. Based on observation, interview and record review, it was determined the facility failed to ensure residents who were at risk for elopement were provided adequate supervision to prevent the elopement of one (#29) of two sampled residents whose records were reviewed for elopement risks. This resulted in an immediate jeopardy. Findings: A facility policy documented, Elopements .Policy Interpretation and Implementation 1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing. 2. If an employee observes a resident leaving the premises, he/she should: a. Attempt to prevent the departure in a courteous manner; b. Get help from other staff members in the immediate vicinity, if necessary; and c. Instruct another staff member to inform the Charge Nurse or Director of Nursing Services that a resident has left the premises. 3. When a departing individual returns to the facility, the Director of Nursing Services or Charge nurse shall: a. Examine the resident for injuries; b. Notify the Attending Physician; c. Notify the resident's legal representative (sponsor) of the incident; d. Complete and file Report of Incident/Accident; and e. Document the event in the resident's medical record When the resident returns to the faciltiy, the Director of Nursing Services or Charge Nurse shall: a. Examine the resident for injuries; b. Contact the Attending Physician and report findings and conditions of the resident; c. Notify the resident's legal representative (sponsor); d. Notify search teams that the resident has been located; e. Complete and file an incident report; and f. Document relevant information in the resident's medical record. Resident #29 was admitted to the facility with [DIAGNOSES REDACTED]. A nurse's note, dated 04/03/17 at 5:40 a.m., documented, Resident up at 0430 (4:30 a.m.) this am and sat in lobby for about 15 min. (minutes) This nurse walked her back to her room when she was ready and she sat in a chair. about 30 min later (name deleted certified nurse aide # 5) stated resident was not in her room. This nurse and aides looked over building then outside. She was found outside by the road. Resident is now at nurses station sitting in chair. According to Weather Underground, the temperature on 04/03/17 at 5:35 a.m. was 51.8 degrees with a west wind of 11.5 miles per hour. A nurse's note, dated 05/26/17 at 12:20 p.m., documented (Resident #29) CONT (continues) ON OBS (observation) D/T (due to) RECENT FALL, NO NEW INJURIES VISIBLE. RES UP FOR BREAKFAST AND LUNCH WITH HER HUSBAND, VERY PLEASANT WHILE HUSBAND IS AT HER SIDE. CONT WITH TEARFULNESS WHEN HE LEAVES, WILL WANDER T/O (throughout) FACILITY LOOKING FOR HER HUSBAND. STAFF ED (educated) ON FREQ (frequent) KEEPING RES (resident) IN VIEW WHILE SHE IS AT BACK LOBBY DOOR D/T (due to) HIGH ELOPEMENT RISK. RES VOICES NO C/O'S (complaints) AT THIS TIME. An annual assessment, dated 08/11/17, documented the resident's cognition was severely impaired, she required limited assistance with ambulation and used a wheelchair for mobility. A care plan, undated, documented the resident was alert to self and was a wandering resident at times. She had been observed attempting to exit the facility looking for her husband and she was at risk for elopement. The goal documented the resident's safety will be maintained and staff would ensure she does not exit the facility without staff or family supervision. Interventions included the residents picture was to be kept in an elopement book at the nurse's station, staff were to continue to observe exits for the resident and staff were to provide the resident with diversional activities as needed or when the resident would allow. A wandering risk assessment, dated 09/09/17, documented the resident was disoriented times two spheres, she was forgetful/short attention span and does have poor decision making ability. Her Behavior/Mood documented she exhibited/expressed fear and/or anxiety. The assessment documented she was independent with mobility, had a [DIAGNOSES REDACTED]. On 10/26/17 at approximately 12:47 p.m., the resident was observed walking down the street approximately 1 and 1/2 blocks away from the facility. A surveyor stayed with the resident as she continued to walk away from the facility. The remaining surveyors then went into the facility to observe if staff had identified the resident was not in the building. There was no indication by staff they were aware the resident was missing. The administrator was notified of the observation of the resident walking down the street away from the facility. The resident was approximately 1/4 of a mile from the facility when the administrator picked her up. At 1:36 p.m., the administrator was shown the nurse's note from 04/03/17. He was asked if he was made aware of this documentation. He stated he was unaware of the incident. The administrator stated he reviewed the cameras and she was gone for approximately 9 minutes. He observed the laboratory staff open the door and let her out.

On [DATE] at 10:38 a.m., the facility administrator, director of nurses (DON) and the corporate registered nurse (RN) were informed of the IJ situation related to the facility's failure to initiate CPR for a resident when she became unresponsive, had no blood pressure, no pulse and had exercised her right to request a full code status. A plan of removal for the IJ situation was requested. At 2:58 p.m., the administrator provided the survey team with an acceptable plan of removal. He stated the plan of removal components had already been completed when the plan of removal was provided. The facility's plan of removal documented the following: Immediate Jeopardy 11:50am 1. All staff will be re-educated regarding location of resident code status and when to initiate CPR. 2. An audit of resident charts has been completed to ensure accuracy of resident code status. 3. A resident list of code status will be kept at the nurse station, crash cart, and supply room 4. Implementation of CPR will be conducted when a resident is a FULL CODE status and when the resident is found to be without a pulse 5. Employees that are unable to be reached will not work until they have been properly in-serviced. On [DATE] and [DATE], interviews were conducted with a total of 12 employees who worked different shifts and in different departments. The employees verified they had been inserviced regarding the components documented in the plan of removal and that they understood the information provided. On [DATE] at 3:18 p.m., the administrator was informed the IJ had been removed as of [DATE] at 3:00 p.m. The deficient practice remained at a level of actual harm, isolated. Based on record review and interview, it was determined the facility failed to initiate CPR for one (#10) of one sampled residents who had no pulse and no blood pressure and was designated as a full code. The facility's Emergency Procedure - Cardiopulmonary Resuscitation policy and procedure documented: Personal have completed training on the initiation of Cardiopulmonary Resuscitation (CPR)/Basic Life Support (BLS) in victims of sudden [MEDICAL CONDITION] .[MEDICAL CONDITION] is defined as inadequate cardiac contractions resulting in insufficient blood flow throughout the body (pulselessness) .Victims of [MEDICAL CONDITION] may initially have gasping respirations or may even appear to be having a [MEDICAL CONDITION]. Training in BLS includes recognizing the atypical presentations of SCA (sudden [MEDICAL CONDITION]) .Any unnecessary interruptions in chest compressions (including longer than necessary pauses for rescue breathing) decreases CPR effectiveness .The goal of early delivery of CPR is to try to maintain life until the emergency medical response team arrives to deliver Advanced Life Support (ALS) .If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: a. It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR .exists for that individual; or b. There are obvious signs of irreversible death (e.g. rigor mortis) .Begin CPR if the adult victim is unresponsive and not breathing normally (ignoring occasional gasps) without assessing the victim's pulse .Following initial assessment, begin CPR with chest compressions rather than opening the airway and delivering rescue breathing .All rescuers, trained or not, should provide chest compressions to victims of [MEDICAL CONDITION] . A physician's orders [REDACTED]. Resident #10 was admitted to the facility for skilled nursing services on [DATE]. Her [DIAGNOSES REDACTED]. The clinical record was reviewed. There was a sticker placed on the first tab inside of the residents record which indicated she was a FULL CODE. The admission assessment, dated [DATE], documented the resident had severe cognitive impairment and had received speech therapy, occupational therapy and physical therapy during the 7 days prior to the assessment date. A comprehensive care plan had not been developed for the resident. (She had been in facility 11 days prior to her death.) A nurse's note, dated [DATE] at 8:16 a.m., documented the following: (Resident) was in the dining room eating, her head dropped and she was unresponsive. Sternum rub applied nothing. (Resident) was taken to her room and placed on her bed by (certified nurse aides). the ambulance was called, the crash cart was taken to her room. Unable to feel pulse or obtain (blood pressure). (Respirations) were 5, gulps per minute. Eyes were rolled back. Daughter (name withheld) and Dr (name withheld) notified. The note was entered by licensed practical nurse (LPN) #1. There was no documentation in the clinical record which indicated CPR had been initiated on the resident at any time. An emergency medical services (EMS) prehospital care report, dated [DATE], documented in the initial assessment/treatment at 8:06 a.m., the resident was apneic, had an absent carotid pulse, and no blood pressure. The EMS report narrative was as follows: Dispatched to Purcell Care Center on an 85 (year old female) who is unresponsive, full code. (Arrived on scene) to find laying semi-fowlers in bed unresponsive and without nursing home staff performing CPR. EMS learned that the patient was in the mess hall eating breakfast when she had an acute change in responsive, became unresponsive, and staff brought her back into her bed. EMS found an absent carotid pulse and CPR was performed .Pt .taken to ambulance .was placed on the cardiac monitor .which revealed asystole. The EMS report documented the resident's primary reason for treatment was [MEDICAL CONDITION], cause unspecified. The report documented the resident's secondary reason for treatment was [MEDICAL CONDITION], unspecified. A nurse's note, dated [DATE] at 9:07 a.m. documented: THIS NURSE NOTIFIED (RESIDENT) WAS (DEAD ON ARRIVAL). On [DATE] at 8:25 a.m., LPN #1 was asked if she recalled who resident #10 was. She stated she did. She was asked if she remembered if the resident was full code or do not resuscitate status. She stated the resident was full code status and I recall that very well. The LPN was asked if CPR was initiated on the resident when she became unresponsive in the dining room and was taken to her room the morning of [DATE]. She stated the resident had started to breathe on her own and showed the surveyor the way the resident was breathing. The example of breathing was gasps. She stated the crash cart was taken to the resident's room and the previous director of nurses (DON), three or four certified nurse aides and herself were present in the room. The LPN was shown the nurse's note, dated [DATE] at 8:16 a.m., and was asked why CPR was not performed when the resident had no pulse. She stated the resident was breathing. The surveyor asked if breathing circulated blood. She stated, No. LPN #1 stated the previous DON was telling her what to do. She stated the DON stayed in the resident's room and she went to the nurses' station to call the ambulance and get the transfer paper work ready. The surveyor asked LPN #1 if she saw CPR administered on the resident. She stated, No. She was asked if CPR should have been started on an unresponsive resident with no pulse and who was full code status. She stated, Yes. On [DATE] at 9:30 a.m., the DON was asked to review the closed clinical record of resident #10 and was asked if the resident was full code status. He pointed to the physician's orders [REDACTED]. The DON was asked if CPR was initiated when the resident became unresponsive in the dining room and was taken to her room and placed in her bed. He read the nurse's note, dated [DATE] at 8:16 a.m., and stated the note did not document that CPR was performed. The DON was asked if CPR should have been performed for a resident who was full code status and who had no pulse. He stated, That's standard protocol. The DON was asked if the facility had conducted any inservices regarding DNRs and full code status since [DATE]. He stated, No. On [DATE] at 11:06 a.m., the surveyor interviewed one of the emergency medical technicians (EMTs) who came to the facility on [DATE] and attended resident #10. He was asked if the facility staff were performing CPR on the resident when he arrived on the scene. He stated, No. The EMT was asked if the resident had a pulse. He stated, No. He further stated the resident had agonal breathing with long pauses. On [DATE] at 1:00 p.m., the former DON was asked if resident #10 was supposed to be a full code. She acknowledged the resident was a full code. The surveyor asked the former DON about the incident in the dining room on [DATE] when resident #10 became unresponsive. The former DON stated the resident was seated in a geri-chair and staff pushed her out of the dining room and down the hallways into the resident's room. She stated she sent LPN #1 for the crash cart. The former DON stated resident #10 had agonal breathing and she put oxygen on her because she knew oxygen wasn't getting to her (resident #10's) brain. She stated the resident's pulse oximeter reading was 0. She was asked approximately how much time went by from the point she obtained the initial pulse oximeter reading, applied oxygen to the resident and EMS arrived. She stated, Probably ,[DATE] minutes. The former DON was asked again why, if she knew the resident was not getting oxygen to her brain, chest compressions were not started. She stated the resident had a faint pulse and agonal breathing. She was asked if the application of oxygen would be effective if the resident had no circulation. She stated, She still had a pulse. She further stated she was just hooking the ambu bag to the oxygen tubing when EMS arrived. The surveyor asked the former DON if she had documented the incident anywhere in the resident's clinical record. She stated, No.

On [DATE] an immediate jeopardy situation (IJ) was determined to exist due to the facility's failure to assess, monitor, and intervene appropriately and timely for a resident who had a change of condition related to an injury of unknown origin which was first documented on [DATE]. The facility failed to thoroughly assess, monitor, intervene and investigate an injury of unknown origin on [DATE]. The facility failed to intervene regarding a change in the resident's condition which began on [DATE]. The resident was admitted to an acute care facility on [DATE] and required emergent intraosseous infusion for hydration and pain control. The physician's discharge summary [MEDICAL CONDITION], aspiration pneumonia, acute kidney injury, UTI, and [MEDICAL CONDITIONS]. The resident expired on [DATE]. On [DATE] at 11:30 a.m., the Oklahoma State Department of Health (OSDH) was notified and verified the IJ situation. On [DATE] at 11:55 a.m., the administrator and director of nursing were notified of the IJ situation. At 2:07 p.m., the facility presented an acceptable plan of removal to the survey team. [DATE] .(facility name) plan of removal for Immediate Jeopardy: 1. Resident best practical well-being - All staff will be inserviced (see attached) regarding notification of change in resident condition and pain assessment. This inservice will be signed, dated and timed for each staff member. Nursing notes will be reviewed by DON and or MDS/Care plan coordinator to ensure that any residents with a change in condition within the last 7 days have had notifications to Physician and Family. Pain assessments for any noted residents from the above review will also be reviewed by DON or designee and completed if necessary. 2. Accidents/Hazards - Nursing staff will be inserviced (see attached) on how to tell if a resident is care planned for a mechanical lift by facility MDS/Care plan Coordinator. This inservice will be signed, dated and timed for each staff member. Residents requiring assistance with transfers will be reviewed by facility MDS/Care plan Coordinator to ensure that care plans accurately reflect transfer method. Care plans will be reviewed quarterly and with any change of conditions by Interdisciplinary team. 3. Inservicing will be completed on nursing staff currently working immediately and additional staff via telephone or face to face by 11:30pm tonight or they will not be allowed to again (sic) until education has been completed. Any staff not reeducated by 11:30pm tonight will be removed from the schedule until education has been completed. On [DATE] at 7:04 p.m., the Immediate Jeopardy was removed after all staff had been in-serviced in regards to recognizing pain, intervening when a resident has a change of condition, reporting and documentation of signs and symptoms of a change in a resident's condition, and determining lift transfers and how to find the information on the care plan. This deficient practice remained at a pattern level of actual harm. Based on observation, staff, resident, and family interviews, and review of the facility's policy and procedures, it was determined the facility failed to assess, monitor, and intervene for a resident who sustained an injury of unknown origin with signs and symptoms of a significant change in condition for one (#1) of five sampled residents with change in condition. This deficient practice resulted in an immediate jeopardy situation for the resident who was hospitalized , required emergent intraosseous infusion for hydration and medication management. The resident was diagnosed with [REDACTED]. The resident expired. The facility identified 12 residents who have had a change in condition in the last 60 days. Findings: A facility policy titled, Change in a Resident's Condition or Status, dated [DATE], documented, .Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g. changes in level of care . 1. .The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been .A discovery of injuries of an unknown source .A significant change in the resident's physical/emotional/mental condition .A need to transfer the resident to a hospital/treatment center .Instructions to notify the physician of changes in the resident's condition . 2. .A 'significant change' of condition is a decline or improvement in the resident's status that .Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting) .Impacts more than one area of the resident's health status .requires interdisciplinary review and/or revision to the care plan . 3. .Unless otherwise instructed by the resident, the Nurse Supervisor/Charge Nurse will notify the resident's family or representative (sponsor) when . a. The resident is involved in any accident or incident that results in an injury including injuries of unknown source . b. There is a significant change in the resident's physical, mental, or psychosocial status . e. It is necessary to transfer the resident to a hospital/treatment center . 6. .The Nurse Supervisor/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status . A facility policy titled, Pain Assessment and Management, dated [DATE], documented, .Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals . 2. .Pain management is a multidisciplinary care process that includes the following . a. Assessing the potential for pain . b. Effectively recognizing the presence of pain . c. Identifying the characteristics of pain . d. Addressing the underlying causes of pain . g. Monitoring for the effectiveness of interventions . h. Modifying approaches as necessary . 5. .Conduct a comprehensive pain assessment .whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain . 6. .Assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain . .Recognizing Pain: 1. Observe the resident (during rest and movement) for physiologic and behavioral (non-verbal) signs of pain . .Possible Behavioral Signs of Pain . a. Verbal expressions such as groaning, crying, screaming . b. Changes in gait, skin color and vital signs . c. Behavior such as resisting care, irritability, depression, decreased participation in usual activities . .Possible Physiological Signs of Pain: a. Increased blood pressure . b. [MEDICAL CONDITION]. c. Increased respirations .and d. Diaphoresis . .Documentation: 1. Document the resident's reported level of pain with adequate detail (i.e. enough information to gauge the status of pain and the effectiveness of interventions for pain) as necessary and in accordance with pain management program . .Report the following information to the physician or practitioner . 1. Significant changes in the level of the resident's pain . 2. Adverse effects from pain medications . 3. Prolonged, unrelated pain despite care plan interventions . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan, revised on [DATE], documented, .Focus .(resident) is unable to voice her needs at this time r/t cognition. She doesn't communicate with staff, staff reports she will yell out frequently in her w/c t/o the day .Goal .Staff will anticipate residents needs d/t non communication .Interventions .Anticipate and meet all needs .Ensure/provide a safe environment .Monitor/Document for physical/nonverbal indicators of discomfort or distress, and follow-up as needed . A quarterly assessment, dated [DATE], documented she was severely impaired cognitively for daily decision making skills. She required extensive assistance of two persons for bed mobility, transfers, dressing, toilet use, and hygiene. She had limited upper body range of motion on both sides, and was totally incontinent of bowel and bladder. The assessment further documented she was on scheduled pain medication and was not in pain during the look back period. A Medication Administration Record [REDACTED].[MEDICATION NAME] Patch 72 Hour .Apply 25 mcg [MEDICATION NAME] every 72 hours related to GENERALIZED PAIN .[MEDICATION NAME] Tablet 325 MG ([MEDICATION NAME]) Give 2 tablets by mouth every 4 hours as needed for Mild Pain related to GENERALIZED PAIN . A nurse's note, dated [DATE] at 12:25 a.m., documented, .VS ,[DATE] p 68 r 18 t 97.2 on 2400 rounds cna found skin tear 2.5cm x 3cm to right shin cleansed with wound cleanser applied steri strips and covered Left shin is slightly swollen and faint bruise starting placed icepack on left shin call light in reach no distress noted notified DR DON and administrator via telephone . A nurse's note, dated [DATE] at 12:45 a.m., documented, .Took ice pack off shin resident completion (sic) is pale in color. Placed HOB at 60 degree angle call light in reach no distress noted . A facility incident report form, dated [DATE] at 2:41 a.m., documented, .2400 rounds cna found 2.5cm x 3cm skin tear to right shin cleaned with wound cleanser placed steri strips and wrapped with conforming gauze. Left shin is slightly swollen and faint bruising starting placed icepack on left shin. VS ,[DATE] p68 r18 t97.2 call light in reach notified DR DON and administrator via telephone . The facility incident report did not contain documentation of an investigation with interviews of the night staff by the charge nurse in regards to the new skin tear and swelling/bruising to left lower extremity. A nurse's note, dated [DATE] at 8:52 a.m., documented, .t99.0 Res has bi-lat crackeles (sic) with expiration. Non productive cough. N/O for CXR,[MEDICATION NAME] and [MEDICATION NAME] capsules BID x 10 days . A restorative aide note, dated [DATE] at 10:57 a.m., documented, .passive rom to bu/bl ext x 15 reps each, hand roll in right hand to prevent further contracture . A nurse's note, dated [DATE] at 10:44 a.m., documented, .NOTED SWELLING TO L KNEE RES SHOWS S/S OF PAIN AND DISCOMFORT NOTIFIED (PHYSICIAN #1) REC'D ORDERS TO X RAY L KNEE AND HIP RES DTR (NAME WITHHELD) NOTIFIED OF ORDERS. (X-RAY COMPANY NAME WITHHELD) NOTIFIED FOR X RAY WILL BE HERE THIS AFTERNOON . A restorative aide note, dated [DATE] at 1:16 p.m., documented, .passive rom to bu/bl x 15 reps each, hand roll in right hand to prevent further contracture . A nurse's note, dated [DATE] at 9:42 p.m., documented, XXX,[DATE] VS - 97.9, 95, 24, ,[DATE], 84% on RA. RESIDENT ASSISTED TO G/C AND STAFF PROPELS (SIC) HER TO THE D/R FOR MEAL. RESIDENT CONTS. WITH NP COUGH AND LABORED BREATHING AT THIS TIME. BEGAN TO COUGH DURING FEEDING AND STAFF BROUGHT TO THE FRONT LOBBY TO SIT UP BEFORE LAYING IN BED. CONTS. ON ABT FOR URI WITHOUT ANY NOTED A/R. CALL LIGHT IN REACH. FALL MAT IN PLACE . The clinical record did not contain documentation the physician was notified of the abnormal vital signs and labored breathing. A MAR, dated [DATE], documented [MEDICATION NAME] was given. The documentation did not contain why or how many tablets were given. A nurse's note, dated [DATE] at 12:29 p.m., documented, .T 98.4 RES CONT ABT FOR URI W/O S/S OF ADVERSE REACTIONS NOTED CONT TO HAVE COUGH WITH CONGESTION FLDS ENC AT MEAL TIMES, CONT TO HAVE SLIGHT SWELLING TO L KNEE AT THIS TIME, NO REPORT ON X RAY TO L HIP AND KNEE AT THIS TIME. CONT. TO MONITOR . A Final X-Ray Report documented the date of service was [DATE]. The x-ray report contained documentation the physician was faxed on [DATE] with the results. A nurse's note, dated [DATE] at 8:54 a.m., documented, .(Physician #1) called re: Fx of the L Tibia Plateau without displacement. Ordered consult with Orthopedic specialist. Will notify SS. Need apt stat. DON notified POA . A unsigned physician order, dated [DATE] at 10:11 a.m., documented, .Tylenol with [MEDICATION NAME] #3 Tablet ,[DATE] MG ([MEDICATION NAME]-[MEDICATION NAME]) Give 1 tablet by mouth every 4 hours as needed for Pain related to AGE-RELATED [MEDICAL CONDITION] WITHOUT CURRENT PATHOLOGICAL FRACTURE . A MAR, dated [DATE] at 10:42 a.m., documented, .Resident received two Tylenol 325 mg po for complaints of pain in both legs per nurse . An initial Incident Report Form faxed to the Oklahoma State Health Department, dated [DATE], documented, .Per CN, it was noted that res left knee was [MEDICAL CONDITION] and dark purplish discoloration and tender to touch. PCP notified with new orders to X-ray left knee, left leg, and left hip. Res given pain meds to help alleviate pain and she was placed on close observation. Bruising and [MEDICAL CONDITION] are of unknown origin. X-Ray back and clean fx to left tibia. (Physician #1) notified and N/O for ortho consult. We are in process of calling ortho and seeing which one we can get res into the quickest and not sure what ortho will do r/t res age of 98 yo. At this time, all staff that worked around the 7th are being interviewed to find out what happened to left leg due to res unable to tell us . A nurse's note, dated [DATE] at 9:40 p.m., documented, .transferred to (hospital name withheld) ER for aspiration pneumonia. (Daughter name withheld) was called and informed of the transfer. continued on antibiotics for uri. Vital signs Blood presser (sic) ,[DATE], pulse 79, temperature 97.4, o2 sat 90% on room air . A hospital laboratory report, dated [DATE] at 9:42 p.m., documented, .Urine culture .Escherichia coli .CBC .WBC .22.5* (4XXX,[DATE].0) .Hgb .8.4*(12XXX,[DATE].5) .BUN .88*(,[DATE]) .Creat .3.20*(0XXX,[DATE].60) .D-Dimer .2833*(,[DATE]) .CXR .'Diffuse mild pneumonia. [MEDICAL CONDITIONS] is also a consideration but the heart is not enlarged' .XR TIBIA AND FIBULA LEFT (Results pending) .XR TIBIA AND FIBULA RIGHT (Results pending) . The hospital record further documented, .Clinical Impression .Final diagnosis .Pain in both lower extremities .SOB (shortness of breath) .Fall, initial encounter .Abdominal pain, acute .Dehydration .Acute [MEDICATION NAME] with hematuria .Sepsis associated [MEDICAL CONDITION], and [MEDICAL CONDITION] . A hospital record, dated [DATE] at 11:01 p.m., documented an emergent intraosseous insertion for infusion for fluid and medication administration. A final Incident Report Form, faxed to the Oklahoma State Department of Health, dated [DATE], documented, .Obtained statements from all nursing staff that worked [DATE], no one noticed resident legs with unusual [MEDICAL CONDITION] and no discoloration at all. Resident had a CXR ordered on [DATE] for congestion and PCP also placed her on ABT at that time. CXR came back clear. Res was sent to ERD on [DATE] for respiratory issues and received call from physician on [DATE] to report res had expired. All staff were inserviced that if they notice anything unusual about any resident that is not per their norm or even if it is per their norm but there is a change to notify the nurse immediately . On [DATE] at 2:10 p.m., a family member of resident #1 was asked what happened which caused your mother to be transferred to the hospital. The family member stated, The head nurse on ,[DATE] called and stated three of them were carrying her down the hall and they dropped her. The family member further stated, We did not send her to the hospital for the fracture, we sent for congestion. The family member was asked if their mother was in pain while at the hospital. The family member stated, Very, very significant pain. They were pumping [MEDICATION NAME] through the I.V., it lasted for hours. The family member further stated, Nobody could stand the moaning and groaning. On [DATE] at 3:15 p.m., RA #1 was asked what do you do when you provide range of motion exercises to a resident and they experience pain. She stated, I notify the nurse. She was asked when is this documented. She stated, I document when I chart. She further stated, I don't document the pain, I just let them know. I just document what I did. She was asked if she had any concerns when she provided range of motion exercises for resident #1 on [DATE]. She stated, There wasn't anything that concerned me on that day. I couldn't move her around much, but did not see any blood on the blankets. She was asked if she saw any swelling or bruising on her left leg when she provided range of motion exercises to the resident. She stated, I did not personally see any swelling or anything out of the ordinary the three times I did range of motion exercises on her. She was asked if the resident experienced pain during the exercises. She stated, No more noises than usual. On [DATE] at 7:30 a.m., LPN #2 was asked what happened with the resident which caused you to document the left shin was swollen and had a faint bruise. She stated, The CNAs told me about the skin tear on her shin but I think the swelling was on her knee not her shin. We repositioned her throughout the night and she didn't have any pain, made no noise at all. She further stated, Her left knee looked swollen like it was [MEDICAL CONDITION]. She was asked if the CNAs had transferred the resident out of her bed during the night shift. She stated, No, she was in bed when we got here at 11:00 p.m. She further stated, She never gets out of bed on the night shift. She was asked if the resident had been dropped. She stated, No, she did not fall or was dropped on my shift. She was asked if she was in pain. She stated, I saw nothing out of the norm. She never complained of pain during the times we repositioned her, no grimacing either. She was asked if she had investigated the skin tear, swelling and bruise. She stated after she notified the DON she filled out the facility incident report however; did not investigate. She was asked what, in her opinion, happened to resident #1. She stated, I don't know, could have happened if the CNAs dropped her and then put her to bed without telling anyone. We have to clean up problems on the evening shift all the time. On [DATE] at 7:44 a.m., LPN #1 was asked if she had been told in report the resident had sustained a fall or had been dropped. She stated, No. She was asked if she had instructed the restorative aide (RA) to postpone performing range of motion exercises on the resident due to the swelling and bruising. She stated, I did not tell the RA not to perform ROM exercises on her. She just does her thing. She was asked if the RA had reported to her any difficulty or pain experienced by the resident. She stated, She did not report to me the resident had any problems. She was asked when you obtained the order for an x-ray from the physician, how long does it normally take to get the results. She stated, Usually the same day unless they come out late and then it would be the next day. She was asked when you documented on [DATE] the physician was faxed regarding the x-ray which was performed on [DATE]. Did you follow-up on [DATE] with the x-ray company to check on the results. She stated, I left about 3:00 p.m. on the 7th and had not received the results. I did not follow-up on the 8th like I should have. When I did get the results, I called and faxed the physician. She was asked when you read the x-ray report and it documented the resident had a fractured tibia plateau, did you instruct the RA not to perform ROM exercises. She stated, No. On [DATE] at 8:00 a.m., LPN #3 was asked how was pain assessed on a resident who was severely impaired cognitively. She stated, With (resident), she would moan very loudly when moved. She was asked to describe the events on [DATE] when she came on duty. She stated, When I went down to look at her leg that morning, it was very swollen. She had obvious crackles and labored breathing. I was more concerned with her breathing than I was with her leg. She was not moaning at all. She further stated she had called the physician however; did not remember if the family was notified. All I know is that someone 'bumped' her leg. She started moaning loudly more than usual. She stated on the morning of the 9th, she had received the x-ray results and the physician was notified. The physician did not send her to the emergency room however; asked us to get an orthopedic consult. She stated she had informed the family of this physician order. On [DATE] at 9:30 a.m., resident #6 was asked if she remembered resident #1. She stated, Yes. She was asked if she witnessed the staff transfer resident #1 from her wheelchair to the bed. She stated, Yes. She was asked if she had witnessed the staff drop the resident during transfer. She stated, Yes. She was asked what time of day did the incident happen. She stated, After dinner. She was asked if she knew which staff person dropped the resident. She stated, No. She was asked if the resident was crying out. She stated, Yes. She was asked if she felt safe in the facility. She stated, No. On [DATE] at 9:35 a.m., physician #1 was asked on [DATE] you were notified of a fractured left tibia plateau without displacement on resident #1. Why was she not sent to the emergency room . He stated, I would have sent her but the fracture was non-displaced. I recommended an ortho consult. He was asked if he was aware of the resident's labored breathing and congestion prior to obtaining the x-ray. He stated, Yes, she had [MEDICAL CONDITION]. He was asked if the nursing staff had informed him of a reason why the leg was fractured. He stated, No, they did not. On [DATE] at 10:30 a.m., CNA #3 was asked how long she had cared for resident #1. She stated, About 12 months. She was asked to describe the details surrounding the evening of [DATE] when she cared for resident #1. She stated, At around 5:30 p.m. to 6:00 p.m., I transferred her from her wheelchair to bed using a sit-to-stand lift. I transferred her by myself. She was asked if this was the facility policy to transfer a resident using a lift by yourself. She stated, No, I should have had help. She further stated, While she was in her wheelchair, I put the belt around her, then stood her up, pushed away the wheelchair. I gave her pericare and changed her brief while she was standing up in the lift. After applying a clean brief, I lowered her onto the bed, removed the belt and then removed the lift so I could lay her down. She was asked if the resident had sustained a skin tear while using the lift. She stated, I never saw a skin tear. She further stated, I never saw any swelling at her legs or knees either. She was asked if she had dropped the resident. She stated, No. She was asked if the resident's roommate was in the room at the time. She stated, Yes, she was sitting in her wheelchair watching TV. She was asked if the resident had complained of pain after the transfer. She stated, No, she never complained of pain at anytime during the transfer. On [DATE] at 10:35 a.m., the DON was asked when did she start her investigation into the skin tear and swelling to left leg. She stated she came to work on the 9th and began an investigation. She stated she interviewed every staff person however; no one heard or saw anything out of the normal. She stated she observed the left knee and it was swollen up to her thigh. The bruise was dark and purplish in color. I really don't know what happened. I spoke to the doctor and he thought it could have been pathological in nature. She was asked if during her investigation she spoke to the resident' roommate about what happened. She stated, No, I did not think about it. She was asked if that information from the roommate would have changed the course of her investigation. She stated yes.

On [DATE] an immediate jeopardy situation (IJ) was determined to exist due to the facility's failure to provide the necessary supervision to prevent injury during transfers which initially resulted in an injury of unknown origin first documented on [DATE]. The facility failed to provide the supervision necessary to prevent injury, provide a safe transfer technique to prevent injury, and complete a thorough investigation of an injury of unknown origin. Resident #1 sustained an tibia plateau fracture without displacement which was first documented on [DATE], was transferred to an acute care facility on [DATE]. The resident expired on [DATE]. On [DATE] at 11:30 a.m., the Oklahoma State Department of Health (OSDH) was notified and verified the IJ situation. On [DATE] at 11:55 a.m., the administrator and director of nursing were notified of the IJ situation. At 2:07 p.m., the facility presented an acceptable plan of removal to the survey team. [DATE] .(facility name) plan of removal for Immediate Jeopardy: 1. Resident best practical well-being - All staff will be inserviced (see attached) regarding notification of change in resident condition and pain assessment. This inservice will be signed, dated and timed for each staff member. Nursing notes will be reviewed by DON and or MDS/Care plan coordinator to ensure that any residents with a change in condition within the last 7 days have had notifications to Physician and Family. Pain assessments for any noted residents from the above review will also be reviewed by DON or designee and completed if necessary. 2. Accidents/Hazards - Nursing staff will be inserviced (see attached) on how to tell if a resident is care planned for a mechanical lift by facility MDS/Care plan Coordinator. This inservice will be signed, dated and timed for each staff member. Residents requiring assistance with transfers will be reviewed by facility MDS/Care plan Coordinator to ensure that care plans accurately reflect transfer method. Care plans will be reviewed quarterly and with any change of conditions by Interdisciplinary team. 3. Inservicing will be completed on nursing staff currently working immediately and additional staff via telephone or face to face by 11:30pm tonight or they will not be allowed to again (sic) until education has been completed. Any staff not reeducated by 11:30pm tonight will be removed from the schedule until education has been completed. 16DEC15 - INSERVED (SIC) ALL STAFF EITHER BY PHONE OR IN PERSON ON HOW TO ACCESS THE CAREPLANS. ONCE SIGNED INTO PCC ON THE MAIN PAGE TO CLICK ON CLINICAL BUTTON AT TOP LEFT OF PAGE, GO TO THE ALPHABETICAL LISTING OF THE RESIDENTS, CLICK ON RESIDENT'S NAME, GO TO THE CAREPLAN TAB ON THE GREY BAR, NEXT TO THE BLUE DATE CLICK ON THE EDIT BUTTON AND ALL CAREPLANS FOR THE RESIDENT WILL BE VIEWABLE, INFORMED STAFF THAT SOME RESIDENT'S COULD HAVE UP TO 10 PAGES OF CAREPLANS, TO LOOK FOR THE ADL CARE PLAN THAT WILL LIST HOW THE RESIDENT COMPLETES TRANSFERS (EXTENSIVE, LIMITED, STANDBY, ETC) AND OTHER ADL'S (TRANSFERS, TOILETING, DRESSING, EATING, BATHING, ETC.) INFORMED STAFF THAT ALL CARE PLANS ARE INDIVIDUALIZED FOR EACH RESIDENT BASED ON THE CARE THAT THEY NEED BY EITHER WHAT THE RESIDENT VOICES OR THE STAFF REPORTS IN THEIR ADL CHARTING . On [DATE] at 7:04 p.m., the Immediate Jeopardy was removed after all staff had been in-serviced in regards to determining lift transfers and how to find the information on the care plan. This deficient practice remained at an isolated level of actual harm. Based on observation, staff, resident, and family interviews, and review of the facility's policy and procedures, it was determined the facility failed to provide supervision to prevent injury and thoroughly investigate an injury of unknown origin for one (#1) of six sampled residents whose clinical records were reviewed. This deficient practice resulted in an immediate jeopardy situation for resident #1 who was hospitalized on [DATE] and expired on [DATE]. The facility identified one resident who had a fracture in the last 60 days. Findings: A facility policy titled, Safety and Supervision of Residents, dated [DATE], documented, .Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities . A facility policy titled, Safe Lifting and Movement of Residents, dated [DATE], documented, .In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents . .Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessments shall include: a. Resident's preferences for assistance; b. Resident's mobility (degree of dependency); c. Resident's size; d. Weight-bearing ability; e. Cognitive status; f. Whether the resident is usually cooperative with staff . A facility policy titled, Accidents and Incidents - Investigating and Reporting, dated [DATE], documented, .All accidents or incidents involving residents .shall be investigated and reported to the Administrator . .Initiation of Investigation .The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan, dated [DATE], documented, .Focus .(Resident) depends on staff for all ADL's. She needs extensive to total assistance with eating, dressing, grooming, oral hygiene, turning and repositioning, transfers, mobility and incontinent care. She uses a Geri-chair for mobility. She is incontinent of bowel and bladder, she is on a check and change program at this time, before and after each meal and PRN. She doesn't use the toilet at this time. She has a hx of being combative with staff while they are providing her with ADL care and assistance. She eats all meals in the dining room and is fed by staff. She is in a low bed with a fall pad at bedside. She is to have a rolled washcloth in R hand and needs staff to ensure it is there .Goal .(Resident) will have no decline in her ADL function and staff will anticipate and meet her needs .Interventions .2 person transfer with a gait bait (sic) unless unable to bear wt then use hoyer lift for all transfers .She needs 2 staff members for ADL care .Notify physician and family of any changes in resident's condition . A quarterly assessment, dated [DATE], documented she was severely impaired cognitively for daily decision making skills. She required extensive assistance of two persons for bed mobility, transfers, dressing, toilet use, and hygiene. She had limited upper body range of motion on both sides, and was totally incontinent of bowel and bladder. The assessment further documented she had no falls during the look back period. A nurse's note, dated [DATE] at 12:25 a.m., documented, .VS ,[DATE] p 68 r 18 t 97.2 on 2400 rounds cna found skin tear 2.5cm x 3cm to right shin cleansed with wound cleanser applied steri strips and covered Left shin is slightly swollen and faint bruise starting placed icepack on left shin call light in reach no distress noted notified DR DON and administrator via telephone . A nurse's note, dated [DATE] at 12:45 a.m., documented, .Took ice pack off shin resident completion (sic) is pale in color. Placed HOB at 60 degree angle call light in reach no distress noted . A facility incident report form, dated [DATE] at 2:41 a.m., documented, .2400 rounds cna found 2.5cm x 3cm skin tear to right shin cleaned with wound cleanser placed steri strips and wrapped with conforming gauze. Left shin is slightly swollen and faint bruising starting placed icepack on left shin. VS ,[DATE] p68 r18 t97.2 call light in reach notified DR DON and administrator via telephone . The facility incident report did not contain documentation of an investigation with interviews of the night staff by the charge nurse in regards to the new skin tear and swelling/bruising to left lower extremity. A nurse's note, dated [DATE] at 10:44 a.m., documented, .NOTED SWELLING TO L KNEE RES SHOWS S/S OF PAIN AND DISCOMFORT NOTIFIED (PHYSICIAN #1) REC'D ORDERS TO X RAY L KNEE AND HIP RES DTR (NAME WITHHELD) NOTIFIED OF ORDERS. (X-RAY COMPANY NAME WITHHELD) NOTIFIED FOR X RAY WILL BE HERE THIS AFTERNOON . A nurse's note, dated [DATE] at 12:29 p.m., documented, .T 98.4 RES CONT ABT FOR URI W/O S/S OF ADVERSE REACTIONS NOTED CONT TO HAVE COUGH WITH CONGESTION FLDS ENC AT MEAL TIMES, CONT TO HAVE SLIGHT SWELLING TO L KNEE AT THIS TIME, NO REPORT ON X RAY TO L HIP AND KNEE AT THIS TIME. CONT. TO MONITOR. A Final X-Ray Report documented the date of service was [DATE]. The x-ray report contained documentation the physician was faxed on [DATE] with the results. A nurse's note, dated [DATE] at 8:54 a.m., documented, .(Physician #1) called re: Fx of the L Tibia Plateau without displacement. Ordered consult with Orthopedic specialist. Will notify SS. Need apt stat. DON notified POA . An initial Incident Report Form faxed to the Oklahoma State Health Department, dated [DATE], documented, .Per CN, it was noted that res left knee was edematous and dark purplish discoloration and tender to touch. PCP notified with new orders to X-ray left knee, left leg, and left hip. Res given pain meds to help alleviate pain and she was placed on close observation. Bruising and edema are of unknown origin. X-Ray back and clean fx to left tibia. (Physician #1) notified and N/O for ortho consult. We are in process of calling ortho and seeing which one we can get res into the quickest and not sure what ortho will do r/t res age of 98 yo. At this time, all staff that worked around the 7th are being interviewed to find out what happened to left leg due to res unable to tell us . A nurse's note, dated [DATE] at 9:40 p.m., documented, .transferred to (hospital name withheld) ER for aspiration pneumonia. (Daughter name withheld) was called and informed of the transfer. continued on antibiotics for uri. Vital signs Blood presser (sic) ,[DATE], pulse 79, temperature 97.4, o2 sat 90% on room air . A hospital laboratory report, dated [DATE] at 9:42 p.m., documented, .Urine culture .Escherichia coli .CBC .WBC .22.5* (4XXX,[DATE].0) .Hgb .8.4*(12XXX,[DATE].5) .BUN .88*(,[DATE]) .Creat .3.20*(0XXX,[DATE].60) .D-Dimer .2833*(,[DATE]) .CXR .Diffuse mild pneumonia. Pulmonary edema is also a consideration but the heart is not enlarged .XR TIBIA AND FIBULA LEFT (Results pending) .XR TIBIA AND FIBULA RIGHT (Results pending) . The hospital record further documented, .Clinical Impression .Final diagnosis .Pain in both lower extremities .SOB (shortness of breath) .Fall, initial encounter .Abdominal pain, acute .Dehydration .Acute cystitis with hematuria .Sepsis associated hypotension, and Hyperkalemia . A hospital record, dated [DATE] at 11:01 p.m., documented an emergent intraosseous insertion for infusion for fluid and medication administration. A final Incident Report Form, faxed to the Oklahoma State Department of Health, dated [DATE], documented, .Obtained statements from all nursing staff that worked [DATE], no one noticed resident legs with unusual edema and no discoloration at all. Resident had a CXR ordered on [DATE] for congestion and PCP also placed her on ABT at that time. CXR came back clear. Res was sent to ERD on [DATE] for respiratory issues and received call from physician on [DATE] to report res had expired. All staff were inserviced that if they notice anything unusual about any resident that is not per their norm or even if it is per their norm but there is a change to notify the nurse immediately . On [DATE] at 2:10 p.m., a family member of resident #1 was asked what happened which caused your mother to be transferred to the hospital. The family member stated, The head nurse on ,[DATE] called and stated three of them were carrying her down the hall and they dropped her. The family member further stated, We did not send her to the hospital for the fracture, we sent for congestion. The family member was asked if their mother was in pain while at the hospital. The family member stated, Very, very significant pain. They were pumping Lidocaine through the I.V., it lasted for hours. The family member further stated, Nobody could stand the moaning and groaning. On [DATE] at 7:30 a.m., LPN #2 was asked what happened with the resident which caused you to document the left shin was swollen and had a faint bruise. She stated, The CNAs told me about the skin tear on her shin but I think the swelling was on her knee not her shin. We repositioned her throughout the night and she didn't have any pain, made no noise at all. She further stated, Her left knee looked swollen like it was Osteoporosis. She was asked if the CNAs had transferred the resident out of her bed during the night shift. She stated, No, she was in bed when he got here at 11:00 p.m. She further stated, She never gets out of bed on the night shift. She was asked if the resident had been dropped. She stated, No, she did not fall or was dropped on my shift. She was asked if she was in pain. She stated, I saw nothing out of the norm. She never complained of pain during the times we repositioned her, no grimacing either. She was asked if she had investigated the skin tear, swelling and bruise. She stated after she notified the DON she filled out the facility incident report however; did not investigate. She was asked what, in her opinion, happened to resident #1. She stated, I don't know, could have happened if the CNAs dropped her and then put her to bed without telling anyone. We have to clean up problems on the evening shift all the time. On [DATE] at 8:00 a.m., LPN #3 was asked how was pain assessed on a resident who was severely impaired cognitively. She stated, With (resident), she would moan very loudly when moved. She was asked to describe the events on [DATE] when she came on duty. She stated, When I went down to look at her leg that morning, it was very swollen. She had obvious crackles and labored breathing. I was more concerned with her breathing than I was with her leg. She was not moaning at all. She further stated she had called the physician however; did not remember if the family was notified. All I know is that someone 'bumped' her leg. She started moaning loudly more than usual. She stated on the morning of the 9th, she had received the x-ray results and the physician was notified. The physician did not send her to the emergency room however; asked us to get an orthopedic consult. She stated she had informed the family of this physician order. On [DATE] at 8:38 a.m., the MDS coordinator was asked how was resident #1 transferred. She stated, She was a two person assist with a gait belt. On [DATE] at 9:30 a.m., resident #6 was asked if she remembered resident #1. She stated, Yes. She was asked if she witnessed the staff transfer resident #1 from her wheelchair to the bed. She stated, Yes. She was asked if she had witnessed the staff drop the resident during transfer. She stated, Yes. She was asked what time of day did the incident happen. She stated, After dinner. She was asked if she knew which staff person dropped the resident. She stated, No. She was asked if the resident was crying out. She stated, Yes. She was asked if she felt safe in the facility. She stated, No. On [DATE] at 10:25 a.m., CNA #3 was asked how long she had cared for resident #1. She stated, About 12 months. She was asked to describe the details surrounding the evening of [DATE] when she cared for resident #1. She stated, At around 5:30 p.m. to 6:00 p.m., I transferred her from her wheelchair to bed using a sit-to-stand lift. I transferred her by myself. She was asked if this was the facility policy to transfer a resident using a lift by yourself. She stated, No, I should have had help. She further stated, While she was in her wheelchair, I put the belt around her, then stood her up, pushed away the wheelchair. I gave her pericare and changed her brief while she was standing up in the lift. After applying a clean brief, I lowered her onto the bed, removed the belt and then removed the lift so I could lay her down. She was asked if the resident had sustained a skin tear while using the lift. She stated, I never saw a skin tear. She further stated, I never saw any swelling at her legs or knees either. She was asked if she had dropped the resident. She stated, No. She was asked if the resident's roommate was in the room at the time. She stated, Yes, she was sitting in her wheelchair watching TV. She was asked if the resident had complained of pain after the transfer. She stated, No, she never complained of pain at anytime during the transfer. On [DATE] at 10:30 a.m., RN#1 was asked if he was the charge nurse on duty the evening of [DATE]. He stated yes. He was asked what occurred that evening when the resident was transferred from her wheelchair to the bed. He stated, I am not aware of any issues from that evening. I don't remember that far back. He was asked if knew how the resident obtained the skin tear to her right shin and what could have caused the swelling and bruising to her left knee. He stated, No. He was asked if he was aware of the resident having been dropped during his shift. He stated, I am not aware of it. He was asked if the resident's roommate was in her room at the time. He stated, I don't know. On [DATE] at 10:35 a.m., the DON was asked when did she start her investigation into the skin tear and swelling to left leg. She stated she came to work on the 9th and began an investigation. She stated she interviewed every staff person however; no one heard or saw anything out of the normal. She stated she observed the left knee and it was swollen up to her thigh. The bruise was dark and purplish in color. I really don't know what happened. I spoke to the doctor and he thought it could have been pathological in nature. She was asked if during her investigation she spoke to the resident' roommate about what happened. She stated, No, I did not think about it. She was asked if that information from the roommate would have changed the course of her investigation. She stated yes.

On 01/27/15, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure licensed nursing staff was provided adequate training and was competent to care for a resident who was dependent on a respiratory ventilator to sustain respirations. Licensed nursing staff was unaware of life saving measures to take in the event of an emergency related to the respiratory ventilator. The facility and respiratory therapist were unable to provide documentation of appropriate training related to emergency procedures for a respiratory ventilator dependent resident. At 9:46 a.m., the existence of the IJ situation was verified with the Oklahoma State Department of Health (OSDH). At 10:00 a.m., the administrator and the DON were notified of the existence of an IJ situation. At 11:27 a.m., an acceptable plan of removal was received from the facility. The plan of removal documented: "(named facility) To remove the immediacy the following steps will be taken: 1. The ventilator dependent resident will be discharged to (named facility), an established facility for ventilator dependent individuals. (named transport service) will be on site at approximately 12:00 noon to transport. (named LPN #2 ) will remain in resident's room and be in constant contact with (named respiratory therapist #1), Respiratory Therapist (via telephone) until (named transport service) arrives at facility. In the future no individuals requiring ventilator care will be admitted to the facility." The IJ was removed on 01/27/15 at 1:15 p.m., after all components of the plan of removal had been completed. The deficient practice remained at a pattern level with a potential for more than minimal harm. Based on observation, clinical record review, staff and resident interviews, review of facility policy and procedures and review of published nursing standards and articles, it was determined the facility failed to ensure licensed nursing staff was provided training and was knowledgeable of what constituted an emergency situation and necessary life saving measures to take for a resident who was dependent on a respiratory ventilator to sustain respirations for one (#1) of one sampled resident reviewed who was dependent on a respiratory ventilator. This had the potential to affect one resident identified by the facility who was dependent on a respiratory ventilator. Findings: A facility policy, titled [MEDICAL CONDITION] Care, documented, "...Purpose...The purpose of this procedure is to guide [MEDICAL CONDITION] care and the cleaning and sterilization of reusable metal [MEDICAL CONDITION] Procedure Guidelines... 5. Inspect skin and stoma site for signs and symptoms of...dislodged tube. Check resident for respiratory distress or asymmetrical chest expansion... Miscellaneous... 7. A replacement [MEDICAL CONDITION] must be available at the bedside at all times..." A facility policy, titled Suctioning the Lower Airway Endotracheal (ET) or [MEDICAL CONDITION], documented: "...Purpose...The purpose of this procedure is to remove secretions, maintain a patent airway, and prevent infection of the lower respiratory tract... General Guidelines... 1. Complications of suctioning the lower airway include trauma to the airway, infection, [MEDICAL CONDITION], hypoxemia, and cardiac [MEDICAL CONDITION] (resulting from hypoxemia). To minimize the risk of complications, apply the following guidelines: a. Suction only as needed, based on assessment of the resident's level of respiratory distress... d. Hyperoxygenate the resident by increasing the oxygen flow (as ordered) before the procedure and between suctioning (Note: After the procedure, oxygen should be readjusted as ordered to prevent oxygen toxicity and increased CO2 in [MEDICAL CONDITION] residents.)... Assessment... 1. Identify the following risk factors for impaired airway clearance or aspiration: a. Impaired cough or gag reflex; b. Dysphagia... f. Presence of feeding tube... 2. Assess for the following signs and symptoms of respiratory distress/[MEDICAL CONDITION]/hypoxemia: a. Diminished breath sounds; b. Tachypnea; c. Dyspnea; d. Gurgling, crackling or wheezing upon inspiration; e. Cyanosis; f. Decreased oxygen saturation... g. Restlessness; and/or h. Drooling, secretions or vomitus in mouth..." A facility policy, titled Mechanical Ventilation: Setup and Monitoring, documented: "Purpose...The purpose of this procedure is to provide assisted or controlled ventilation to a resident with acute or chronic respiratory insufficiency... General Guidelines... 2. Long-term ventilator care may be used for residents with neuromuscular disease, spinal cord injury, advanced [MEDICAL CONDITION], or other chronic conditions that affect independent respiratory function... Assessment...While the resident is on mechanical ventilation, assess for the following: 1. Signs and symptoms of [MEDICAL CONDITION], including: a. Restlessness; b. Increased pulse rate; c. Increased rate and depth of respirations; d. Diminished lung sounds; e. Cyanosis; f. Fatigue; g. Pallor; and/or h. Confusion. Reporting... 1. Notify the supervisor if the resident refuses the procedure. 2. Report other information in accordance with facility policy and professional standards of practice." A published document from the American College of Emergency Physicians, titled The Crashing Ventilated Patient, documented: "...The [MEDICAL CONDITION]/Near Arrest Patient: Time is of the essence in the patient with [MEDICAL CONDITION] or near arrest. ACLS algorithms should be implemented quickly. Additionally, there are some key points to remember in the ventilated patient who has a [MEDICAL CONDITION] or becomes acutely hemodynamically unstable.... However, it is also important to determine and address special circumstances that the ventilator can precipitate. The most significant of these are tension pneumothorax... Breathing-Hand ventilate with 100% oxygen...Ensure that 100% oxygen is being delivered and limit the respiratory rate to 8 to 10 breaths per minute... Airway-Determine that the endotracheal tube is functioning and in the proper position. The ET tube functions by providing a conduit to the lower trachea. Its cuff attempts to create a seal between it and the inner wall of the trachea...Dislodged or obstructed ET tubes require re-intubation..." A published article from the American Nurse Today, titled Top 10 Care Essentials for Ventilator Patients, documented: "...Evidence-based Interventions and Teamwork are Crucial When Caring for Patients on Mechanical Ventilators...Check Ventilator Settings and Modes. Read the patient's order and obtain information about the ventilator. Compare current ventilator settings with the settings prescribed in the order. Familiarize yourself with ventilator alarms and the actions to take when an alarm sounds. Locate suction equipment and review its use. Look for a bag-valve mask, which should be available for every patient with an artificial airway; be sure you know how to hyperventilate and hyperoxygenate the patient... Suction Appropriately...Patients receiving positive-pressure mechanical ventilation have a [MEDICAL CONDITION], endotracheal, or nasotracheal tube...If your patient has an endotracheal tube, check for tube slippage into the right mainstem bronchus, as well as inadvertent extubation. Other complications of [MEDICAL CONDITION] include tube dislodgment, bleeding, and infection. To identify these complications, assess the tube insertion site, breath sounds, vital signs...For help in assessing and managing tube complications, consult the respiratory therapist... Manage the Airway...The cuff on the endotracheal or [MEDICAL CONDITION] provides airway occlusion. Proper cuff inflation ensures the patient receives the proper ventilator parameters, such as TV and oxygenation. With assistance from an experienced colleague, change the [MEDICAL CONDITION] or [MEDICAL CONDITION] ties and endotracheal tube-securing devices if they become soiled or loose. Incorrect technique could cause accidental extubation..." Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. An facility in-service, dated 11/11/14, documented, "...Subject of discussion: Vent, suctioning,[MEDICAL CONDITION], et vent... Date held: 11/11/14... Scope of meeting...Triology ventilator,[MEDICAL CONDITION], notify charge nurse whenever any alarms are going off..." Eighteen staff member signed the in-service record. A hired/re-hired employee list, dated 11/01/14 through 01/26/15, was reviewed. Thirteen staff members had been hired since the in-service conducted on 11/11/14. The facility was unable to provide documentation of in-service related to the care of ventilator dependent resident for the thirteen staff members. A physician's orders [REDACTED]. [MEDICATION NAME] 7 trach- spare kept at bedside every shift for [MEDICAL CONDITION]/[MEDICAL CONDITION] date 11/12/14... O2 (at) 3L via triology vent continuously for shortness of breath every shift for [MEDICAL CONDITION]/shortness of breath...order date 11/12/14... Primary setting: Tidal volume- 500, Ventilator Rate- 6, Peak Flow Rate- Auto, Pressure limit- Greater than 60, Sensitivity- Auto. Use while resident is awake every shift for [MEDICAL CONDITION] date 11/12/14... Respiratory Therapy to evaluate monthly and PRN...order date 11/12/14... Secondary Settings: Tidal Volume- 500, Ventilator Rate- 12, Peak Flow Rate- Auto, Pressure limit- Greater than 60, Sensitivity- Auto, Pressure limit- Greater than 60, Sensitivity-Auto, Use while resident is sleeping/napping every shift...order date 11/12/14..." A care plan, dated 11/13/14, documented, "Focus: The resident is ventilator dependent r/t paralysis and [MEDICAL CONDITION] Goal: The resident will remain free of complications r/t ventilator dependence including upper respiratory infection, pneumonia, atelectasis, decreased cardiac output, pneumothorax, subcutaneous [MEDICAL CONDITION], decreased renal perfusion, increased ICP, hepatic congestion... The resident will maintain a patent airway... Interventions: ...Assess for s/s of [MEDICAL CONDITION]: Altererd level of consciousness, listlessness, cyanosis... Educate resident/family/caregivers purpose/mode and encourage resident to relax and deep breath with the ventil (sic) alarms; teach importance of deep breathing... Maintain [MEDICAL CONDITION] the bedside... Maintain ventilator setting... Monitor for changes in respiratory rate or depth...for use of accessory musculature, breath sounds... Observe for indications of tube obstruction..." A respiratory clinician set-up checklist, dated 11/14/14, documented, "...Client: (named resident #1)...Caregiver...Nursing home staff... Continuously wears primary during day...Secondary (at) night... Instructed the client/caregiver on the basic mechanics of the HMV (home mechanical ventilation) device. Discussed the use of Home Mechanical Ventilation in the management and treatment of [REDACTED]. Instructed the client/caregiver on the basic use and operation of the specific HMV device... Discussed the need for compliance to the physician's orders [REDACTED]. Reviewed possible HMV side effects. Advised client/caregiver to contact physician if problems develop. Reviewed with the client/caregiver that HMV device alone is designed to operate as life supporting devices... (signed name resident's daughter in law)... (signed by respiratory therapist #2)..." There was no documentation of a caregiver signature on the set-up checklist. An admission assessment, dated 11/18/14, documented the resident was moderately impaired in cognitive skills for daily decision making. The assessment documented she required total assistance from staff with transfers, dressing, hygiene and bathing. The assessment documented she had a dependence on a respirator and she had a gastric feeding tube. A ventilator performance record, dated 12/04/14, documented, "...(named resident #1)...Comments Pt seems to be doing better. Recent hospitalization for AMS. A heater and humidifier was added for moisture. Adjusted circuit disconnect and VTE alarm..." There were no other progress notes provided by the respiratory therapist during the survey. A respiratory supply order document, dated 12/08/14, documented, "...(written in) vent check training..." A respiratory supply order document, dated 12/30/14, documented, "...(written in) vent chk and troubleshooting..." A licensed nursing staff schedule, dated January 2015, was reviewed. There were 25 licensed nursing staff members scheduled to work at the facility during the month of January. There were only nine staff members with documentation of ventilator training. This ventilator training consisted of [MEDICAL CONDITION] care, suctioning and mechanical ventilation set up and monitoring. On 01/26/15 at 10:30 a.m., during initial tour of the facility an observation was made of the resident. She was on a respiratory ventilator. The resident was asked how long she had resided in the facility. She stated since November. She was then asked how long she had required ventilator assistance with her respirations. She stated for eight months. She then stated she was at a different facility and aspirated on a bite of food. She was then asked if she was able to breathe on her own without the use of a ventilator. She responded no. At 10:35 a.m., the administrator was asked if staff have received training to care for the ventilator dependent resident. He stated staff had received training. He further stated, "We have an RN with lots of experience. We have an RT who comes one time a week and if we need him, he will come." At 4:00 p.m., the DON was asked if all recently hired staff had been in-serviced on how to determine an emergency and/or how to respond to an emergency related to a resident dependent on a ventilator for respirations. She stated she had ensured all staff were trained except for two newly hired staff. She further stated she just in-serviced them over the phone. She then stated, "I should have already done those two. Normally they get trained right off the bat." She was then asked if she documented training related to emergency care of resident on a ventilator. She stated, "No. (named respiratory therapist) did that." She further stated I do new RN, LPN, aide in-service on new hire. I didn't document training related to emergency ventilator concerns. On 01/26/15 at 4:30 p.m., respiratory therapist #1 was asked how often he visits the facility to assess the resident. He stated he had been out to the facility close to every week or two. He further stated a new mandate was about to change facility visits to every 30 days. He then stated, "We come out at least every 30 days." He was then asked if the resident was able to breathe without the ventilator. He stated, "Yes, but she wears out very quick." He was asked how long the resident could breathe without the ventilator. He stated, "To be honest we haven't even done a trial but the hospital told us two hours." He was then asked if he had provided the licensed nursing staff training related to the respiratory ventilator and emergency concerns and responses to emergencies. He stated, "Before she came I was there two to three times." He then stated he educated the staff over operation of the vent, suctioning and emergencies. He was asked if he had provided any further in-services since the resident's admission. He stated, "Some minor one on ones." He then stated he had spoke with the DON and administrator several times. He further stated most of the training he provided after the initial inservice was related to troubleshooting. He then stated he came to the facility at times and provided refresher training on the ventilator. He was then asked if he had maintained records of the in-services he provided. He stated, "I have records. Not of every in-service." He was then asked if he could provide documentation promptly of the in-services he had provided the licensed nursing staff. He stated, "I'm working on it now. I'm hoping it didn't vanish into thin air." He was asked if he had documentation of progress notes from his visits to the facility to assess the resident. He stated, "I will get those faxed now." On 01/27/15 at 6:10 a.m., LPN #4 was asked if she had received any training from the facility or respiratory therapist related to care of a ventilator dependent resident. She stated yes. She was then asked what the in-service covered. She stated, "How to clean trach. I can't remember anymore." On 01/27/14 at 9:00 a.m., the DON was asked if the respiratory therapist had provided documentation of the in-services he provided. She stated, "No." She further stated the supply company accompanied the respiratory therapist on the days he provided the in-services. She then stated the respiratory therapist hoped the supply company could find documentation of the in-services. At 9:05 a.m., LPN #6 was asked if she had received any training from the facility or respiratory therapist related to care of a ventilator dependent resident. She stated she received training in December. She was asked what action she would take if the resident was to extubate herself. She stated, "Call 911." She was then asked what action she would take while waiting on emergency services to arrive. She stated she did not know. She stated she would stay with the resident and get her vital signs. At 9:05 a.m., LPN #5 was asked how long she had worked at the facility. She stated she had worked at the facility for about a year. She was then asked how often she was assigned to care for the resident. She stated, "I probably take care of her two to three times a week." She was asked if she had received any training related to how to care for a ventilator resident. She stated, "We did vent training with vent people. I don't know how long ago that was." She was asked what the in-service covered. She stated she was trained to call the respiratory therapist when the ventilator alarm was alerting for high. She further stated, "We are to call them so they can assess it." She then stated she was shown how to check hoses and connections and how to suction the resident. She was asked what action she would take if the resident was to extubate herself. She stated, "I would get the DON." She was then asked what she would do if the DON was not available. She stated, "I would call EMS so I can send her out." She was then informed that if the resident was to extubate herself she would not be able to breathe. She was asked what she would do while she waited for emergency services to arrive. She stated, "I don't know. I would just call EMS if I didn't have anyone to help me." She was asked if she had received any training related to emergency procedures for a ventilator dependent resident. She stated, "I don't remember them going over how to handle the situation if she extubates or other emergencies. She was asked if she would consider using an ambu bag to assist the resident with respirations. She stated, "If I had to. Yes, I guess I would." She then stated, "I would just stay with her until help arrived." On 01/27/15 at 9:10 a.m., LPN #2 was asked how often she had worked at the facility. She stated, "Three months." She was then asked how often she was assigned to care for the resident. She stated, "I care for her three times a week or more." She was asked if she had received any in-service from the facility related to care of a ventilator dependent resident. She stated, "I missed the big in-service so two days ago (named respiratory therapist) came in." She was asked what the respiratory therapist in-serviced her over. She stated he discussed what to do if the tubing leaks, to check for leaks and who to call. She then stated, "That's mainly it." She was asked if the respiratory therapist discussed possible complications which could arise for a ventilator dependent resident. She stated he didn't really go over emergencies. She was asked if she had any experience with ventilator dependent residents. She stated no she did not. On 01/27/15 at 9:20 a.m., the DON was asked how long does it take for the respiratory therapist to arrive if you need him at the facility. She stated, "Approximately 45 minutes to one hour."

Based on observation, record review and interview, it was determined the facility failed to provide wound care as ordered and thoroughly skin for one (#1) of five sampled residents with wounds. The facility identified four residents with wounds. This deficient practice resulted in actual harm to resident #1 related to the development of infections. Findings: Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, dated 07/29/13, documented, "...Problem (named resident) has potential for discomfort and side effects related to the use of antibiotics for the [DIAGNOSES REDACTED]. A care plan, dated 09/22/13, documented, "...Problem Wound infection: Cellulitus... Goal I will be cured from current infection..." A monthly physcian order, dated October 2013, documented, "...12/27/2012 SKIN ASSESSMENT - weekly skin assessment on Wednesday on 3-11 (3:00 p.m., to 11:00 p.m.)..." An annual assessment, dated 10/25/13, documented the resident was independent in cognitive skills for daily decision making. The assessment documented he was independent with bed mobility, transfers, ambulation and hygiene. The assessment documented he required setup only with eating and bathing. The assessment documented he had functional limitations in range of motion in his upper extremities on one side and he was continent of bowel and bladder. A weekly skin assessment, dated 10/30/13, documented, "...Any rashes? yes (x) No (blank) comments: cellulitus to bilat (lower) extremities, drsgs C, D, I..." A facility treatment sheet, dated November 2013, documented, "...Pt to return to wound care clinic Mon - Wed - & Friday..." The treatment sheet documented it was noted 11/13/13. A nurses's note, dated 11/05/13 at 9:30 a.m., documented, "...Noted on resident bedside table two forks (c) knife taped up like a make shift back scratcher. Reported to DON & adm & removed." A wound care center order, dated 11/06/13, documented nurse visit 11/08/13 and 11/11/13. A home health patient instruction sheet, dated 11/06/13, documented, "...Pt to return to wound care Mon, Wed, and Fri...Return Fri [DATE] & Mon [DATE]..." A weekly skin assessment, dated 11/06/13, documented, "...Any rashes? yes (x) No (blank) comments: (blank)..." A lab report form the wound care clinic, dated 11/06/13 and verified 11/10/13, documented, "...source Leg/Right...organism #2 Staphylococcus Aureus light amount of growth...Organism #3 Gram Positive Rod resembling Diphtheroids rare amount of growth..." A weekly skin assessment, dated 11/08/13, documented, "...Any rashes? yes (x) No (blank) comments: (blank)..." A wound care center order, dated 11/13/13, documented dressing change three times per week. A home health patient instruction sheet, dated 11/13/13 documented, "...Pt to return to wound care Monday, Wednesday, and Friday..." The resident did not go to the wound care clinic on Friday or Monday and was transferred to the hospital on Wednesday. A weekly skin assessment, dated 11/13/13, documented, "...Any rashes? yes (x) No (blank) comments: (blank)..." A nurse's note, dated 11/19/13 at 11:00 p.m., documented, "Le (late entry)...Resident has redness to buttocks, groin between legs and under abd folds. Resident refused to take a bath. Refused to let this nurse clean area or apply ordered medication. notified (named physcian) rec'd TO for [MEDICATION NAME] 100 mg 1 po q day x 14 days..." A telephone order, dated 11/19/13 documented, "[MEDICATION NAME] 100 mg 1 Q day x 14 days redness/irritation..." A nurse's note, dated 11/20/13 at 5:30 a.m., documented, "...Resident in room still not ready yet states he doesn't want to go today states he is worried about his drainage from excoriated groin and inner ABD folds..." A nurse's note, dated 11/20/13 at 10:30 a.m., documented, "...noted (decreased) LOC, appears pale (decreased) O2 (oxygen) sat 83% c/o's weakness & SOB noted, called aunt noted order to transfer to...for eval..." A hospital wound assessment, dated 11/20/13, documented, "...Traumatic Wound Abrasion(s)... orientation: left; right; anterior; posterior... location: abdomen... trauma description -- partial thickness... treatment -- open to air; cleansed... Wound Lower: other (comments) Abdomen... orientation: Lower; Other (comments) (initials) abdominal fold... location: Abdomen... Wound Characteristics -- Partial Thickness; [DIAGNOSES REDACTED]; Purple or maroon localized area of discolored intact skin..." A hospital nurse's progress note, dated 11/20/13 at 5:12 p.m., documented, "...Patient has excessive areas of excoriated skin in the groin and abdominal area. He also has excoriated tissue on his legs..." A hospital history and physical, dated 11/21/13, documented, "...34 yo male from NH who has rash/cellulitus across lower abd (inra-pannis) and gu area bleeding, excoriated/confluent. He states this is painful...He has open sores on thorax..." A hospital discharge summary, dated 11/22/13, documented, "...AND/gu rash...concerned [MEDICAL CONDITION] from extensive rash/staph/uti..." A physcian's progress note, dated 11/22/13 at 10:05 a.m., documented, "...Assessment and Plan: 1. [MEDICAL CONDITION] (Principal), profound and strong possibility is a fungemia..." A final lab report documented, "...Specimen: Micro; abdominal Lesion 11/23/13... Culture 2+ growth Escherichia coli (ESBL) Culture 3+ growth Proteus mirabillis Culture 3+ growth Diphtheroids Gram Stain 2+ [DIAGNOSES REDACTED]s Gram Stain 2+ Gram negative bacilli..." On 12/03/13 at 9:15 a.m., LPN #2 was asked if she had observed the resident scratching his legs. She stated, "He was scratching with the dressing, he would stick anything he could find." At 10:10 a.m., LPN #3 was asked to describe the resident's skin the day he was transferred out to the hospital. She stated, "I cleaned his abdomen and performed the treatment. It was red before he went out and some drainage with a foul odor." She was then asked to describe the resident's skin the week prior. She stated, "It was red but no drainage or odor." At 10:25 a.m., the DON was asked why the resident had missed four of his appointments at the wound care clinic. She stated, "The 15th the van driver had a death and he missed his appointment and on the 18th he refused. The others I don't know." There was no documentation in the clinical record showing the resident had refused to go to any wound care clinic appointments. At 12:00 p.m., Physcian #1 was asked when he became aware of the resident's rash on his abdomen. He stated, "I don't recall exactly when I became aware. They started him on [MEDICATION NAME], I don't have the chart here. We were treating it with powder and cream first before the [MEDICATION NAME]." On 12/04/13 at 8:50 a.m., the Wound Care Clinic Manager was interviewed and asked their procedure for wound culture results obtained at their facility. She stated, "We usually don't do a lot with slight and rare. We just watch the wounds for a couple of visits, but he never returned." At 9:10 a.m., LPN #1 was asked to describe the resident's skin on his abdomen, groin and thigh area. The LPN stated, "It wasn't really a wound he had a rash off and on for months especially in his folds." She was then asked when the first time she noticed it was getting worse. She stated, "On the night before he went out when I entered the room. I smelt an odor of yeast. I looked at his skin it was red and excoriated on his groin, thigh and abdomen folds. He wouldn't let me clean the area or provide the treatment. I called (named physcian) for oral [MEDICATION NAME]." On 12/04/13 at 1:00 p.m., Physcian #1 was asked if anyone had made him aware of the resident using foreign objects to scratch under the dressings on his legs. He stated, "No." At 1:15 p.m., RN #1 was asked if she had notified the physcian of the resident using foreign objects to scratch under his dressings. She stated, "No." At 1:25 p.m., LPN #3 was asked if she had notified the physcian of the resident using foreign objects to scratch under his dressings. She stated, "No." At 2:50 p.m., LPN #4 was asked to describe the resident's skin. She stated the last day she looked at him would have been the 15th. She stated both legs below the knees looked excoriated in a couple of areas and there were scratches like he had been itching on his groin and scrotum area. At 3:50 p.m., LPN #1, who had completed the skin assessments, was asked what she included on the skin assessment. She stated the whole body. She was then asked if had any pressure sores. She stated the night before he went to the hospital, he had a couple of red dots on his lower bilateral buttocks.

On [DATE] an Immediate Jeopardy (IJ) situation was determined to exist due to the failure of the facility's governing body to establish and/or maintain and implement policies and systems to ensure care, services and supervision were provided to residents to ensure their highest practicable well being. The Oklahoma State Department of Health (OSDH) was notified and verified the IJ situation. At 5:08 p.m., the administrator, DON and ADON were notified of the IJ situation. An acceptable plan of removal was received on [DATE] at 7:34 p.m. The plan of removal documented: "Plan of Removal for Immediate Jeopardy [DATE] Management of Nursing Facility 1. The owner, (name deleted), agrees to immediately appoint other members to join him as a governing body responsible for the oversight of the nursing facility. 2. A Certified Public Accountant or other individual who understands the fiscal management of nursing facilities will be asked to join the governing board to ensure that the funds are available for operation of the nursing facility. A review of the revenue and expenses will be made to ensure that management of the nursing facility is following acceptable accounting practices. 3. Another owner and/or Licensed Nursing Home Administrator will be asked to join the governing body to help identify problems which could lead to adverse outcomes in all facets of operation of the nursing facility and to ensure regulatory requirements for operation of a nursing facility are met. 4. The governing body will be appointed no later than [DATE] at 5:00 p.m." On [DATE] at 1:25 p.m., the owner presented an agreement between himself and a consultant. He stated that he had a meeting scheduled with a CPA that day at 11 a.m., but cancelled it to come to the facility because the surveyors were there. At 2:53 p.m., the administrator and the owner were informed that the IJ could not be removed. At 4:02 p.m., the administrator stated that she had talked to an accountant that she knew about the possibility of being on their governing board. She stated that the owner had not come up with anyone. An acceptable addendum to the plan of removal was received on [DATE] at 5:10 p.m., which documented: "The owner (name deleted) called an emergency meeting through phone conference with the new governing board for consideration of appointment of a financial manager. (Financial Consultant name deleted), tax consultant and accountant, was asked to consider appointment to the Board for advice on the fiscal management of the nursing facility. He will let the Secretary, (administrator name deleted), know of his decision by [DATE] 5:00 p.m. The Board is also speaking with him about retaining his services for managing the account for revenue and expenses of the nursing facility and producing a financial statement for the Board's monthly review, and as needed." The IJ was removed, effective [DATE] at 4:33 p.m., when all components of the plan of removal were completed. The deficient practive remained at a pattern level of actual harm. Based on observation, interview and record review, it was determined the facility's governing body failed to establish and/or maintain and implement policies and systems to ensure care, services and supervision were provided to residents to ensure their highest practicable well being. The facility failed to assess, monitor and intervene in a timely manner for resident #9 whose medical condition was deteriorating and failed to provide care necessary to prevent further decline and death. The resident expired shortly after transferred to the hospital. The facility failed to provide supervison to prevent multiple elopements for two residents, #2 and #6. This had the potential to affect all 54 residents who resided in the facility. Findings: 1. The facility failed to: ~ ensure one resident with uncontrolled diabetes (#9) in an acute state and with a declining condition was thoroughly assessed and monitored; and failed to ensure the resident received care necessary to prevent further decline and/or death. Three residents resided in the facility with uncontrolled diabetes. ~ ensure assessment, monitoring and the necessary care was provided for a resident's declining wound status for one (#2) of three sampled residents with wounds. The facility identified four residents with wounds other than pressure ulcers. ~ ensure residents with urinary tract infections received antibiotics that were effective against the organisms isolated for one (#11) of two sampled residents with urinary tract infections. Fourteen residents had urine testing done in the last three months. Refer to F309. 2. The facility failed to: ~ provide supervision to prevent multiple elopements of two (#2 and #6) of two sampled residents whose clinical records were reviewed for elopement risks. The facility identified 15 residents who wandered and three residents at risk of elopement. ~ ensure staff transferred residents in a way to prevent injury for four (#7, 8, 18 and #20) of 10 sampled residents who required assistance with transfers. Resident #8 had actual harm when she was lifted from under her arms and sustained a fractured arm. The facility identified 31 residents who required assistance with transfers. Refer to F323. 3. The facility failed to ensure that all residents/residents' legal representatives had the right to voice grievances to the administrator in respect to their treatment. When interviewed, residents/residents' legal representatives stated they did not feel free to speak with the administrator when they had grievances or needs. Refer to F165. 4. The facility failed to: ~ have a registered nurse for eight hours a day, seven days a week for 11 ([DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]) of 92 days reviewed; and ~ have a director of nursing on a full time basis for six (weeks of [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]) of 13 weeks reviewed. This had the potential to affect all 54 residents who resided in the facility. Refer to F354.

On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to ensure a resident whose medical condition was deteriorating was assessed, monitored and received the care necessary to prevent further decline and/or death. The Oklahoma State Department of Health was notified and verified the Immediate Jeopardy situation. At 5:10 p.m., the administrator, the director of nursing (DON) and the assistant director of nursing (ADON) were notified of the IJ situation. On [DATE] at 7:30 p.m., an acceptable plan of removal was presented to the survey team. The Plan of Removal documented: "...3. All LPN staff will be required to review the Nursing Practice Act...The Registered Nurses (RN) will conduct the in-service and conduct the skills checklist... 4. The facility will go over scope of practice with all new hires and will conduct in-service training and skills checklists a minimum of every six months. 5. All LPN staff will receive training on assessment of resident(s) with a change of condition and the necessity of monitoring that resident(s) condition closely until resident condition has stabilized. The LPN staff will express an understanding of the Nursing Practice Act and know when to notify the registered nursing supervisor and/or the physician as required. The in-service will be completed not later than [DATE] at 5:00 p.m. 6. The Quality Assurance (QA) Committee will review all new hires within the month of committee meeting and will be reviewed every three months in QA Committee meetings to ensure compliance with regulatory requirements." When the sign in sheets were obtained in regard to the completion of the in-service, it was determined there was no evidence to verify either LPN #1 or LPN #2 had received and read the in-service. On [DATE] at 1:00 p.m., LPN #3 when interviewed stated she received the information but, "hadn't had a chance to read it yet." On [DATE] at 2:09 p.m., the DON was asked about the nurses who did not read and/or sign the inservices. She stated most of them did. On [DATE] at 2:53 p.m., the administrator and owner were informed the IJ could not be removed. They were asked for an addendum to the plan of removal. The "Addendum to IJ" was received on [DATE] at 5:10 p.m. and documented: "The RN, (Name deleted), will in-service the LPN staff regarding the proper way to assess a resident, monitor a resident, and report about a resident who experiences a change in condition during their shift. (Name deleted) will also help teach the LPN staff proper chart document. The in-service will be face to face with all LPN staff. This will be accomplished not later than [DATE] 5:00 p.m." The IJ was removed on [DATE] at 2:00 pm. when all components of the plan of removal had been completed. The deficient practice remained at an isolated level of actual harm. Based on observation, interviews and medical record review, it was determined the facility failed to: ~ ensure one resident with uncontrolled diabetes (#9) in an acute state and with a declining condition was thoroughly assessed and monitored; and failed to ensure the resident received care necessary to prevent further decline and/or death. Three residents resided in the facility with uncontrolled diabetes. ~ ensure assessment, monitoring and the necessary care was provided for a resident's declining wound status for one (#2) of three sampled residents with wounds. The facility identified four residents with wounds other than pressure ulcers. ~ ensure residents with urinary tract infections received antibiotics that were effective against the organisms isolated for one (#11) of two sampled residents with urinary tract infections. Fourteen residents had urine testing done in the last three months. Findings: 1. The last available comprehensive assessment for resident #9, dated [DATE], (discharged [DATE]) documented the resident was non-ambulatory and required extensive assistance for transfer, dressing and for bathing. The resident was always incontinent of bowel and bladder. The Brief Interview for Mental Status (BIMS) was a 9, which indicated the resident had a moderately impaired cognition. The assessment documented the resident had an impaired decision making ability. Her care plan documented, "I do at times stare into space." The resident had [DIAGNOSES REDACTED]. Review of the closed medical record documented the resident's FSBS had extreme fluctuations-both high and low. A nurse's note documented on [DATE] at 12:00 p.m., "Res (Resident) FSBS (arrow down) to 30. Gave glucose tube. FSBS (arrow up) to 38. Noted to be sweating. Eyes closed hard to arouse. FSBS (arrow down) to 33. Placed call-to (Name deleted) EMS (emergency medical services). EMS came out and started IV (intravenous) and administered D50 ([MEDICATION NAME]) solution. After a few minutes res aroused, smiled and FSBS was 338..." Documented FSBS's for [DATE], ranged from 43 to 475. The FSBS's were being done before meals and at bedtime. On [DATE] at 4:00 a.m., a nurse's note documented: "Summoned to room per CNA-resident diaphoretic, resp. (respiration) 22, BP (blood pressure) ,[DATE], P (pulse) 107, T (temperature) 97.4. C/O (complaint of) chest hurting-upon questioning determined not [MEDICAL CONDITION] or heart related pain but due to congestion, wheezes et (and) crackles noted throughout, 650 mg (milligrams) [MEDICATION NAME] given for discomfort, FSBS checked, is not hypoglycemic, will continue to monitor." The nurse's note was signed by (Name deleted) LPN #4. At 4:30 a.m., a nurse's note documented: "RN to asses. 0435 (4:35 a.m.) RN reports status decreasing to call EMS-RN placed call at 0435 call placed again @ (at) 0445 (4:45 a.m.), EMSA arrived @ 0500 (5:00 a.m.) - continued." The nurse's note was signed by (name deleted) LPN #4. "CPR (cardio [MEDICAL CONDITION] resuscitation) began @ (at) 0440 (4:40 a.m.), EMS arrived et (and) took over @ 0500 (5:00 a.m.)." The nurse's note was signed by (Name deleted) LPN #4. "0530 (5:30 a.m.) EMT's (emergency medical technician) transferred resident to ER (emergency room ), accompanied to ambulance by nursing staff." The nurse's note was signed by (Name deleted) LPN #4. LPN #4 was interviewed at 11:00 a.m. on [DATE]. When asked what she remembered about the night of [DATE], and resident #9, she stated she would never forget, it was her "first code." She stated the resident was a brittle diabetic and would, "bottom out quickly." She stated she did her blood sugar around 12 midnight. When asked what the resident's blood sugar was that night, she stated she forgot, it was low, but she was still alert. She stated she gave her something to bring up her blood sugar; things like orange juice and sugar until she got it up around an hour later. When asked what she got the blood sugar up to, she stated she didn't remember, but it was normal. She stated, later on regular rounds, a certified nurse aide (CNA) came and got the residents blood sugar and it was around 500. When asked about documenting the blood sugar results, the LPN stated she had not recorded them anywhere. When asked if she had notified the physician of the low blood sugar result, she stated, "No." She stated she did try to notify him of the high blood sugar but he did not answer. Her attempt to reach a physician was not documented, and she did not know what time it was when she had called. She stated around 4:,[DATE]:30 or 5:00 a.m., when she went in the resident's room the resident appeared "kind of sweaty, had labored breathing and didn't look good." She stated the resident said she had "chest pain" but the LPN stated she herself had decided it was not, "heart pain," it was like respiratory. When asked if she notified the physician of the resident's condition, she stated, "No." The LPN said, "within a few minutes she got worse" and that was when she got RN #1 to assess the resident and she called EMSA as soon as she saw her. RN #1 was interviewed at 11:45 a.m., on [DATE]. When asked about the same night and what had occurred, she stated she had gotten to work a little before 4:00 a.m. that morning. She stated she always came in a little early. She stated she had been making rounds and did not know there was a problem with resident #9. She stated it was about 4:30 a.m., when LPN #4 asked her to assess the resident. She stated when she saw the resident, she asked her if she was having chest pain at that time and she stated, "No." She stated she assessed her but did not document the results of her assessment. The RN stated, she told them to call EMS immediately and to get the crash cart. She stated, "She went down on us and we started CPR." When shown the notes written by the LPN, she stated, "This is not what happened. She did not tell me at all that the resident was having chest pain." When asked if the resident had ever exhibited chest pain before, she stated, "Not to my knowledge." The RN stated when she saw the resident, "I thought it was heart. Every minute makes a difference. I should have been told about this when I walked in the building...critical...I was an ER nurse for [AGE] years." When asked what the resident's BS was at that time, she stated, "Don't know what it was, but it was normal or would have asked her to check it again." The RN reviewed the resident's medical record for documentation of the resident's blood sugar during that shift; what was done for her low blood sugar and how she responded; notification of a physician or her assessment when she saw the resident at 4:30 a.m. She verified none of this information was documented. No nurses' notes in regard to the resident's unstable condition were documented for this resident on the night shift, until the note by LPN #4 at 4:00 a.m. The physician was not notified of the resident's low blood sugar, high blood sugar or change of condition including complaint of chest pain. The CNA (#5) who was working on the ,[DATE] shift on [DATE], was interviewed at 2:55 p.m. on [DATE], and was asked what occurred that night. The CNA stated when she first got there that night, the resident's blood sugar was, "acting up" and her roommate pulled her call light and said, "She (resident #9) was acting not herself." The CNA stated she went and looked at the resident and she was, "full of sweat." She also felt her pulse and she had a good one. The CNA had a phone and called the LPN from the resident's room. The LPN checked her blood sugar. She stated she did not know what it was, but it was low. LPN #4 told the CNA to give her 2, 8 ounce glasses of orange juice. "Then she was okay." She stated maybe ,[DATE] hours later she was sweating real bad and was not responding. She stated at that time, the LPN checked her blood sugar, but was not sure what it was. The CNA stated she left then and went back up the ramp to answer another call light and when she came back they were doing CPR. The CNA stated she hadn't layed in there long because the roommate had called, "maybe 4 times for help." She stated the resident was sweating so bad that it was going through her clothes. The CNA stated the resident said she saw her brother, who had died , and felt like she was dying. After the facility staff were notified of the IJ, the LPN was given a "Verbal/Written Warning" by the facility for "[MEDICATION NAME] outside scope of practice..." The LPN documented, "I did not practice outside of my scope of practice. I did fail to document thoroughly. I did everything in my power to do my job well. If I had to do again I would have done everything just as I did, only made sure I documented more thoroughly." The form was signed by LPN #4 and also by the DON. The emergency room (ER) notes documented the resident was received into the ER at 5:19 a.m., "Pt (patient) from Wadley's care center found in full arrest, intubated by EMS...CPR in progress." The resident's recorded blood sugar at 5:29 a.m. was 549 with a reference range of ,[DATE]. The resident expired at 7:26 a.m. The final [DIAGNOSES REDACTED]." 2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The daily nurse's notes documented the resident was extremely confused, was incontinent at times and required assistance with his ADLs (activities of daily living.) The admission nursing assessment, dated [DATE], documented the only altered skin conditions were a scar on the left chest from a pacemaker and a bandage to the right forearm, which the resident stated was a skin tear, but had refused for the dressing to be removed. It was documented the resident had dry skin. A comprehensive resident assessment, dated [DATE], contained no documentation of an assessment having been conducted. All areas were blank. A nurse's note, dated [DATE], documented the resident had an abrasion on his right knee and the first digit of his right foot after experiencing a fall. A nurse's note, dated [DATE], documented the resident had an abrasion on the right ankle, the top of the right foot, the right knee and a scabbed area covering the second toe on the left foot. A large blood blister to the second toe of the right foot was also documented. The physician was notified and dressing orders were received. The wounds continued to deteriorate and various dressing change and treatment orders were received. A physician's orders [REDACTED]. [MEDICATION NAME] was to be applied to the right heel. The facility policy titled, 'Wound Care', documented: "Purpose: The purpose of the procedure is to provide guidelines for the care of wounds to promote healing.... Steps in the procedure: 1. Use disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table. Place all items to be used during procedure on the clean field.... 2. Wash and dry your hands thoroughly. 3...Place disposable cloth next to resident (under the wound) to serve as a barrier to protect the bedlinen and other body sites. 4. Put on exam glove. Loosen tape and remove dressing. 5. Pull glove over dressing and discard...Wash and dry your hands thoroughly. 6. Put on gloves.... 14. Be certain all clean items are on clean field... Documentation: The following information should be recorded in the resident's medical record...All data assessment (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound..." On [DATE] at 10:40 a.m., LPN #5 was observed performing the wound care on the resident's right foot. She was assisted by CNA #7. Prior to the care, the LPN had laid out the dressing supplies on the bedspread beside the resident's feet. No protective barrier had been placed on the bed. The LPN and the CNA entered the room and donned gloves. The CNA held the resident's leg up off the bed while the LPN removed the soiled dressing. The dressing had adhered to the heel wound and the LPN sprayed the dressing with Dermacleanz to loosen it. After spraying the wound she tossed the Dermacleanz spray bottle directly onto the bedspread. The bottle shifted and the nozzle came to rest while in contact with the bedspread. She repeated this process twice until the dressing was able to be removed. Both times the nozzle rested on the bedspread. The LPN proceeded to cleanse the toes, lateral ankle and the heel wounds without changing gloves. She picked up the [MEDICATION NAME] and realized she did not have all the supplies she needed to complete the dressing change. She removed her gloves and left the room. The resident began moving his right leg and the CNA laid it down so the clean open wound on the heel came into contact with the bedspread. The LPN re-entered the room and placed the supplies on the bedspread. Without washing or sanitizing her hands, she donned gloves and used a wooden blade to apply the [MEDICATION NAME] to the second toe and the lateral ankle. She opened the [MEDICATION NAME] swab packet and painted the other toes, an area on the upper aspect of the ankle and the heel. She placed a non-adherent dressing over the wounds and wrapped them with gauze. She removed the gloves and after gathering the supplies, she proceeded to the door. LPN #5 and CNA #7 were asked if there was anything they would have done differently during the care. Both stated, "No." LPN #5 was asked if she had set up a protective field for her supplies prior to the wound care. She stated, "No." She was asked if the spray bottle nozzle had become contaminated when it touched the bedspread. She stated, "Yes." She was asked if she had changed her gloves after removing the soiled dressing and cleaning the wounds. She stated, "No, I should have." CNA #7 was asked if she had placed the resident's heel on the bedspread after it had been cleaned. She stated, "Yes." She was asked if this had contaminated the wound. She stated, "Yes." No skin or wound assessments were located in the clinical record. On [DATE] at 8:55 a.m., the ADON was asked if there was a skin or wound assessment book. She stated they had just started one when they hired the new wound care nurse last week. She was asked where the physician ordered skin assessments were located. She stated, "Should be on the TARS (treatment administration records)." She was asked where the wound assessments were located. She stated, "If they did them, in the chart." At 1:20 p.m., LPN #5 was asked if she did skin or wound assessments. She stated, "Nothing formally - nothing documented." She was asked if she did wound assessments with measurements and wound descriptions. She stated, "No." She stated they hired a wound nurse to come in two times a week and she would be doing them. She was asked if she had ever documented a thorough wound assessment on resident #2. She stated she thought she had measured the wounds one time, but wasn't sure. She stated she didn't know she was supposed to. No care plan was located in the resident's clinical record. On [DATE] at 9:50 a.m., the DON (director of nursing) was asked if she could locate the care plan for the resident's wounds. At 9:55 a.m., the DON presented the care plan. They were reviewed with her. There was one care plan for being a full code, one on activities, one on elopement and three on falls. She was asked if there was a care plan for wounds. She stated, "That's all I have." On [DATE] at 10 :30 a.m., the DON was informed about the wound care observations. She stated, "That's not good practice." 3. Resident #11 had [DIAGNOSES REDACTED]. A preliminary report, dated [DATE] at 11:08 a.m., for a urine culture collected on [DATE], documented three organisms were isolated, each at greater than 100,000 colonies/ml. The organisms were [DIAGNOSES REDACTED] Pneumoniae, Proteus mirabilis and Escherichia Coli. For Escherichia Coli, the report documented, "Extended spectrum beta-lactamase present; confers resistance to pencillins (sic), cephalosporins, and aztreonam." LPN #3 had written on the bottom of the report, "*E-Coli ESBL (Extended spectrum beta-lactamse) - super resistant strain [DATE] Noted & (physician) was called- (LPN intitials) Noted order [MEDICATION NAME] BID x 7 days; - (LPN initials)." Page 2 of the report documented the organisms sensitivity to different antibiotics. The report documented the [DIAGNOSES REDACTED] Pneumoniae was sensitive to Cipro. The Proteus Mirabilis was intermediate suggesting treatment with an alternative drug. The Escherichia Coli (ESBL) was resistant to Cipro. A nurse's note, dated [DATE] at 12:30 p.m., documented, "Received lab results from urine culture E-Coli ESBL; (physician) was notified; noted N/O [MEDICATION NAME] x 1 po BID x 7 days; dx: UTI..." A physician's orders [REDACTED]." A hand-written note on a final report of the culture and sensitivity documented, "Faxed [DATE]..." and "on abt (antibiotic)/ for this as of [DATE]..." On [DATE] at 10:05 a.m., LPN #3 was asked about the lab results from the urine culture and how they were conveyed to the physician. She stated that she had called them to the physician and he was informed the organism was sensitive to Cipro. She pointed to the first column that reported the sensitivity testing for [DIAGNOSES REDACTED] Pneumoniae.

On 09/13/13, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to provide supervision to prevent elopement for a resident who had eloped three times in three days. The existence of the IJ was verified with the Oklahoma State Department of Health (OSDH). At 5:08 p.m., the administrator, the DON and the ADON were notified of the existence of the IJ. At 8:01 p.m., an acceptable plan of removal was received. The facility's plan of removal documented: "Plan of Removal for Immediate Jeopardy declared on 09/13/13 at 5:08 p.m. It is the policy of this facility to prevent the elopement of residents who have an admission or on-going assessment that identifies them at risk for elopement. ELOPEMENT 1. The Director of Nurses, (name withheld) and the Assistant Director of Nurses, (name withheld) will in-service staff on elopement risk; how to be aware of helping to prevent a resident from leaving the premises; what to do if it is determined that a resident is missing from the facility. The in-service will be completed not later than Saturday September 14, 2013 at 5:00 p.m. 2. New hire staff will be oriented to residents who are at risk of elopement by a review of the resident elopement assessment and care plan. Staff will demonstrate a return demonstration of understanding of identifying residents who may be exit seeking and how to re-direct them and the necessity of monitoring those residents until the exit seeking behavior is diminished. In-service will completed not later than September 14, 2013 at 5:00 p.m. 3. An immediate check of all the exit doors was done by the maintenance personnel to ensure that all the exits that have 'keyed' entry were in working order. This is completed not later than September 13, 2013 at 9:00 p.m. 4. Residents at risk of elopement will be identified and assessed and staff will be in-serviced for awareness of those resident(s) at risk of elopement. This will completed not later than September 14, 2013 at 5:00 p.m. 5. Periodic inspections to ensure that doors are in proper working order will be documented and kept on file for review in QA (quality assurance) Committee meetings. 6. The owner has hired a consultant with several years of regulatory experience to review all incident reports and Quality Assurance Committee meeting minutes for the next ninety (90) days. The contract will be signed not later than September 13, 9:00 p.m. The consultant reports will be sent to the Administrator and included in monthly QA Committee meetings for the ninety (90) day period." On 09/17/13 at 10:30 a.m., the administrator was asked for the list of residents the facility had identified as being an elopement risk. She stated she would have to ask the ADON. She then asked RN #1 where the list was. RN #1 stated she didn't know of any list but the in-service should be in the administrator's office. At 10:40 a.m., the administrator was asked for the in-service presented for the elopement plan of removal. She presented a folder. The folder contained the copies of an in-service, dated 08/08/13, along with a list of employee signatures who attended the in-service. It also contained a copy of the 'Elopements' policy presented to the team on 09/13/13 along with a list of employee signatures/names contacted for the in-service. No list of residents identified at risk of elopement was located in the folder. At 10:45 a.m., the DON was asked for the list of residents identified at risk for elopement. She stated the ADON had taken that over. The ADON was asked for the list of residents identified at risk for elopement. She stated the SSD was "putting it together right now." She was asked if the staff had been in-serviced on the individual residents they had identified at risk of elopement. She stated, "No, we just did a general in-service on elopement." At 10:50 a.m., the DON, ADON and the SSD were asked if the staff had been in-serviced on the specific residents identified at risk. The DON and the ADON shook their heads, "No." The SSD stated she had given examples of residents but had not given the full list to the staff. They were asked what the return demonstration from the staff consisted of. The ADON stated the staff verbalized the current policy on who to report to and how to get help if following a resident out the door. The SSD was asked if a current elopement risk assessment was completed on the residents she was identifying on the list. She stated she didn't do one because the nurses did them and she didn't know if one had been done. The administrator was asked if elopement risk assessments had been completed. She turned and asked RN #1 if the assessments had been completed. RN #1 stated, "I don't think we have an elopement risk assessment." At 10 :55 a.m., the ADON was asked if a current elopement risk assessment had been completed on the residents they had identified at risk. She stated she didn't do them so there were probably none completed. At 11:10 a.m., the SSD was asked for the list of residents identified as elopement risks. She presented a resident roster with 'wanderer' written beside 15 resident names. She was asked if all these residents were considered an elopement risk. She stated most were in wheelchairs and didn't know if they would be considered at risk or not. She was asked who did she think was an 'elopement risk'. She named three residents. She named resident #6 because he had eloped before. She named a resident (#33) who was not in the facility at the present because he had told them he "was going to run away." She named a resident (#27) who had just been admitted . She stated he had shown no exit seeking behaviors but was still being monitored for a few days. At 1:00 p.m., housekeeper #1 was asked what she would do to prevent a resident from eloping. She stated, "Be calm, try to redirect." She was asked what she would do if she discovered a resident missing. She stated, "report it immediately." She was asked which residents were at risk for elopement. She stated resident #22 and resident #23. At 1:15 p.m., the DON presented "Initial Wandering Assessments" on every resident in the facility. She also presented two notebooks with every 30 minute monitoring sheets in them on eight residents. She stated the staff would use the books to do every 15 minute monitoring of those residents. At 1:30 p.m., CNA #8 was interviewed. Housekeeper #1 had to interpret for her as she spoke no English. She was asked how to prevent a resident from eloping. She stated, "Tell the nurse." She was asked what to do if she discovered a resident was missing. She stated she would tell the nurse and report it to the police. She was asked how the residents were monitored. She stated, "should check on them every two hours." She was asked which residents were at risk for elopement. She stated, "Resident #22 and resident #6. She was asked if she had been in-serviced on elopement. She stated, "No." At 1:45 p.m., CNA #9 was asked how to prevent a resident from eloping. She stated to make sure the doors and windows were secure. She was asked what to do if a resident was discovered to be missing. She stated, "report it, call 911 and issue an APB (all points bulletin)." She was asked how to monitor a resident at risk for elopement. She stated to make sure they don't go near the doors and they should be checked on every 30 minutes. She was asked which residents were at risk for elopement. She stated resident #24, resident #22 and resident #25. She was asked when she was in-serviced on elopement. She stated a week or two ago. On 09/17/13 at 2:25 p.m., the DON was asked if the 'wandering assessments' she had presented at 1:15 p.m., were the current elopement assessments. She stated, "That is the elopement assessment." She was informed elopement risk assessment forms had been observed in the clinical records. She stated she would look. She was asked how the notebooks would be used. She stated the staff would use them when wandering behaviors were observed, like pacing the halls or entering other resident's rooms. At 2:52 p.m., a maintenance employee was asked if had been in-serviced on monitoring the door locks. He stated this was his first day and he had not been told anything about making rounds on the doors. He stated he was "actually their computer guy." He stated he had come in on Sunday and recoded all the doors except the main west door because the staff could not get the doors unlocked. He stated the codes had been posted at all the doors. He was asked if he had documentation of this. He stated, "No, the maintenance guy would have done that." On 09/17/13 at 2:53 p.m., the administrator was asked about resident #6 eloping from the facility last night. She stated he exited through the smoking courtyard. She stated a CMA picked him up. The administrator was informed that there was no documentation of door checks. Also that the elopement assessments had not been done until today. Eight residents were identified by the facility to be at risk for elopement. When staff were interviewed, they did not know which residents were at risk for elopement. She was informed that we would not be able to remove the IJ at this time. She was asked to provide an amended plan of removal for the IJ. An addendum to the plan of removal was received and accepted on 09/17/13 at 5:10 p.m. The addendum documented: "The Administrator will work with (RN #1), RN to conduct a proper in-service to all staff for elopement risk of residents who reside in this building. There will be an assessment of all residents who are at risk of elopement conducted by September 18, 2013 at 5:00 p.m. The staff will have knowledge and be able to name those residents who are at risk for elopement and what to do when exit seeking behavior is identified. The facility will conduct missing resident drills on a monthly basis to ensure all new staff and current staff remain familiar with policy and procedure." On 09/20/13 at 9:28 a.m., the administrator was asked for the elopement assessments to determine who was at risk for elopement. The administrator provided the assessments that had previously been provided last week. She was asked for the new assessments. She stated she didn't know where the new assessments were. She stated, "I'm not a nurse." At 9:30 a.m., the DON was asked if she knew about the new elopement assessments. She stated, "I'll go see if I can find them. I was off Friday." At 9:40 a.m., the administrator stated they decided it was three residents, residents #6, 23 and 33. She was asked how they came to that conclusion. She stated she didn't know how. On 09/20/13 at 10:00 a.m., the administrator stated the last inservices for elopement were completed on 09/19/13 at 2:00 p.m., except for CNA #3, who was on vacation and CNA #13 who was to return to work last night at 11 p.m. She was to be inserviced when she came to work last night at 11 p.m. At 10:10 a.m., the administrator stated, CNA #13 was clocked in last night, but there was no documentation of an inservice. She stated she would call her and inservice her now on elopement. At 12:10 p.m., the DON brought in elopement assessments for the eight residents previously assessed to be at risk of elopement. She reported three were determined to be at risk for elopement, residents #6, 23 and 33. The facility provided documentation that CNA #13 was inserviced on elopement on 05/20/13 at 1:14 p.m. The IJ was removed on 05/20/13 at 1:14 p.m., when all components of the plan of removal had been completed. The deficient practice remained at an isolated level of actual harm. Based on record review and interview, it was determined the facility failed to: ~ provide supervision to prevent multiple elopements of two (#2 and #6) of two sampled residents whose clinical records were reviewed for elopement risks. The facility identified 15 residents who wandered and three residents at risk of elopement. ~ ensure staff transferred residents in a way to prevent injury for four (#7, 8, 18 and #20) of 10 sampled residents who required assistance with transfers. Resident #8 had actual harm when she was lifted from under her arms and sustained a fractured arm. The facility identified 31 residents who required assistance with transfers. Findings: A policy titled, Safe Lifting and Movement of Residents, documented: "Policy Statement In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Policy Interpretation and Implementation 1. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. 2. Manual lifting of residents shall be eliminated when feasible. 3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan... 4. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices..." 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A social services progress note, dated 06/13/13, documented, "...he has a very poor long and short term memory...was at another facility before being discharged here...he requires a locked unit due to his dementia..." A Risk of Elopement Assessment, dated 06/13/13, documented, "...Note: All new admissions should be closely observed for changes & any patterns of elopement attempts for the first 14 days... Diagnosis: [REDACTED]. Mental Status: A & O x 1 (alert and oriented times one)... Orientation: (person was circled)... Exhibited wandering behavior in the last 60 days: Duration (checked)... Past history of leaving facility/previous residence (checked)... Recent move of room or facility (checked)... Resident wanders aimlessly (checked)... History of pushing on door handles (checked)... Makes statements such as: other statements (checked)... Resident: ambulates independently (circled)... YES RESIDENT IS AT RISK FOR ELOPEMENT... door alarms (checked)..." A nurse's note, dated 06/13/13 at 6:30 p.m., documented, "...Has tried to leave X 3. Pushes on door. Asking about his boat. Staff redirects. Taken to room, or assisted to L/R (living room)..." A nurse's note, dated 06/14/13, documented, "1200 (12:00 noon)...Confused. Has had belongings in hand looking for car or for pickup...Redirected x 4 of location et staff...2300 (11:00 p.m.)...Has asked numerous x's about his car..." A care plan, dated 06/14/13, documented, "Problem: I am at risk for injuries relating to attempting elopement. I am seeking to return to Harrah Oklahoma. I am worried about the location of my car." Interventions: 1. Facility will continue to maintain coded doors to outside access in proper working order, maintaining Code to open doors in a secure manner. 2. Staff will remind visitors and staff to be aware of doors closing and not to allow residents outside the Facility without administrative approval. 3. Staff will attempt to reorient (Resident) to facility and placement as needed." An incident report, dated 06/15/13 at 2:30 p.m., documented, "(Local) PD (police department) notified facility that they have res (resident) in protective custody two blocks away. It is unknown how res (resident) exited facility. Officer stated res fell on to his bottom & scraped elbow. Res arrived @ 1445 (2:45 p.m.) to facility escorted by police officers. (No) c/o (complaints) @ this time. Denies any pain. Abrasion to elbow 2mm x 2mm... Level of consciousness: Alert & oriented to person only. Dementia and Alzheimer's DXs (diagnoses) present. "Attempting to go home to Harrah." Additional comments and/or steps taken to prevent recurrence: Notify DON, ADON, and administrator. Place notes on front & back exits stating families cannot let residents out of the doors..." An update to the care plan, dated 06/15/13, documented, "(Resident) was found outside facility and returned s injury... Staff will attempt to interest me (Resident) in activities of interest and remind him of upcoming scheduled activities- 6-15-13..." An incident report, dated 06/16/13 at 2:30 p.m., documented, "...(Local) PD notified facility that they have res. in protective custody beside purcell hospital. It is unknown how res exited building. (No) injuries noted/reported. Res arrived @ facility escorted by officer @ 1915 (7:15 p.m.)... Level of consciousness: Alert & oriented to person only. Dementia & Alzheimer's DXs present. Stated he was "going home to Harrah."... Additional comments and/or steps taken to prevent recurrence: 1:1 (one on one) initiated. Nurse @ both ramp & (lower) ramp nurse's station..." Updates to the care plan, dated 06/16/13, documented, "I get restless after meals", and "(Resident) was found off of property and returned." Updates to interventions included, "6-16-13 Paying extra attention after meals... Staff will provide me one-on one staff caregiving assistance to ensure safety until the new doors and dementia unit precautions are implemented- 6-16-13..." An update to the interventions on the care plan, dated 06/17/13, documented, "...Staff will provide nametag stating "resident of WCC" for (resident) to wear while oob (out of bed) as he allows.-6-17-13... " A social services progress note, dated 06/17/13 at 8:30 a.m., documented, "Over weekend (Resident) had left the facility to my understanding 2X on Saturday. On Sunday I was bringing another resident back from the hospital and found him outside walking. I brought him back inside and let staff know he was outside walking. I watched the video with (former administrator) and the time period that I was here to figure out how he was getting out. We seen where he was going out a side door that was unlocked..." On 09/13/13 at 12:40 p.m., an environmental tour was conducted with emphasis on outside access from the interior of the facility. Seven doors were observed. Six doors had access to the outside only by the use of a keypad. These six doors were locked and exit was not obtained. The seventh door entered into a fenced courtyard. This door was not locked. A six foot PVC fence, with a gate, was observed on the north side of the courtyard. Two gate latches were located on the outside of the gate. As the gate was being examined, resident #4 came to the gate and offered to show how the gate opened. He was asked if the gate was used by the residents. He stated some people use it, but mainly the owner. He stated, "It's real easy to get open and proceeded to demonstrate opening the gate without difficulty. At 3:50 p.m., the ADON was interviewed. She was shown the elopement risk assessment, dated 06/13/13, and was asked if this meant the facility was aware he was at risk to elope. She stated, "Yes." She was asked what interventions the facility had put in place after the resident's first elopement. She stated signs were place on the front and back door to not let residents out. She was asked if signs were placed on the other four doors. She stated she never saw any. She was asked what interventions were put in place after the resident's second elopement. She stated the resident had been placed on 1:1 observation. She reviewed the clinical record and stated there was no documentation the resident had been on 1:1 observation. She also stated a nametag was placed on the resident. She stated the past administrator had wanted to open a dementia unit and had placed locked doors at the bottom of the ramp. She stated this administrator had contacted "the state" and then the doors were unlocked. She was asked if the resident had been in the locked area at the time of the elopements. She stated she thought he had, that was why they couldn't figure out how he was exiting. She was asked if there was a policy on how the exit doors were to be monitored. She stated she didn't know of any. She was asked how the facility determined how he eloped. She stated the administrator had viewed the video and found the south ramp door was malfunctioning and was unlocked. She was asked if the staff had ever been in-serviced on the resident's elopement risk. She stated, "No." At 7:30 p.m., the administrator was asked for the elopement policy. At 7:40 p.m., the administrator presented an "Elopements" policy and stated, "This is very generic." The policy did not address risk assessments or care planning. The policy documented: "Elopements Policy Statement: Staff shall investigate and report all cases of missing residents.... Policy Interpretation and Implementation... 1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing... 2. If an employee observes a resident leaving the premises, he/she should: a. Attempt to prevent the departure in a courteous manner; b. Get help from other staff members in the immediate vicinity, if necessary; and c. Instruct another staff member to inform the Charge Nurse or Director of Nursing Services that a resident has left the premises... 3. When a departing individual returns to the facility, the Director of Nursing Services or Charge Nurse shall: a. Examine the resident for injuries; b. Notify the Attending Physician; c. Notify the resident's legal representative (sponsor) of the incident; d. Complete and file Report of Incident/Accident, and e. Document the event in the resident's medical record... 4. If an employee discovers that a resident is missing from the facility, he/she shall: a. Determine if the resident is out on an authorized leave or pass; b. If the resident was not authorized to leave, initiate a search for the building(s) and premises; c. If the resident is not located, notify the Administrator and the Director of Nursing Services, the resident's legal representative (sponsor), the Attending Physician, law enforcement officials, and (as necessary) volunteer agencies (i.e., Emergency Management, Rescue Squads, etc.); d. Provide search teams with resident identification information; and e. Initiate an extensive search of the surrounding area... 5. When the resident returns to the facility, the Director of Nursing Services or Charge Nurse shall: a. Examine the resident for injuries; b. Contact the Attending Physician and report findings and conditions of the resident; c. Notify the resident's legal representative (sponsor); e. Complete and file an incident report; and f. Document relevant information in the resident's medical record..." At 7:50 p.m., the DON was asked if she could locate the elopement policy which addressed risk assessments and care planning. She stated she had looked but couldn't find one. She stated, "We do an elopement risk assessment on admit and quarterly, I believe." At 8:20 p.m., the SSD (social services director) was asked for her notes on the resident. They were presented at 8:30 p.m. On 09/17/13 at 1:45 p.m., the SSD was asked if she knew resident #2 was an elopement risk prior to his admission. She stated, "Yes, that is why they called us - we had locks." She was asked if he had eloped from the previous facility. She stated she thought he had gotten out of the facility but not off the property. She was asked where the resident was located when she found him outside on 06/17/13. She stated he was on the grass turning the northwest corner of the facility. She stated she had gotten the car, gone to the hospital to pick up another resident and when she returned she saw him. She stated he couldn't have been out but 20 minutes or less. She was asked if an incident report was written on the incident. She stated the nurses write them and didn't know if one had been written or not. She was asked if she had informed the nurse. She stated she had told them the resident was out, was going to get him and there was another resident in the car. She was asked when she had looked at the video with the past administrator. She stated it was the following Monday. She stated they never saw him go out the door but when they viewed the time frame when she was at the hospital they saw him come around the southwest corner of the building. She stated they went to the southeast door and found it unlocked. She was asked when the door was repaired. She stated, "That day." She was asked if a specialty company had fixed the door. She stated, "No, just a little adjustment, so maintenance did it." 2. Resident #6 was admitted to the facility 07/11/13 with [DIAGNOSES REDACTED]. An admission assessment was not available according to facility staff. An Order to Determine Placement, dated 09/27/12, from the District Court of (name deleted) County documented the resident was incompetent due to dementia and that he had "gross impairment in memory and executive functioning." A Risk of Elopement Assessment completed by facility staff, dated 07/11/13, documented under "Yes Resident is at risk for elopement", the use of door alarms. The assessment documented the resident was anxious, confused at times, and ambulatory. A careplan, dated 07/11/13, documented, "I am at risk for elopement. I have a DX of dementia and I become easily confused." The goal documented, "I will not exit the building unattended by staff thru next review date." Interventions included: "...Offer another indoor activity... Approach in a calm manner... Speak in a relaxed tone of voice... Minimize the use of the word 'No or Can't'... If redirection id (sic) difficult seeks assistance, keep those assisting at an effective minimum... If resident is agatated (sic) and exit seeking staff is to offer (resident) to go for a walk in the courtyard if the weather is nice... Redirect my attention." An incident report, dated 07/31/13, documented the resident was determined to be missing from the facility at 3:50 p.m. after being let out the door and going outside with facility owner. He was returned to the facility by staff who witnessed him leaving. An update to the care plan, dated 07/31/13, documented, "I eloped with a visitor. I walked out c him after he entered the code in the security door. I walked east on the paved road and made it the next block over to green street. I was not injured." A new intervention, dated 07/31/13, documented, "One on One monitoring x 4 (hours) then q 15 min (minutes) safety checks x 24 (hours)." A nurse's note, dated 09/16/13 at 5:10 p.m., documented "Rec'd call from CMA #1 stating resident was at Green Ave and Washington walking. States will try to see if res will get into car...." The note further documents after the resident was returned to the facility from his elopement he was sent to (hospital) at 7:15 p.m. for psychiatric evaluation. He returned from the hospital to the facility at 3:00 a.m. on 09/17/13. On 09/17/13, at 2:45 p.m., an interview was conducted with LPN #10 who was assigned to the resident's unit the evening of 09/16/13 when he eloped. She was asked how it was determined that the resident was missing. She stated that facility staff became aware the resident had eloped when an off-duty employee, CMA #1 observed the resident walking down the street several blocks from the facility, phoned the facility, and notified them of the resident's location. She stated prior to this phone call she had no knowledge that the resident was missing. 3. Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The care plan was dated 08/27/12, and was reviewed on 08/14/13. One of the problems was for Activities of Daily Living (ADL's) which documented, "ADL - self care deficit: d/t (due to) decline and cognitive deficit. I require more assistance this review. I require total assistance with...Transfers..." Two of the interventions documented, "...I require total assistance with all transfers..." and "...Provide appropriate level of assistance to promote my safety..." The quarterly assessment dated [DATE], documented the resident required the extensive assistance of two plus persons for transfers. An incident report dated 05/20/13, had been sent to the Oklahoma State Department of Health. This report documented, "...On 05/20/13 at approximately 12:30 p.m., (Resident #8) wanted to be transferred from her wheelchair to a recliner in the living area. (CNA # 4) and (LPN #9) transferred (Resident #8) by holding her under the arms each on one side of the resident when (CNA #4) heard a pop from (Resident #8's) left arm. (Resident #8) expressed a sensation of pain at the time of the transfer. Resident's granddaughter, (name deleted), was standing there when they did the transfer and witnessed the event. At 10:30 pm, rounds were made at shift change and they found that the resident's arm was extremely swollen. At that time, the ambulance was called to take the resident to the hospital for further care. Upon return from (hospital name deleted) ER (emergency room ) after midnight, the nurses learn that she has a closed fracture in her left humerus shaft..." The 5 day final report for the incident report documented, ..."She saw an orthopedic doctor this week that stated she has a hairline fracture and is to continue to wear the sling for one more week. Staff has been in-serviced on proper use of a gait belt for transfers by a physical therapist. Next week we will also do in-servicing on proper use of the lifts for transfers..." The first mention of the incident in the nurses' notes was dated 05/20/13 at 2150 (9:50 p.m.) and documented, "This LPN called down to res (resident) rm (room) per LPN (Licensed Practical Nurse - initials deleted) to check res shoulders. Upon assessment noted L (left) shoulder edematous & painful to touch (no) bruising or discoloring visible. Res reported that earlier today she was being transferred into recliner from w/c (wheelchair) by staff X2 & she heard a pop from L shoulder & now her shoulder was hurting. Ice pack applied @ 2205 (10:05 p.m.) & instructed CMA (certified medication aide) to adm.(administer) PRN (as needed) Tramadol..." The 'Orders Sheet' for May 2013, documented the resident was administered Tramadol 50 mg. on 05/20/13, at 1:30 p.m. for complaints of leg and back pain and at 10:00 p.m. for complaint of left shoulder pain. An 'In Service Educational Program' was conducted on 05/23/13 from 2:00 p.m. until 3:00 p.m. which documented, "...gaitbelt training/transfer demonstration with physical therapist." On 09/13/13 at 9:40 a.m. the resident's granddaughter was interviewed and was asked about the above incident. She stated she was present when the transfer occurred. She stated her grandmother was moved from her wheelchair to her recliner, and her left arm popped. She stated her grandmother immediately started complaining of pain. She was asked how the staff transferred her. She stated, by lifting under her arms. She then stated that since the fracture occurred she was only transferred using a lift. On 09/13/13 at 8:15 p.m. the ADON (Assistant Director of Nurses) was interviewed and was asked if she thought lifting a resident from under their arms was an improper way to transfer a resident. She stated, "You know it is." On 09/17/13 at 1:48 p.m., CNA #4 was interviewed concerning the incident. He stated he and the LPN moved the resident over in the wheelchair close to her recliner. He stated they put their arms behind her and held their arms under her arms. He stated he heard a pop when she was sitting down. He stated, "I'll never forget that sound it just scared the tar out of me." He was asked if he had used a gait belt for the transfer. He stated he did not. He was asked what the facility polic

On 07/31/13, an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to ensure a thorough investigation was conducted for allegations of abuse and the facility's failure to protect residents until a thorough investigation was completed. The Oklahoma State Department of Health was notified and verified the Immediate Jeopardy Situation. At 7:22 p.m. the administrator and the assistant director of nursing were notified of the IJ situation. On 08/01/13 at 4:00 p.m., an acceptable plan of removal was presented to the survey team. The Plan of Removal documented: "Plan of Removal for Immediate Jeopardy declared 07/31/2013 7:23 p.m. It is Policy and Procedure of this nursing facility to prevent the abuse, neglect, and the misappropriaton of resident property and to screen potential employees and to train employees in the identification of and proper reporting of allegations. 1. The Administrator immediately had the LPN (LPN #1 initials deleted) escorted from the building at approximately 7:40 p.m. on July 31, 2013, to protect the residents from potential harm. 2. The Social Services and/or Activities personnel will speak with a random sample of ten (10) cognitive residents to identify if abuse has affected other residents in the facility and will complete these samples and bring to the Administrator not later than 12:00 noon, August 1, 2013. 3. The ADON prepared an in-service, shortly after 7:30 p.m., July 31, 2013, for all staff currently in the building to read and sign. The ADON began collecting signatures of employees on the 3-11 shift. All employees reporting to work will read the in-service on abuse and sign that they understand what the components of abuse, neglect, and misappropriation of resident property is. Employees will not be allowed to work until their in-service is completed and signed. The in-service instructs staff to report allegations to the Administrator, Director of Nurses, immediate supervisor, or designee immediately. All facility staff will have been inserviced in person or by telephone conference by noon on August 1, 2013. New hire employees will receive abuse and neglect prevention training as part of orientation and staff will continue to be in-serviced periodically as necessary. 4. A thorough investigation was done on the incident by the Administrator on 07/22/13. Although no evidence of abuse was identified the Administrator will continue to use systemic approach to (1) prevent, (2) screen, (3) identify, (4) train, (5) protect, (6) investigate, and (7) report any allegations of subsequent abuse reported by any source. The Administrator interviewed the resident, several staff, and directed the Social Services worker to speak with a random sample of cognitive residents to find out if there were other unreported incidents of abuse. The administrator documented her conversation with the resident on the final report faxed on 07/22/2013. The Administrator is submitted with this plan of removal a note written by the Social Services Director that records a conversation she witness were the resident stated 'he did not want to make a statement'.....'he didn't have a problem with the nurse and no incident occurred'...The investigation is deemed complete on August 1, 2013 at shortly after 1:30 p.m. 5. The Administrator will begin further investigation of this incident effective immediately. The resident involved in the allegation has left the facility against medical advise and left no forwarding address nor phone number. However, the Administrator will make every effort to locate this resident for re-interview. The staff on the shift that the incident was alleged to occur will be re-interviewed and statements will be taken. The employee accused of the allegation of abuse has been suspended again, pending investigation, and will be asked to return a location outside the facility for interview. The investigation will fully explore the components of the incident and statements will continue to be collected as they become available. The Administrator anticipates that the re-investigation can be completed no later than 5:00 p.m. on August 2, 2013. 6. The Administrator or designee will monitor through random questionnaires of a sample of minimum of ten (10) cognitive residents and four (4) staff selected randomly from all three shifts and document findings for presentation to the QA meeting. The residents and staff will be allowed to submit questionnaires anonymously with the assurance that the statements can remain confidential without a fear of reprisal. Responses will be kept confidential with a need to know basis and following regulatory requirements. Random sample questionnaires will be completed on a weekly basis for four (4) weeks beginning the week of August 1, 2013 and reported to the QA Committee. The QA Committee will consist of the Medical Director, the Administrator, a member of the nursing staff, and at least three (3) other staff. Random sample questionnaires will continue to be done on a monthly basis and reported to QA to ensure the facility remains in compliance with policy, procedures, and regulatory requirements." The Immediate Jeopardy was removed on 08/05/13 at 10:15 p.m., when the facility completed all components of the plan of removal. The last staff member who was present on the shift of the incident, and witnessed interactions between the resident and the staff member, was interviewed from 10:00 to 10:15 p.m. on 08/05/13. The deficient practice remained at an isolated level with a potential for more than minimal harm. Based on interviews and review of clinical records, policies and procedures, personnel records, and staff schedules, it was determined the facility failed to complete a thorough investigation of allegations of abuse for one (#1) of one sampled residents with allegations of verbal abuse. The facility failed to protect residents until a thorough investigation was completed. This had the potential to affect all 59 residents who resided in the facility. Findings. A policy, titled Freedom from Abuse Policies, documented: "Resident Abuse and Neglect Policy If any person observes or becomes aware of an incident of resident abuse and/or neglect, whether alleged, suspected, or observed, that person MUST report the incident to the nursing supervisor immediately. This includes incidents occurring anywhere in the facility, on the grounds, at school, workshops, or away from the facility. The nursing supervisor will initiate the procedure for the incident reporting... Abuse includes, but is not limited to: ...Verbal Abuse: Oral, written, or gestured language which includes sarcastic remarks, derogatory statements, directed to residents, families or significant others. ...Physical Abuse: Humiliation, sarcasm, harrassment, being ignored, and favortism to others, degrading, criticizing, threats, deprivation, punishment, ridiculing, and involuntary seclusion..." A policy, titled Abuse Investigation Protocol, documented: "Policy Statement Wadley Care Center management promptly and thoroughly investigates all reports of resident abuse, neglect, injuries of an unknown source, resident-to-resident and resident-to-staff abuse. Police (sic) Interpretation and Implementation 1) Should an incident or suspected incident of resident abuse, neglect, injury of unknown source, resident-to-resident abuse, and/or resident-to-staff abuse be reported, the administrator, or their designee, will appoint an individual to investigate the incident... 3) The individual conducting the investigation will, as a minimum: ...e) Interview the person(s) reporting the incident; f) Interview any witnesses to the incident; g) Interview the resident (as medically appropriate);... i) Interview staff members (on all shifts) who have had contact with the resident during the 48-hour period prior to the time of the incident; j) Interview the resident's roomate (if any/as appropriate); k) Interview the resident's family members and visitors who have had contact with the resident during the 48-72 hour period prior to the time of the incident; l) Interview the accused individual(s) or accused employee(s). (Note: If the accused individual is an employee, review the personnel file to determine if a background check was completed and if appropriate educational/orientation programs were attended.); m) Interview other residents to whom the accused employee provides care or services, to determine if they have complaints about the employee; n) Interview other employees to determine if they have ever witnessed other incidents of mistreatment involving the accused employee; and o) Review all events preceding the alleged incident; 4) The following guidelines will be used when conducting interviews: a) Each interview will be conducted separately and in a private location; b) The purpose and confidentiality of the interview will be explained thoroughly to each person involved in the interview process;... 5) Witness reports will be reduced to writing. Witness will be required to sign and date such reports. (Note: A copy of such reports must be attached to the (Incident Report Form".)... 7) Employees of this facility who have been accused of resident abuse will be suspended from duty until the administrator has reviewed the results of the investigation... 8) The individual in charge of the investigation will consult with the administrator as necessary concerning the progress/findings of the investigation. 9) The administrator will inform the resident and their representative (sponsor) of the results of the investigation. 10) The investigator will compile a written report of the results of the investigation. A copy of the 'Incident Report Form' must be attached to the investigator's report. 11) A copy of the investigator's report and a completed copy of the 'Incident Report Form' will be provided to the administrator within 5 working days of the reported incident. 12) The administrator will inform the resident and their representative (sponsor) of the results of the investigation and corrective action within 5days of the completion of the investigation..." A policy, titled Investigating Allegations of Verbal or Mental Abuse, documented: "Policy Statement All reported incidents of verbal or mental abuse are promptly and thoroughly investigated. Policy Interpretation and Implementation 1) Verbal abuse is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe resident's regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm, telling the resident that he/she will be separated from other residents, etc. 2) Mental abuse includes, but is not limited to, humilation, harassment, threats of punishment or deprivation (e.g. withholding food or services from the resident), etc. 3) When conducting an investigation of verbal or mental abuse, implement the following protocol: a) Determine if the resident/family perceived the abuse to be disparaging, threatening, humiliating or derogatory; b) Determine the resident's/family's response to the abusive act (e.g. Was the resident/family upset, humiliated, frightened, etc.); and c) Determine if the intent of the abusive act was willful. 4) Conduct the investigation in accordance with established policy. See policy entitled 'Abuse Invsetigation Protocol' (page 2)." Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An admission care plan documented, "...Monitor I+O dly (daily) - [MEDICAL CONDITION] + urine retention - S/P TURP..." A comprehensive assessment was not completed for the resident. A nurse's note, dated 07/10/13 at 11:00 p.m., documented, "C/O inability to urinate, call placed to (physician) d/t res reporting that he hasn't urinated since 1 pm this day. N/O received per V/O (physician); May straight cath x 1 only. Order received + noted." A nurse's note, dated 07/10/13 at 11:30 p.m., documented, "Res lying flat in bed, straight cathed using sterile technique, immediate return 600ml of clear yellow urine. Tol procedure s c/o voiced relief. Will cont to assess elimination status." A nurse's note, dated 07/11/13 at 12:00 p.m., documented, "Pt states he's having problems urinating; he states he's having pain when he urinates..." A nurse's note, dated 07/11/13 at 1:30 p.m., documented, "Noted N/O to straight cath prn bladder distention (TURP) + UA c C+S (TURP)." A hospital emergency record, dated 07/11/13 at 3:34 p.m., documented: "...History... Voiding Problems TURP 2 weeks ago at (hospital name deleted) (physician) unable to void last night straight cath completed. pt straight cathed himself this am. Male [MEDICAL CONDITION] The primary symptoms include [MEDICAL CONDITION]. The primary symptoms do not include dysuria or flank pain. The history is provided by the patient. This is a recurrent problem. The current episode started yesterday. The problem occurs constantly. The problem has not changed since onset. The quality of the pain is described as aching. The pain is at a severity of 2/10...The past medical history includes urological procedure. Urine output has decreased. The last void occurred 6 to 12 hours ago. Associated symptoms include urgency... GU Assessessment...difficulty voiding pt states he has not voided since cath this am..." The resident's [DIAGNOSES REDACTED]. An indwelling urinary catheter was placed. The resident was instructed to see his urologist on 07/15/13. A physician's orders [REDACTED]." A nurse's note, dated 07/11/13 at 7:00 p.m., documented, "Resident returned to facility @ 5:30 p.m. c (RN name deleted) in van...Has F/C noted drning (draining) dark amber colored urine...F/C also emptied upon arrival. 400 urine emptied." A nurse's note, dated 07/11/13 at 11:00 p.m., documented, "...Bag emptied by CNA obtained 300ml...F/C con't (continues) to drain s problems..." A nurse's note, dated 07/11/13, documented, "late entry 0645 (6:45 a.m.) This LPN in to (check) on res, res reported that he had removed used straight cath from garbage rinsed it off + st. (straight) cath's himself, noted orange urine in toilet bowel (sic). Verbally advised res on the repercussions of cathing self + dangers i.e. infection, (increased) trauma R/T recent TURP res verbally acknowledged understanding ..." A nurse's note, dated 07/12/13 at 7:30 a.m., documented, "Lying in bed c (both eyes) open, c/o pain groin area; f/c was assessed; prn [MEDICATION NAME] given." A nurse's note, dated 07/12/13 at 10:00 a.m., documented, "Lying in bed c (both eyes) open; c/o muscle spasms; [MEDICATION NAME] 10mg x 1 po given; f/c patent + draining red colored urine; pt cont's to c/o being uncomfortable + feeling like he has to urinate..." An untimed nurse's note, dated 07/12/13, documented, "...had a syringe & removed his foley catheter on his own. said he had a straight cath in his bathroom unsure where he got that, unsure & he refused to answer any questions..." This note was written by LPN #2. A nurse's note, dated 07/15/13 at 1:00 p.m., documented, "Returned from urologist appt (appointment); dx: [MEDICAL CONDITION] & [MEDICAL CONDITION]; 0 N/O's noted." The daily asignment sheet for 07/15/13 on the 11:00 p.m. - 7:00 a.m. shift documented the following staff assignmments: Ramp: LPN#1 Night Nurse: LPN #4 North CNA: CNA #3 South CNA: CNA #4 CMA: CMA #2 Ramp CNA: CNA #5 Float CNA: CNA #6 A nurse's note, dated 07/16/13 at 1:00 a.m., documented, "This LPN (LPN #1) in to res rm (room) making rounds + received from 3-11 LPN in report that res (unable to read) st. (straight) cathing self s assist. Has order from from (sic) Dr. (name deleted) (urologist) May st. cath prn distention/retention. This LPN asked res where cath was + he voiced to me that st. cath was in drawer....Verbally explained to res the dangerous consequences of not using approriate (sic) sterile tech (technique) & the risk of (increased) infection + potential for trauma to urinary system if procdure not performed accurately by trained personnel res verbally acknowledged understanding, then replied 'I'll do what I damn well want to if I have to pee I'm gonna pee.' (Physician) + (physician) aware of res self cathing + 0 (no) orders or instructions sent to nrsg (nursing) staff to not allow staff res to self cath..." A nurse's note, dated 07/16/13 at 2:30 a.m., documented, "Res (up) in lobby fully dressed upset that this LPN woke him for SN assessment V/S + teaching. Res voiced 'I feel like I'm in a prison R/T this LPN removing used straight cath from room + discarding...Res remains sulky + frustrated, res then attempts to contact local EMS for transport to (hospital name deleted), his attempt failed, this LPN notified my immediate supervisor, (owner), he spoke c res on the phone + spvsr (supervisor) reassured this LPN res would be ok now + that he was (res) going to return to his room + go back to bed. Instead res still (up) in lobby trying to call his urologist (name deleted), + answering service instructed res to put this LPN on phone. I spoke c answering service + informed that res was not in physical distress that he wanted to talk to (physician) because he wanted to be admitted to (hospital) since the EMS ref. (refused) to pick him (up) + take him to (hospital). Answering service ref to call (physician) d/t 0 emergency. This LPN re-contacted immediate supervisor (owner) informed him of latest actions during my conversation c (owner) res was attempting to contact his cardiologist. Res then requested to speak c my supervisor + res spoke c my supervisor + verbalized to him that he would be discharging himself later this AM...LPN offered res a prn [MEDICATION NAME] 0.25mg for (increased) anxiety res refused q time..." A handwritten statement, dated 07/16/13, documented, "(Resident #1) - 7/16/13 7/16/13 1:00 - lights came on - (resident #1) was asleep (LPN #1) walks in and asks for the catheter. Told him it was unsanitary. Told him he did not have a catheter order to self cath. (Resident #1) says he saw doctor that day and he said he could. She started opening the drawers looking for other catheters and the syringe (LPN #1) said to (resident #1) If you have an order, I'll bring them back. If no order you know you can't do this. I'm only looking out for you. She was gone for awhile - (resident) went to nurses station - (LPN #1) called (owner) He (owner) said he would take care of it in the morning - (LPN #1) brought catheters back to his room with syringes- (Owner) talked to (resident #1) telling him that if he didn't calm down he was going to be sent for a psych eval. That he (resident #1) needed to just take a [MEDICATION NAME] and calm down. (LPN #1) said - 'God d**n you' (Resident #1) if you don't stop you're going to get us all in trouble. Several nights ago, (LPN#1) was in his room and said 'You know what (name) rhymes with?' He said yes - She said 'F**ker' and laughed. Last night, (resident #1) told her to leave him alone and he wants to move to another facility. We have faxed paperwork to (facility name deleted)." The document was not signed. A handwritten statement, dated 07/16/13, documented: "(LPN #2) (Resident #1) - (LPN #2) heard (LPN #1) cuss at (resident #1)- words: F**k, s**t, damn words used in 'not a good context' 'You're being so damn irritating' (LPN #1) said to (Resident #1). 'You are the most irritating resident we have.' He was asleep and she woke him up. Re: Rhyming with (name) -(LPN #1) said something about grabbing the cat's tail while you f**ker. (LPN #1) was working on changing his catheter. -The catheter popped it and he pee'd everywhere. She said G** damn it m****r f****r, you got pee all over me. Occurrences happened 7/15/13 night shift" There was no signature on the document. A hand-written document, dated 07/16/13, documented: "(LPN#1) CNA #5 was present and CNA #6. She states she has never cussed at him. She called (owner) two times. She treated him with kid gloves." The document was not signed. An OSDH Incident Report form, dated 07/16/13, faxed to OSDH on 07/16/13 at 9:00 p.m., documented: "... Initial (checked) ... Incident Date 07-16-2013 Incident Location Resident Room Resident(s)/Client(s) Involved (Resident #1), resident and (LPN #1) Incident Type (checked) Allegations of Abuse/Mistreatment... Part B ...(Resident #1) came to the Administrator on 07/16/13 stating that at 1:00am in the morning 07/16/13 (LPN #1) came into his room, turned on the lights, woke him up, and told him he could not have have the straight catheters in his room. She started to go through his drawers to find the supplies and remove them from his room. (Resident) tried to tell her that he had seen the doctor that day and that (physician) told him to straight cath whenever he needed to and there should be orders on the chart. (Resident) states that (LPN #1) started to get agitated. She then left the room with the supplies she had found. Later (resident) went up to the nurses station. (LPN #1) called (name deleted), owner and he said he would take care of it in the morning. (LPN #1) brought the catheters back to his room when she found the order in the chart for him to self cath if needed. (LPN #1) called (owner) again, and (owner) told (resident) that if he did not calm down he was going to be sent for a psych eval, and that he needed to take a [MEDICATION NAME] and calm down. (LPN #1) told (resident) 'God d**n you' (resident), if you don't stop you are going to get us all in trouble. Also, several nights ago (LPN #1) was trying to cath the resident and said 'you know what rhymes with (name)? 'F**ker.' and she laughed. Last night, he told her to leave him alone and he wants to move to another facility. We have faxed paperwork to (name deleted facility). (LPN #1) will be suspended pending an investigation. (Resident #1) stated that (LPN #2) was present during these conversations. Interviews with employees will be conducted. Safe interviews will be conducted for residents..." The reporting party was Administrator #1. A Late Entry nurse's note, dated 07/17/13, documented, "Wrote report for (Administrator #1) about (LPN #1) & pt having problems, see (Administrator #1) administrators notes, resident very unhappy tried to calm him down..." This note was signed by LPN #2. A nurse's note, dated 07/18/13 at 5:00 a.m., documented, "...Cont to have [MEDICAL CONDITION] + self catheterizes self." An undated statement, with a faxed date on 07/19/13 at 10:15 at the top of the page, documented: "To Whom it may concern, 07-15-13 into 07-16-13 I am writing this statement in regards to the untrue allegation that I spoke inappropriately to (resident #1). All events + verbage used on the afore mentioned noc - has + was documented in the nurse's notes. I do swear all nurse's notes are true + accurate as they occurred. Sincerely, (LPN #1)." An untitled document, dated 07/19/13, documented, "Resident's name: (Resident #5) Date: 7-19-13 ...Have you ever had any employees be verbally abusive to you? (Handwritten) Yes. 11 - 7 nurse -(LPN #1)- (Resident) states he ask for a PRN and she told him you know your just killing yourself and started singing it like a song." An untitled document, dated 07/19/13, documented, "Resident's name: (Resident #6) Date: 7-19-13 ...Have you ever had any employees be verbally abusive to you? (The following was hand-written on the form) Yes 11-7 nurse - (LPN #1) was hateful with her tone of voice telling (resident #6) - she needs to come out of her room for breakfast - (LPN #1) told her alls (sic) she (resident #6) wanted to do was sleep..." A care plan, dated 07/22/13, addressed a problem of hypertension and a problem of conflict with staff. The care plan documented: "...Problem (Resident) has Conflict with Staff Relating to Ineffective coping skills Anger management problem Manipulative behavior Adjustment disorder As evidenced by: Verbalizes dissatisfaction with staff performance Verbally abusive toward staff members He has threatened to turn staff in to owner of facility and State Board Of Nursing when his expectations are not met. Goal Resident will demonstrate effective coping behavior Resident will have minimal violent verbal outburst episodes toward others while in facility through next review. Interventions Allow resident to talk about feelings, and let resident know staff is empathetic Assist resident to process feelings and find positive outcomes Educate resident about facility routines and practices Assist resident to plan care and schedule that is satisfactory to resident Interact with resident in calm, non-threatening manner Explain all procedures Keep all promises and follow up as stated to build trust with resident Give resident as many choices as possible Involve family in care-planning." A written statement, dated 07/22/13, by the facility's owner, documented: "At approximately 1:00 a.m. on July 16, 2013 I received a phone call from my charge nurse, (LPN #1). She stated that she had gone into (resident #1's) room to take vital signs and to retrieve a foley catheter. (Resident #1) was in the background saying 'you should not have woke me up.' I asked to speak with (resident #1) so that he could tell me in his own words what happened. While on the phone with (resident #1), I could hear the charge nurse in the background saying 'I'm sorry, (resident #1).' (Resident #1) seemed to have calmed down and he told me he would see me tomorrow. About 15 minutes later I received another call from (LPN #1) and she stated that (resident #1) was called (sic) doctors at 1:30 in the morning. He was still talking about the catheter. I asked to speak with (resident #1). I explained to him that he could not self-cath and that if he called any more doctors at this early hour that his behavior might indicate that he would need to go to (psychiatric facility name deleted) for a psyche (sic) evaluation. The nurse asked to speak with me again. (LPN #1) informed me that (resident #1) had asked her for a [MEDICATION NAME] to go to bed. I asked (LPN #1) if (resident #1) had a prescription and she told me she did. I asked was he within his time for taking the medication and she indicated that he was. I suggested she honor his request for the medication so that he might go to bed. I received no further calls regarding this incident." This statement was signed by the owner. A typed statement, signed by LPN #1 on 07/22/13, documented: "Statement of (LPN #1) taken by Administrator in presence of owner, (name deleted), (name deleted), Acting DON. Administrator asked (LPN #1) to tell what happened, who what where when why how... I came in 'on ramp' making rounds saved (resident #1) for last because he is time consuming. ... we (resident #1) visit ... I try to make him feel that he won't be here forever and socialize....He will get apartment....helping with the discharge planning. I didn't think it a big deal to wake him...every time I am working 'on ramp' wake him...probably five times prior Not care planned to not wake the resident.....LPN believed that residents who came here came because of some type of mental health issues... LPN has [AGE] years of experience in nursing, and six years mental health and addiction ... This particular night I was making rounds. From the prior shift report (might have been (LPN #1)) said (resident #1) is cathing himself. LPN checked order...he has order for cath, but not self cath. She knew allowing him to self-cath without an order was out of her scope to allow him to do so. LPN sat on side of his bed, talking to him...LPN then began discussing cath.....stated you have order to be straight cath, but we must do it because of recent prostate surgery, could damage penis, etc. There is a risk for infection without sterile techniques....he pulled it out of his garbage to st (straight) cath himself. LPN removed cath eqpt (equipment) from his top drawer. (Resident told her where to find cath.).... He is SNF and LPN is required to get vitals on SNF. Sole purpose of going into the room was to do SNF assessment, not to get cath. because he and I talked about it I took it.... What set him off? I brought more cath for him and educated him not to re-use cath. I wanted to and needed to remove cath because I was so scared for him. I advised him he can introduce infection by pulling one out of trash. .....(Resident #1) told me where it was....he didn't make me feel like I was rummaging through his possessions. He was angry because he was awakened, not because of cath issue. (Owner) was on the phone and heard the LPN apologizing to the resident. (Owner) heard her saying on the phone that 'it wasn't care planned', didn't know not to wake him up. (LPN #1)" A Follow-up OSDH Incident Report Form, faxed to OSDH on 07/22/13 at 4:31 p.m., documented: "...Incident Date 7/16/2013... Resident(s)/Client(s) Involved (Resident #1), resident (LPN #1), facility 11-7 staff... Resident alleges verbal abuse by staff LPN... There has been a change of Administrator's since the initial report was filed. This Administrator did her own investigation of this allegation and has found abuse allegation to be unsubstantiated. The resident refused to write a statement for the Administrator and indicated that he would also refuse to speak with investigators about this incident because he states he was not abused. He states that he was angry because he was 'woke up by the nurse'. During the investigation process the LPN states that she must obtain vital signs on this resident during her shift because of his skilled status. She stated that she went to the room to get vital signs as she had at least five other times. This occurrence was different from other times because she also engaged the resident in a conversation about self-cath. The nurse educated him about the dangers of infection and damage from self-cath. He told her the cath supplies were in the drawer and she could remove them. Apparently the resident could not return to sleep and became agitated over being awakened and the supplies being removed from the room. LPN states that she spoke with (owner name deleted) on the phone and (the owner) states that he could hear this LPN trying to calm the resident, apologizing to the resident, and attemptimg to resolve the issue. The resident requested a [MEDICATION NAME] and (the owner) directed him to speak with the nurse about the medication. (The owner) confirmed with the nurse the resident had an order for [REDACTED]. incident, had written a two page accusation against (LPN #1) to the prior Administrator stating that LPN (#1) had a conversation of sexual nature with her boyfriend. Due to this statement this Administrator did not believe the witness to be a reliable source of information, and did not interview her. (Resident #1) states that he does not want (LPN #1) to lose her job and that he doesn't have any problem with her caring for him. All he wants is to not be awakened at night for vital signs. This was care planned and (Resident #1) signed the care plan. (Resident #1) also agrees to work with staff to help decrease his outbursts of anger and signed that care plan as well..." The facility's state reportable incidents were reviewed. The state reportable incident report on 07/22/13, regarding the incident which occurred on 07/16/13, with resident #1, documented the new administrator "did her own investigation" of the incident and determined it was unsubstantiated. There was not evidence to show that a thorough investigation was conducted. There were no interviews with witnesses, or other staff on duty on the shift when the incident occurred, and there was no documented interview with the resi

On 07/31/13, an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to implement their abuse policies to ensure a thorough investigation was conducted for allegations of abuse and to ensure residents were protected until a thorough investigation was completed. The Oklahoma State Department of Health was notified and verified the Immediate Jeopardy Situation. At 7:22 p.m. the administrator and the assistant director of nursing were notified of the IJ situation. On 08/01/13 at 4:00 p.m., an acceptable plan of removal was presented to the survey team. The Plan of Removal documented: "Plan of Removal for Immediate Jeopardy declared 07/31/2013 7:23 p.m. It is Policy and Procedure of this nursing facility to prevent the abuse, neglect, and the misappropriaton of resident property and to screen potential employees and to train employees in the identification of and proper reporting of allegations. 1. The Administrator immediately had the LPN (LPN #1 initials deleted) escorted from the building at approximately 7:40 p.m. on July 31, 2013, to protect the residents from potential harm. 2. The Social Services and/or Activities personnel will speak with a random sample of ten (10) cognitive residents to identify if abuse has affected other residents in the facility and will complete these samples and bring to the Administrator not later than 12:00 noon, August 1, 2013. 3. The ADON prepared an in-service, shortly after 7:30 p.m., July 31, 2013, for all staff currently in the building to read and sign. The ADON began collecting signatures of employees on the 3-11 shift. All employees reporting to work will read the in-service on abuse and sign that they understand what the components of abuse, neglect, and misappropriation of resident property is. Employees will not be allowed to work until their in-service is completed and signed. The in-service instructs staff to report allegations to the Administrator, Director of Nurses, immediate supervisor, or designee immediately. All facility staff will have been inserviced in person or by telephone conference by noon on August 1, 2013. New hire employees will receive abuse and neglect prevention training as part of orientation and staff will continue to be in-serviced periodically as necessary. 4. A thorough investigation was done on the incident by the Administrator on 07/22/13. Although no evidence of abuse was identified the Administrator will continue to use systemic approach to (1) prevent, (2) screen, (3) identify, (4) train, (5) protect, (6) investigate, and (7) report any allegations of subsequent abuse reported by any source. The Administrator interviewed the resident, several staff, and directed the Social Services worker to speak with a random sample of cognitive residents to find out if there were other unreported incidents of abuse. The administrator documented her conversation with the resident on the final report faxed on 07/22/2013. The Administrator is submitted with this plan of removal a note written by the Social Services Director that records a conversation she witness were the resident stated 'he did not want to make a statement'.....'he didn't have a problem with the nurse and no incident occurred'...The investigation is deemed complete on August 1, 2013 at shortly after 1:30 p.m. 5. The Administrator will begin further investigation of this incident effective immediately. The resident involved in the allegation has left the facility against medical advise and left no forwarding address nor phone number. However, the Administrator will make every effort to locate this resident for re-interview. The staff on the shift that the incident was alleged to occur will be re-interviewed and statements will be taken. The employee accused of the allegation of abuse has been suspended again, pending investigation, and will be asked to return a location outside the facility for interview. The investigation will fully explore the components of the incident and statements will continue to be collected as they become available. The Administrator anticipates that the re-investigation can be completed no later than 5:00 p.m. on August 2, 2013. 6. The Administrator or designee will monitor through random questionnaires of a sample of minimum of ten (10) cognitive residents and four (4) staff selected randomly from all three shifts and document findings for presentation to the QA meeting. The residents and staff will be allowed to submit questionnaires anonymously with the assurance that the statements can remain confidential without a fear of reprisal. Responses will be kept confidential with a need to know basis and following regulatory requirements. Random sample questionnaires will be completed on a weekly basis for four (4) weeks beginning the week of August 1, 2013 and reported to the QA Committee. The QA Committee will consist of the Medical Director, the Administrator, a member of the nursing staff, and at least three (3) other staff. Random sample questionnaires will continue to be done on a monthly basis and reported to QA to ensure the facility remains in compliance with policy, procedures, and regulatory requirements." The Immediate Jeopardy was removed on 08/05/13 at 10:15 p.m., when the facility completed all components of the plan of removal. The last staff member who was present on the shift of the incident, and witnessed interactions between the resident and the staff member, was interviewed from 10:00 to 10:15 p.m. on 08/05/13. The deficient practice remained at an isolated level with a potential for more than minimal harm. Based on interviews and review of clinical records, policies and procedures, personnel records, and staff schedules, it was determined the facility failed to implement their abuse policies to ensure: ~ a thorough investigation was completed of allegations of abuse for one (#1) of one sampled residents with allegations of verbal abuse. ~ residents were protected until a thorough investigation was completed. ~ property was not misappropriated for one (#4) of four sampled residents. This had the potential to affect all 59 residents who resided in the facility. Findings: A policy, titled Freedom from Abuse Policies, documented: "Resident Abuse and Neglect Policy If any person observes or becomes aware of an incident of resident abuse and/or neglect, whether alleged, suspected, or observed, that person MUST report the incident to the nursing supervisor immediately. This includes incidents occurring anywhere in the facility, on the grounds, at school, workshops, or away from the facility. The nursing supervisor will initiate the procedure for the incident reporting... Abuse includes, but is not limited to: ...Verbal Abuse: Oral, written, or gestured language which includes sarcastic remarks, derogatory statements, directed to residents, families or significant others. ...Physical Abuse: Humiliation, sarcasm, harrassment, being ignored, and favortism to others, degrading, criticizing, threats, deprivation, punishment, ridiculing, and involuntary seclusion..." A policy, titled Abuse Investigation Protocol, documented: "Policy Statement Wadley Care Center management promptly and thoroughly investigates all reports of resident abuse, neglect, injuries of an unknown source, resident-to-resident and resident-to-staff abuse. Police (sic) Interpretation and Implementation 1) Should an incident or suspected incident of resident abuse, neglect, injury of unknown source, resident-to-resident abuse, and/or resident-to-staff abuse be reported, the administrator, or their designee, will appoint an individual to investigate the incident... 3) The individual conducting the investigation will, as a minimum: ...e) Interview the person(s) reporting the incident; f) Interview any witnesses to the incident; g) Interview the resident (as medically appropriate);... i) Interview staff members (on all shifts) who have had contact with the resident during the 48-hour period prior to the time of the incident; j) Interview the resident's roomate (if any/as appropriate); k) Interview the resident's family members and visitors who have had contact with the resident during the 48-72 hour period prior to the time of the incident; l) Interview the accused individual(s) or accused employee(s). (Note: If the accused individual is an employee, review the personnel file to determine if a background check was completed and if appropriate educational/orientation programs were attended.); m) Interview other residents to whom the accused employee provides care or services, to determine if they have complaints about the employee; n) Interview other employees to determine if they have ever witnessed other incidents of mistreatment involving the accused employee; and o) Review all events preceding the alleged incident; 4) The following guidelines will be used when conducting interviews: a) Each interview will be conducted separately and in a private location; b) The purpose and confidentiality of the interview will be explained thoroughly to each person involved in the interview process;... 5) Witness reports will be reduced to writing. Witness will be required to sign and date such reports. (Note: A copy of such reports must be attached to the (Incident Report Form".)... 7) Employees of this facility who have been accused of resident abuse will be suspended from duty until the administrator has reviewed the results of the investigation... 8) The individual in charge of the investigation will consult with the administrator as necessary concerning the progress/findings of the investigation. 9) The administrator will inform the resident and their representative (sponsor) of the results of the investigation. 10) The investigator will compile a written report of the results of the investigation. A copy of the 'Incident Report Form' must be attached to the investigator's report. 11) A copy of the investigator's report and a completed copy of the 'Incident Report Form' will be provided to the administrator within 5 working days of the reported incident. 12) The administrator will inform the resident and their representative (sponsor) of the results of the investigation and corrective action within 5days of the completion of the investigation..." A policy, titled Investigating Allegations of Verbal or Mental Abuse, documented: "Policy Statement All reported incidents of verbal or mental abuse are promptly and thoroughly investigated. Policy Interpretation and Implementation 1) Verbal abuse is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe resident's regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm, telling the resident that he/she will be separated from other residents, etc. 2) Mental abuse includes, but is not limited to, humilation, harassment, threats of punishment or deprivation (e.g. withholding food or services from the resident), etc. 3) When conducting an investigation of verbal or mental abuse, implement the following protocol: a) Determine if the resident/family perceived the abuse to be disparaging, threatening, humiliating or derogatory; b) Determine the resident's/family's response to the abusive act (e.g. Was the resident/family upset, humiliated, frightened, etc.); and c) Determine if the intent of the abusive act was willful. 4) Conduct the investigation in accordance with established policy. See policy entitled 'Abuse Invsetigation Protocol' (page 2)." 1. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An admission care plan documented, "...Monitor I+O dly (daily) - [MEDICAL CONDITION] + urine retention - S/P TURP..." A comprehensive assessment was not completed for the resident. A nurse's note, dated 07/10/13 at 11:00 p.m., documented, "C/O inability to urinate, call placed to (physician) d/t res reporting that he hasn't urinated since 1 pm this day. N/O received per V/O (physician); May straight cath x 1 only. Order received + noted." A nurse's note, dated 07/10/13 at 11:30 p.m., documented, "Res lying flat in bed, straight cathed using sterile technique, immediate return 600ml of clear yellow urine. Tol procedure s c/o voiced relief. Will cont to assess elimination status." A nurse's note, dated 07/11/13 at 12:00 p.m., documented, "Pt states he's having problems urinating; he states he's having pain when he urinates..." A nurse's note, dated 07/11/13 at 1:30 p.m., documented, "Noted N/O to straight cath prn bladder distention (TURP) + UA c C+S (TURP)." A hospital emergency record, dated 07/11/13 at 3:34 p.m., documented: "...History... Voiding Problems TURP 2 weeks ago at (hospital name deleted) (physician) unable to void last night straight cath completed. pt straight cathed himself this am. Male [MEDICAL CONDITION] The primary symptoms include [MEDICAL CONDITION]. The primary symptoms do not include dysuria or flank pain. The history is provided by the patient. This is a recurrent problem. The current episode started yesterday. The problem occurs constantly. The problem has not changed since onset. The quality of the pain is described as aching. The pain is at a severity of 2/10...The past medical history includes urological procedure. Urine output has decreased. The last void occurred 6 to 12 hours ago. Associated symptoms include urgency... GU Assessessment...difficulty voiding pt states he has not voided since cath this am..." The resident's [DIAGNOSES REDACTED]. An indwelling urinary catheter was placed. The resident was instructed to see his urologist on 07/15/13. A physician's orders [REDACTED]." A nurse's note, dated 07/11/13 at 7:00 p.m., documented, "Resident returned to facility @ 5:30 p.m. c (RN name deleted) in van...Has F/C noted drning (draining) dark amber colored urine...F/C also emptied upon arrival. 400 urine emptied." A nurse's note, dated 07/11/13 at 11:00 p.m., documented, "...Bag emptied by CNA obtained 300ml...F/C con't (continues) to drain s problems..." A nurse's note, dated 07/11/13, documented, "late entry 0645 (6:45 a.m.) This LPN in to (check) on res, res reported that he had removed used straight cath from garbage rinsed it off + st. (straight) cath's himself, noted orange urine in toilet bowel (sic). Verbally advised res on the repercussions of cathing self + dangers i.e. infection, (increased) trauma R/T recent TURP res verbally acknowledged understanding ..." A nurse's note, dated 07/12/13 at 7:30 a.m., documented, "Lying in bed c (both eyes) open, c/o pain groin area; f/c was assessed; prn [MEDICATION NAME] given." A nurse's note, dated 07/12/13 at 10:00 a.m., documented, "Lying in bed c (both eyes) open; c/o muscle spasms; [MEDICATION NAME] 10mg x 1 po given; f/c patent + draining red colored urine; pt cont's to c/o being uncomfortable + feeling like he has to urinate..." An untimed nurse's note, dated 07/12/13, documented, "...had a syringe & removed his foley catheter on his own. said he had a straight cath in his bathroom unsure where he got that, unsure & he refused to answer any questions..." This note was written by LPN #2. A nurse's note, dated 07/15/13 at 1:00 p.m., documented, "Returned from urologist appt (appointment); dx: [MEDICAL CONDITION] & [MEDICAL CONDITION]; 0 N/O's noted." The daily asignment sheet for 07/15/13 on the 11:00 p.m. - 7:00 a.m. shift documented the following staff assignmments: Ramp: LPN#1 Night Nurse: LPN #4 North CNA: CNA #3 South CNA: CNA #4 CMA: CMA #2 Ramp CNA: CNA #5 Float CNA: CNA #6 A nurse's note, dated 07/16/13 at 1:00 a.m., documented, "This LPN (LPN #1) in to res rm (room) making rounds + received from 3-11 LPN in report that res (unable to read) st. (straight) cathing self s assist. Has order from from (sic) Dr. (name deleted) (urologist) May st. cath prn distention/retention. This LPN asked res where cath was + he voiced to me that st. cath was in drawer....Verbally explained to res the dangerous consequences of not using approriate (sic) sterile tech (technique) & the risk of (increased) infection + potential for trauma to urinary system if procdure not performed accurately by trained personnel res verbally acknowledged understanding, then replied 'I'll do what I damn well want to if I have to pee I'm gonna pee.' (Physician) + (physician) aware of res self cathing + 0 (no) orders or instructions sent to nrsg (nursing) staff to not allow staff res to self cath..." A nurse's note, dated 07/16/13 at 2:30 a.m., documented, "Res (up) in lobby fully dressed upset that this LPN woke him for SN assessment V/S + teaching. Res voiced 'I feel like I'm in a prison R/T this LPN removing used straight cath from room + discarding...Res remains sulky + frustrated, res then attempts to contact local EMS for transport to (hospital name deleted), his attempt failed, this LPN notified my immediate supervisor, (owner), he spoke c res on the phone + spvsr (supervisor) reassured this LPN res would be ok now + that he was (res) going to return to his room + go back to bed. Instead res still (up) in lobby trying to call his urologist (name deleted), + answering service instructed res to put this LPN on phone. I spoke c answering service + informed that res was not in physical distress that he wanted to talk to (physician) because he wanted to be admitted to (hospital) since the EMS ref. (refused) to pick him (up) + take him to (hospital). Answering service ref to call (physician) d/t 0 emergency. This LPN re-contacted immediate supervisor (owner) informed him of latest actions during my conversation c (owner) res was attempting to contact his cardiologist. Res then requested to speak c my supervisor + res spoke c my supervisor + verbalized to him that he would be discharging himself later this AM...LPN offered res a prn [MEDICATION NAME] 0.25mg for (increased) anxiety res refused q time..." A handwritten statement, dated 07/16/13, documented, "(Resident #1) - 7/16/13 7/16/13 1:00 - lights came on - (resident #1) was asleep (LPN #1) walks in and asks for the catheter. Told him it was unsanitary. Told him he did not have a catheter order to self cath. (Resident #1) says he saw doctor that day and he said he could. She started opening the drawers looking for other catheters and the syringe (LPN #1) said to (resident #1) If you have an order, I'll bring them back. If no order you know you can't do this. I'm only looking out for you. She was gone for awhile - (resident) went to nurses station - (LPN #1) called (owner) He (owner) said he would take care of it in the morning - (LPN #1) brought catheters back to his room with syringes- (Owner) talked to (resident #1) telling him that if he didn't calm down he was going to be sent for a psych eval. That he (resident #1) needed to just take a [MEDICATION NAME] and calm down. (LPN #1) said - 'God d**n you' (Resident #1) if you don't stop you're going to get us all in trouble. Several nights ago, (LPN#1) was in his room and said 'You know what (name) rhymes with?' He said yes - She said 'F**ker' and laughed. Last night, (resident #1) told her to leave him alone and he wants to move to another facility. We have faxed paperwork to (facility name deleted)." The document was not signed. A handwritten statement, dated 07/16/13, documented: "(LPN #2) (Resident #1) - (LPN #2) heard (LPN #1) cuss at (resident #1)- words: F**k, s**t, damn words used in 'not a good context' 'You're being so damn irritating' (LPN #1) said to (Resident #1). 'You are the most irritating resident we have.' He was asleep and she woke him up. Re: Rhyming with (name) -(LPN #1) said something about grabbing the cat's tail while you f**ker. (LPN #1) was working on changing his catheter. -The catheter popped it and he pee'd everywhere. She said G** damn it m****r f****r, you got pee all over me. Occurrences happened 7/15/13 night shift" There was no signature on the document. A hand-written document, dated 07/16/13, documented: "(LPN#1) CNA #5 was present and CNA #6. She states she has never cussed at him. She called (owner) two times. She treated him with kid gloves." The document was not signed. An OSDH Incident Report form, dated 07/16/13, faxed to OSDH on 07/16/13 at 9:00 p.m., documented: "... Initial (checked) ... Incident Date 07-16-2013 Incident Location Resident Room Resident(s)/Client(s) Involved (Resident #1), resident and (LPN #1) Incident Type (checked) Allegations of Abuse/Mistreatment... Part B ...(Resident #1) came to the Administrator on 07/16/13 stating that at 1:00am in the morning 07/16/13 (LPN #1) came into his room, turned on the lights, woke him up, and told him he could not have have the straight catheters in his room. She started to go through his drawers to find the supplies and remove them from his room. (Resident) tried to tell her that he had seen the doctor that day and that (physician) told him to straight cath whenever he needed to and there should be orders on the chart. (Resident) states that (LPN #1) started to get agitated. She then left the room with the supplies she had found. Later (resident) went up to the nurses station. (LPN #1) called (name deleted), owner and he said he would take care of it in the morning. (LPN #1) brought the catheters back to his room when she found the order in the chart for him to self cath if needed. (LPN #1) called (owner) again, and (owner) told (resident) that if he did not calm down he was going to be sent for a psych eval, and that he needed to take a [MEDICATION NAME] and calm down. (LPN #1) told (resident) 'God d**n you' (resident), if you don't stop you are going to get us all in trouble. Also, several nights ago (LPN #1) was trying to cath the resident and said 'you know what rhymes with (name)? 'F**ker.' and she laughed. Last night, he told her to leave him alone and he wants to move to another facility. We have faxed paperwork to (name deleted facility). (LPN #1) will be suspended pending an investigation. (Resident #1) stated that (LPN #2) was present during these conversations. Interviews with employees will be conducted. Safe interviews will be conducted for residents..." The reporting party was Administrator #1. A Late Entry nurse's note, dated 07/17/13, documented, "Wrote report for (Administrator #1) about (LPN #1) & pt having problems, see (Administrator #1) administrators notes, resident very unhappy tried to calm him down..." This note was signed by LPN #2. A nurse's note, dated 07/18/13 at 5:00 a.m., documented, "...Cont to have [MEDICAL CONDITION] + self catheterizes self." An undated statement, with a faxed date on 07/19/13 at 10:15 at the top of the page, documented: "To Whom it may concern, 07-15-13 into 07-16-13 I am writing this statement in regards to the untrue allegation that I spoke inappropriately to (resident #1). All events + verbage used on the afore mentioned noc - has + was documented in the nurse's notes. I do swear all nurse's notes are true + accurate as they occurred. Sincerely, (LPN #1)." An untitled document, dated 07/19/13, documented, "Resident's name: (Resident #5) Date: 7-19-13 ...Have you ever had any employees be verbally abusive to you? (Handwritten) Yes. 11 - 7 nurse -(LPN #1)- (Resident) states he ask for a PRN and she told him you know your just killing yourself and started singing it like a song." An untitled document, dated 07/19/13, documented, "Resident's name: (Resident #6) Date: 7-19-13 ...Have you ever had any employees be verbally abusive to you? (The following was hand-written on the form) Yes 11-7 nurse - (LPN #1) was hateful with her tone of voice telling (resident #6) - she needs to come out of her room for breakfast - (LPN #1) told her alls (sic) she (resident #6) wanted to do was sleep..." A care plan, dated 07/22/13, addressed a problem of hypertension and a problem of conflict with staff. The care plan documented: "...Problem (Resident) has Conflict with Staff Relating to Ineffective coping skills Anger management problem Manipulative behavior Adjustment disorder As evidenced by: Verbalizes dissatisfaction with staff performance Verbally abusive toward staff members He has threatened to turn staff in to owner of facility and State Board Of Nursing when his expectations are not met. Goal Resident will demonstrate effective coping behavior Resident will have minimal violent verbal outburst episodes toward others while in facility through next review. Interventions Allow resident to talk about feelings, and let resident know staff is empathetic Assist resident to process feelings and find positive outcomes Educate resident about facility routines and practices Assist resident to plan care and schedule that is satisfactory to resident Interact with resident in calm, non-threatening manner Explain all procedures Keep all promises and follow up as stated to build trust with resident Give resident as many choices as possible Involve family in care-planning." A written statement, dated 07/22/13, by the facility's owner, documented: "At approximately 1:00 a.m. on July 16, 2013 I received a phone call from my charge nurse, (LPN #1). She stated that she had gone into (resident #1's) room to take vital signs and to retrieve a foley catheter. (Resident #1) was in the background saying 'you should not have woke me up.' I asked to speak with (resident #1) so that he could tell me in his own words what happened. While on the phone with (resident #1), I could hear the charge nurse in the background saying 'I'm sorry, (resident #1).' (Resident #1) seemed to have calmed down and he told me he would see me tomorrow. About 15 minutes later I received another call from (LPN #1) and she stated that (resident #1) was called (sic) doctors at 1:30 in the morning. He was still talking about the catheter. I asked to speak with (resident #1). I explained to him that he could not self-cath and that if he called any more doctors at this early hour that his behavior might indicate that he would need to go to (psychiatric facility name deleted) for a psyche (sic) evaluation. The nurse asked to speak with me again. (LPN #1) informed me that (resident #1) had asked her for a [MEDICATION NAME] to go to bed. I asked (LPN #1) if (resident #1) had a prescription and she told me she did. I asked was he within his time for taking the medication and she indicated that he was. I suggested she honor his request for the medication so that he might go to bed. I received no further calls regarding this incident." This statement was signed by the owner. A typed statement, signed by LPN #1 on 07/22/13, documented: "Statement of (LPN #1) taken by Administrator in presence of owner, (name deleted), (name deleted), Acting DON. Administrator asked (LPN #1) to tell what happened, who what where when why how... I came in 'on ramp' making rounds saved (resident #1) for last because he is time consuming. ... we (resident #1) visit ... I try to make him feel that he won't be here forever and socialize....He will get apartment....helping with the discharge planning. I didn't think it a big deal to wake him...every time I am working 'on ramp' wake him...probably five times prior Not care planned to not wake the resident.....LPN believed that residents who came here came because of some type of mental health issues... LPN has [AGE] years of experience in nursing, and six years mental health and addiction ... This particular night I was making rounds. From the prior shift report (might have been (LPN #1)) said (resident #1) is cathing himself. LPN checked order...he has order for cath, but not self cath. She knew allowing him to self-cath without an order was out of her scope to allow him to do so. LPN sat on side of his bed, talking to him...LPN then began discussing cath.....stated you have order to be straight cath, but we must do it because of recent prostate surgery, could damage penis, etc. There is a risk for infection without sterile techniques....he pulled it out of his garbage to st (straight) cath himself. LPN removed cath eqpt (equipment) from his top drawer. (Resident told her where to find cath.).... He is SNF and LPN is required to get vitals on SNF. Sole purpose of going into the room was to do SNF assessment, not to get cath. because he and I talked about it I took it.... What set him off? I brought more cath for him and educated him not to re-use cath. I wanted to and needed to remove cath because I was so scared for him. I advised him he can introduce infection by pulling one out of trash. .....(Resident #1) told me where it was....he didn't make me feel like I was rummaging through his possessions. He was angry because he was awakened, not because of cath issue. (Owner) was on the phone and heard the LPN apologizing to the resident. (Owner) heard her saying on the phone that 'it wasn't care planned', didn't know not to wake him up. (LPN #1)" A Follow-up OSDH Incident Report Form, faxed to OSDH on 07/22/13 at 4:31 p.m., documented: "...Incident Date 7/16/2013... Resident(s)/Client(s) Involved (Resident #1), resident (LPN #1), facility 11-7 staff... Resident alleges verbal abuse by staff LPN... There has been a change of Administrator's since the initial report was filed. This Administrator did her own investigation of this allegation and has found abuse allegation to be unsubstantiated. The resident refused to write a statement for the Administrator and indicated that he would also refuse to speak with investigators about this incident because he states he was not abused. He states that he was angry because he was 'woke up by the nurse'. During the investigation process the LPN states that she must obtain vital signs on this resident during her shift because of his skilled status. She stated that she went to the room to get vital signs as she had at least five other times. This occurrence was different from other times because she also engaged the resident in a conversation about self-cath. The nurse educated him about the dangers of infection and damage from self-cath. He told her the cath supplies were in the drawer and she could remove them. Apparently the resident could not return to sleep and became agitated over being awakened and the supplies being removed from the room. LPN states that she spoke with (owner name deleted) on the phone and (the owner) states that he could hear this LPN trying to calm the resident, apologizing to the resident, and attemptimg to resolve the issue. The resident requested a [MEDICATION NAME] and (the owner) directed him to speak with the nurse about the medication. (The owner) confirmed with the nurse the resident had an order for [REDACTED]. incident, had written a two page accusation against (LPN #1) to the prior Administrator stating that LPN (#1) had a conversation of sexual nature with her boyfriend. Due to this statement this Administrator did not believe the witness to be a reliable source of information, and did not interview her. (Resident #1) states that he does not want (LPN #1) to lose her job and that he doesn't have any problem with her caring for him. All he wants is to not be awakened at night for vital signs. This was care planned and (Resident #1) signed the care plan. (Resident #1) also agrees to work with staff to help decrease his outbursts of anger and signed that care plan as well..." The facility's state reportable incidents were reviewed. The state reportable incident report on 07/22/13, regarding the incident which occurred on 07/16/13, with resident #1, documented the new administrator "did her own investigation" of the incident and determined it was unsubstantiated. There was not evidence to show that a thorough investigation was conducted. There we

Based on observation, clinical record review, policy and procedure review, review of transfer documentation and staff interviews, it was determined the facility failed to ensure a DNR status was instituted as indicated by the resident on a hospital transfer form which resulted in resuscitation attempts made against the resident's wishes for one (#1) of three sampled residents who had been transferred to the hospital. This had the potential to affect all 21 residents, who had a DNR status, who resided in the facility. Findings: A facility policy, titled End of Life Treatment Policy, documented: "1. Policy ...D. All decisions regarding the administration of cardiopulmonary resuscitation shall be made by the Resident unless the Resident is unable to make decisions. E. It is the policy of this Facility to comply with a Qualified Resident's Directive and Do Not Resuscitate (DNR) consent..." A facility policy, titled Physician's Do Not Resuscitate Order, documented: "In the event that this Resident stops breathing or his/her heart stops, CPR is not an appropriate response. Do Not Resuscitate This Individual. This means no cardiopulmonary resuscitation (CPR), ambu bag, intubation, ventilation, defibrillation or emergency cardiac drugs are to be used..." Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. An Oklahoma Do Not Resuscitate (DNR) Consent Form, dated [DATE], documented, "I, (Name), request limited health care as described in this document. If my heart stops beating or if I stop breathing, no medical procedure to restore breathing or heart function will be instituted by any health care provider including, but not limited to, emergency medical services (EMS) personnel... I give permission for this information to be given to EMS personnel, doctors, nurses, and other health care providers. I hereby state that I am making an informed decision and agree to a do-not-resuscitate order..." A quarterly assessment, dated [DATE], documented the resident was severely impaired in his cognitive skills for daily decision making. He required limited assistance with dressing, supervision for eating, extensive assistance for personal hygiene and total dependence for bathing. He was continent of bowel and had frequent urinary incontinence. A physician's telephone order, dated [DATE] at 5:00 p.m., documented, "...(3.) DNR..." Physician monthly orders, dated [DATE], documented, "...Print Date: [DATE] 3:57:29PM... Code Status: Do Not Resuscitate..." A nurse's note, dated [DATE] at 12:00 noon, documented, "Resident in therapy PT notified this nurse that resident had c/o SOB et requested (illegible). Upon assessment resident began to c/o CP. O2 sats @ 90% on RA. O2 @ 5L via NC administered. (Physician) et family notified. N/O for transfer to (Hospital) ER for eval & Tx. Resident was pale c purple lips. V/S ,[DATE], 114, O2 sats @ 88% c O2. (Name) EMS arrived to transport resident via stretcher @ this time resident's eyes were rolled back. A resident transfer form, dated [DATE] ay 12:00 p.m., documented, "...Reason for Transfer CP, (decreased) O2 Sat, Nausea ...Code Status: CPR..." A hospital summary note, documented, "...General Data ...Arrival Date/Time: [DATE] - 1226... Assessments [DATE] 12:30 ED (emergency department) Nurses Note Airway and Breathing Assessment:... adventitious lung sound location: Modifiier Anterior Location Throughout Effort Labored Cardiovascular Assessment:... tachycardia Skin Signs Pale, Cyanotic, Cool Neurological Assessment:... Glasgow Coma Scale Eyes opening spontaneous Glasgow Coma Scale Verbal confused/irritable. Cries... An emergency department report, dated [DATE] at 12:32 p.m., documented: "...Chief Complaint: Chest pain History of Present Illness: [AGE] year-old male presents emergent complaining of having chest pain. He was picked up from a local nursing home. The (Named) EMS service and brought the patient to the emergency room and stated that his blood pressure initially was low and he received a total of 700 mL of normal saline fluid resuscitation. On arrival here he had no pain. He was noncommunicable. He was rapidly ventilating or breathing. The paperwork that was brought with (Named) EMS was reviewed. There is no DO NOT Resuscitate paperwork in this... A document, titled EDM Patient Record, documented: "... Patient Notes ...Pt moved to room [ROOM NUMBER] @ 1256 (12:56 p.m.) Pt is pulseless. CPR started @ 1256. Epi given @ 1257. HR 38 @ 1258. HR 77 at 1259. Pt intubated..." A document, titled ED Course/Procedures, documented: "During the emergency room stay the patient rapidly deteriorated. Upon initial presentation appeared the patient was rapidly ventilating having difficulty with the prolonged expiratory phase. It appeared that he was in a [MEDICAL CONDITION] exacerbation. The patient was placed on [MEDICAL CONDITION]. Following this he did clinically improve to a short. Falling a brief period of time on the [MEDICAL CONDITION] he deteriorated again. His pulse rate started to down to the 50s and his respiratory rate started to decline. He was rapidly taken to room [ROOM NUMBER] Procedure: Rapid sequence intubation. Indication for the procedure was [MEDICAL CONDITION]. The patient was [MEDICATION NAME] with 100% oxygen by face mask. ET tube was inspected using a ten mL syringe... The patient was orally, endotracheally intubated... The patient did receive a dose of [MEDICATION NAME]. Chest compressions had been started. Within minutes we did get a return of circulation. The patient was then placed on a ventilator... The daughter arrived and entered the room. She did state he was DO NOT RESUSCITATE. We stated we had no evidence of the DO NOT RESUSCITATE and apologize for initiating a work work up (sic) that was not necessarily wanted by the patient herself (sic)...The son-in-law stated that it was the patient's request to be DO NOT RESUSCITATE and to proceed with his request. At this time the decision was made to terminate efforts. The patient was removed from the ventilator allowed to breathe on his own. Following this he did pass away. The patient's time of death was at 1337 (1:37 p.m.). On [DATE] at 3:55 p.m., CMA #1 was asked where the DNR status codes are located. She stated, "On the doors of the rooms and on the MARs." At 3:58 p.m., CMA #2 was asked how to tell if an unresponsive resident was CPR or DNR. She stated, "I'll find an LPN - first." At 4:00 p.m., CNA #1 was asked how to know if a resident is a DNR. She stated, "I would go get the nurse immediately. Get their chart. Ask the nurse." At 4:02 p.m., CNA #2 was asked how she would tell if a resident was a DNR. She stated, "A lot of DNRs are black dots on doors." At 4:05 p.m., the MDS coordinator was asked the facility's policy on identifying DNR residents. She stated, "In their chart and maybe the TARs and MARS. At 4:08 p.m., LPN #1 was asked how she would identify a DNR resident. She stated, "I would know that by the DNR on the chart." She further added, "Somewhere there is a list. I don't know if it is current." On [DATE] at 4:17 p.m., The DON was asked how the nursing staff knew if a resident was a DNR. She stated when she first came to the facility they had little black dots. She stated, "I have orange stickers. I have ,[DATE] done. I haven't completed it." She was asked about resident #1. She stated, "I did not know he was a DNR." She stated she went through the chart and the paperwork was in the wrong part of the chart and she faxed it to Purcell. (The resident was transported to a different hospital with CPR on the transfer sheet.

Based on observation, record review and interview, it was determined the facility failed to notify the physician and/or family member regarding: a. residents #6 and #13's severe weight loss, which resulted in an actual harm for the residents; b. resident #5 refusing to take a prescribed medication as ordered and; c. resident #14 not receiving any ordered medications for three days. This had the potential to affect an additional 54 residents in the facility. Findings: The facility policy for "Physician Services" documented, "The medical care of each resident is under the supervision of a Licensed Physician... monitoring changes in resident's medical status, and providing consultation to treatment when called by the facility... " The facility policy for "Change in a Resident's Condition or Status" documented, "Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status... The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: ... A significant change in the resident's physical/emotional/mental condition... Refusal of treatment or medications (i.e., two (2) or more consecutive times)... " 1. Resident #6 was admitted to the facility with [DIAGNOSES REDACTED]. An admission assessment dated [DATE], documented the resident had severe cognitive impairment for daily decision making, required extensive assistance with transfers, ambulation and dressing. The assessment also documented the resident had no weight loss prior to being admitted to the facility and required supervision or cueing while eating. A care plan dated 10/26/11, documented, "Problem: (Resident) is at risk for altered fluid balance ET nutritional status R/T decreased level in physical functioning and cognition Et no teeth. Goal: (Resident) will remain free from complications with dehydration and [MEDICAL CONDITION] on daily basis. Approach: Administer Puree ADA 2200 calorie diet and supervise at meal times assisting as needed when eating. Adhere to diet request/specification of no ham or tomato based products prn. Monitor complications with diabetes states with weekly FSBS and administer [MEDICATION NAME] on daily basis labs prn as indicated by physician. Provide diabetic HS snack monitor meal percentages and document offer supplement if less than 50% of meals eaten and document fluid intake at meal times. Staff to encourage fluids with routine rounds/checks every two hours/activities and mealtimes. Monitor for s/s dehydration such as dry skin, cracked kips (sic) change in cognitive status and poor skin turgor ET report to physician prn." The "Monthly Patient Weight Record" for 2012, documented the following weights for the resident: 12/11: 162.0 pounds 01/12: 161.0 pounds 02/12: 161.0 pounds 03/12: 157.0 pounds 04/12: 154.6 pounds 05/12: 157.0 pounds 06/12: 145.0 pounds 07/12: 140.0 pounds "Nutritional Progress Notes" dated 03/14/12, documented, "Wt. 155.6 # (arrow down) 7 #/ 90 days. pt. is receiving double portions @ meal times when first helping is consumed. pt. refuses breakfast meals most days. PO intake good @ other meals. cont. to monitor intakes. (changes) @ this time. Follow prn." The note was signed by the facility CDM. "Nutritional Progress Notes" dated 04/10/12, documented, "Wt. 154.6 # (arrow down) 2.4 #/30 days. Diet (changed) to puree. Pt on Hospice care so wt (arrow down) may be unavoidable d/t disease state. Receiving [MEDICATION NAME] which aids/c (arrow up) appetite...monitor wt & intake, if (arrow down) further consider adding supplement. The note was signed by the licensed consulting dietician. The resident experienced a severe weight loss of 17 pounds (10.49%) from December 2011 to June 2012. A quarterly assessment dated [DATE], documented the resident had a 5% or greater weight loss in one month or 10% or greater for six months. A care plan entry dated 05/10/12, documented, "Continues to be at risk for dehydration & altered nutrition, refuses BHF but usually consumes 100% of lunch and dinner. Currently receiving appetite stimulate, weight stable with slight (arrow down) over past 3 months, will continue/c POC @ this X." The care plan did not address the resident's weight loss of of 17 pounds (10.49%) weight loss. There was no documentation the facility notified the family and/or the physician of the severe weight loss. "Nutritional Progress Notes" dated 06/29/12, documented, "Served a puree diet/c plate guard. Rarely eats breakfast. No ice in his drinks. Snacks offered. No voiced concern for dietary @ this time. Will continue to monitor." The note was signed by the CDM. The July 2012, monthly physician's orders [REDACTED]. The dietary orders were first written on 10/14/11. The monthly orders also documented the resident received [MEDICATION NAME] 15 mg by mouth at bedtime for [MEDICAL CONDITION]. The order was first written on 10/14/11. There was no documentation the resident had any medication for an appetite stimulate. The documented [DIAGNOSES REDACTED]. "Nutritional Progress Notes" dated 07/11/12, documented, "Wt 140 # (arrow down) 5 #/30 days. Pt on Hospice care, wt maybe unavoidable d/t diseases...suggest add health shakes (once) day follow prn." The note was signed by the licensed consulting dietician. The resident experienced a severe weight loss of 21 pounds (13.04%) in the six months from January 2012 to July 2012. There was no documentation to indicate the facility notified the resident's physician and/or family of the continual severe weight loss. On 08/01/12 at 3:20 p.m., a request was made to the DON to have the resident weighed. CNA #3 was observed taking the resident and weighing him. The resident's weight recorded 140.8 pounds. An interview was conducted on 08/01/12 at 3:30 p.m., with the DON. Present during the interview was the ADON and MDS coordinator. The DON was asked about the resident's severe weight loss. The DON stated, "No, I didn't know he had a weight loss." She was asked if the family and physician had been notified of the severe weight loss. The ADON stated, "No, the family and physician have not been notified." An interview was conducted on 08/02/12 at 8:45 a.m., with the QA nurse regarding the resident's weight loss. She was asked if the family and physician had been notified of the resident's severe weight loss by the facility. She stated, "Hospice notified the family of weight loss for (resident #6)." 2. Resident #13 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan dated 03/15/12, documented, "Problem: maintaining body weight. Goal: consult with /c dietician or dietary supplement. Interventions: add house supplement (once) daily..." The "Monthly Patient Weight Record" for 2012, documented the following weights for the resident: 02/12: 124.0 pounds 03/12: 120.0 pounds 04/12: 116.4 pounds 05/12: 113.4 pounds The resident lost 10.6 pounds or 8.55 % (a severe) weight loss from February through May 2012. A physician's telephone order dated 04/24/12, documented, "...Healthy shots BID...DX wound healing..." "Dietary Progress Notes" dated 05/09/12, documented,"Wt 113.4 # (arrow down) 3 #/30 days. Unstg wound to (R) outer ankle noted & wound to (L) shin noted. Zinc, Vit C & healthy shot added 4/24. Suggest (arrow up) house supplement to BID." The progress note was signed by the consulting dietician. There was no documentation to indicate the physician had been notified of the weight loss and of the recommendation to increase the house supplement to BID to aide in the prevention of further weight loss. An interview was conducted on 08/02/12 at 1:50 p.m., with the DON. She was asked if the family and physician had been notified of the severe weight loss and dietary recommendation. She stated, "The May (weight loss) was missed. The doctor was not notified." 3. Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. An admission assessment dated [DATE], documented the resident was cognitively intact, had behaviors of being verbally abusive and had [MEDICAL CONDITION] to his lower extremities. physician's orders [REDACTED]. Review of the resident's May, 2012, MAR, indicated the resident refused the 3:00 p.m. dosage of [MEDICATION NAME] one out of 21 opportunities. Review of the June, 2012, MAR, indicated the resident refused the 3:00 p.m. dosage of [MEDICATION NAME] eleven out of 30 opportunities. A quarterly assessment dated [DATE], documented the resident was cognitively intact, had [MEDICAL CONDITION] to his lower extremities and received a diuretic seven days a week. Review of the July, 2012, MAR, indicated the resident refused the 3:00 p.m. dosage of [MEDICATION NAME] 23 out of 31 opportunities. There was no documentation on the back of the MARs, in the nurses' notes or provided by the facility, to indicate the resident's physician had been notified about the resident's refusal to take the 3:00 p.m. dose of [MEDICATION NAME]. On 08/01/12 at 3:00 p.m. an interview was conducted with LPN #2 regarding the resident refusing the 3:00 p.m. dose of [MEDICATION NAME]. She was asked if the resident's physician was notified about the frequent refusal to take the medication. She stated, "No. The Dr. wasn't notified." 4. Resident #14 was admitted to the facility on [DATE] at 1:50 p.m., with [DIAGNOSES REDACTED]. The resident's admission assessment was completed by LPN #2. The clinical record did not contain any type of physician's orders [REDACTED]. A nurse's note dated 05/14/12, documented, "resident was transferred to et. accompanied into facility by son. VS 97.6, 72, 17, 132/60, wt 99'8, ht 5'0, attending physician notified." Physician's telephone orders dated 05/17/12, documented the following medication orders. Tylenol 500 mg 2 tabs Q 4 hrs PRN. [MEDICATION NAME] PRN q 4 hr sob/wheezing. [MEDICATION NAME] 2.5 mg tab 1 tab po BID. [MEDICATION NAME] 50 mg 1 tab po q day. [MEDICATION NAME] ([MEDICATION NAME]) 40 mg tab 1 tab po q day. Renegel 800 mg 1 tab po TID w/meals. [MEDICATION NAME] 40 mg 1 cap po daily before breakfast. [MEDICATION NAME] 20 gm/30 ml solu take 30 ml po & HS. [MEDICATION NAME] 0.3 mg, 1 tab po TID. [MEDICATION NAME] 25 mg, 1 tab po BID w breakfast and dinner. An admission assessment dated [DATE], documented the resident had moderately impaired cognition with poor decision making skills, required supervision with all tasks and exhibited short term memory loss. The assessment further documented the resident required extensive assistance with all aspects of ADL's. A care plan dated 06/04/12, documented, "Problem: Congested heart failure, Hypertension and [MEDICAL CONDITION]. Goals: systolic B/P will stay within normal limits for me; I will have no shortness of breath, chest pains, [MEDICAL CONDITION] or elevated B/P; I will not have chest pains. Interventions: administer medications as ordered; diet and medication as ordered." On 08/01/12 at 10:30 a.m., CMA #1 was interviewed regarding the resident's lack of medication orders. She stated she had advised the resident's CN (LPN #3) and taken the list of discharged medications to the facility DON and faxed it over to the local pharmacy to be filled. She further stated the pharmacy rejected the list because it was not an actual physician's orders [REDACTED].#3) and advised the DON of the problem. A facility document titled, "Resident Drug Receipt Ledger" documented the above medications were received in the facility on 05/17/12. The resident did not receive her first dosage of medications until 05/18/12 in the a.m. On 08/01/12 at 10:30 a.m., CMA #1 was asked if the resident's family and/or the resident's physician was notified regarding the resident being without medications for three days. She stated she did not notify anyone, but the CN should have notified them of the error immediately. On 08/01/12 at 11:30 a.m., an interview was conducted with the QA nurse. When asked if she thought the nursing system had been effective in keeping the family/physician notified of the resident's care she stated, "There definitely was a break down in the system."

Based on observation, record review, and interviews, it was determined the facility failed to prevent an actual harm of 13.04% severe weight loss in six months for resident #6, and failed to implement dietary recommendations which resulted in an actual harm of 9.96% severe weight loss in three months for one (#13) of three sampled residents who had a weight loss. The resident census and condition dated 07/31/12, documented six residents had unplanned weight change. Findings: The "Weight Monitoring" policy documented, "...this facility will closely monitor weight changes in each resident for each month. Weight variances of 5% in 30 days, 7.5% in 90 days and 10% in 180 days will be thoroughly assessed for causative factors and corrective actions will be taken. Nursing will also notify physician of a resident with a weight loss...of 5 pounds or greater...Immediate notification of responsible party is vital...hospice comfort measure only care plan may be initiated...however, their condition should be monitored and interventions implemented if appropriate..." 1. Resident #6 was admitted to the facility with [DIAGNOSES REDACTED]. An admission assessment dated [DATE], documented the resident had severe cognitive impairment for daily decision making, required extensive assistance with transfers, ambulation, and dressing. The assessment also documented the resident had no weight loss prior to being admitted to the facility and required supervision or cueing while eating. A care plan dated 10/26/11, documented, "Problem: (Resident) is at risk for altered fluid balance ET nutritional status R/T decreased level in physical functioning and cognition Et no teeth. Goal: (Resident) will remain free from complications with dehydration and [MEDICAL CONDITION] on daily basis. Approach: Administer Puree ADA 2200 calorie diet and supervise at meal times assisting as needed when eating. Adhere to diet request/specification of no ham or tomato based products prn. Monitor complications with diabetes states with weekly FSBS and administer [MEDICATION NAME] on daily basis labs prn as indicated by physician . Provide diabetic HS snack monitor meal percentages and document offer supplement if less than 50% of meals eaten and document fluid intake at meal times. Staff to encourage fluids with routine rounds/checks every two hours/activities and mealtimes. Monitor for s/s dehydration such as dry skin, cracked kips (sic) change in cognitive status and poor skin turgor ET report to physician prn." The "Monthly Patient Weight Record" for 2012, documented the following weights for the resident: 12/11: 162.0 pounds 01/12: 161.0 pounds 02/12: 161.0 pounds 03/12: 157.0 pounds 04/12: 154.6 pounds 05/12: 157.0 pounds 06/12: 145.0 pounds 07/12: 140.0 pounds A hand written care plan entry dated 01/25/12, documented, "Problem: Cont to be @ risk for dehydration/ altered nutrition. Goal: Cont current POC over next 90 days." A telephone order and care plan entry dated 02/29/12, documented, "(change) diet to puree." The resident was admitted to the facility on [DATE], with an order for [REDACTED]. "Nutritional Progress Notes" dated 03/14/12, documented, "Wt. 155.6# (arrow down) 7#/ 90 days. pt. is receiving double portions @ meal times when first helping is consumed. pt. refuses breakfast meals most days. PO intake good @ other meals. cont. to monitor intakes.(changes) @ this time. Follow prn." The note was signed by the facility CDM. "Nutritional Progress Notes" dated 04/10/12, documented, "Wt. 154.6# (arrow down) 2.4# /30 days. Diet (changed) to puree. Pt on Hospice care so wt (arrow down) may be unavoidable d/t disease state. Receiving [MEDICATION NAME] which aids /c (arrow up) appetite...monitor wt & intake, if (arrow down) further consider adding supplement. The note was signed by the licensed consulting dietician. The resident experienced a severe weight loss of 17 pound (10.49%) from December 2011 to June 2012. A quarterly assessment dated [DATE], documented the resident had a 5% or greater weight loss in one month or 10% or greater for six months. A care plan entry dated 05/10/12, documented, "Continues to be at risk for dehydration & altered nutrition, refuses BHF but usually consumes 100% of lunch and dinner. Currently receiving appetite stimulate, weight stable with slight (arrow down) over past 3 months, will continue /c POC @ this X." The care plan did not address the resident's weight loss of 17 pounds (10.49%) weight loss in six months from December 2011 through June 2012. There was no documentation the facility implemented interventions to aide in the prevention of further weight loss. There was no documentation the facility notified the family and the physician of the severe weight loss. There was no documentation the consulting dietician recommended interventions to prevent the further decline of the resident. "Nutritional Progress Notes" dated 06/29/12, documented, Served a puree diet /c plate guard. Rarely eats breakfast. No ice in his drinks. Snacks offered. No voiced concern for dietary @ this time. Will continue to monitor. The note was signed by CDM. The July 2012, monthly physician's orders [REDACTED]. The monthly orders also documented the resident received [MEDICATION NAME] 15 mg by mouth at bedtime for [MEDICAL CONDITION]. The order was first written on 10/14/11. There was no documentation the resident had any medication for an appetite stimulate. The documented [DIAGNOSES REDACTED]. The resident experienced a severe weight loss of 21 pounds (13.04%) in the six months from January 2012 to July 2012. "Nutritional Progress Notes" dated 07/11/12, documented, "Wt 140 # (arrow down) 5#/30 days. Pt on Hospice care, wt maybe unavoidable d/t diseases...suggest add health shakes (once) day follow prn." The note was signed by the licensed consulting dietician. There was no documentation to indicate the facility notified the resident's physician and family of the continual severe weight loss. The care plan was not developed to address the resident's continual weight loss. The March, April, May, June and July, meal percentage records documented the resident refused his breakfast meal greater then 80% of the time. There was no documentation the facility addressed the resident's continual refusal of breakfast. A telephone order dated 07/13/12, documented, "Health shake/ po daily..." Prior to 07/13/12, there were no interventions in place to prevent the continual weight decline which resulted in a severe weight loss of 13.04% in six months. The care plan was not updated with the health shake intervention implemented on 07/13/12. During the morning and noon meals on 07/31/12, the resident was observed receiving a pureed meal. There was no plate guard on the residents plate. The resident consumed 75% of each meal. On 08/01/12 at 3:20 p.m., a request was made to the DON to have the resident weighed. CNA#3 was observed taking the resident and weighing him. The resident's weight recorded 140.8 pounds. An interview was conducted on 08/01/12 at 3:30 p.m., with the DON. Present during the interview was the ADON and MDS coordinator. The DON was asked about the resident's severe weight loss. The DON stated, "No, I didn't know he had a weight loss." She was asked if the family and physician had been notified of the severe weight loss. The ADON stated, "No, the family and physician have not been notified." They were asked if a resident being on Hospice service would be a reason to not address a resident's weight loss. The MDS coordinator stated, "No, it's not appropriate to not address the weight loss just because they are on hospice." They were asked what interventions had been put into place to address the resident's weight loss. The DON stated, "We moved him to a feeder table." The MDS coordinator looked through the care plan and stated, "I don't see any other interventions on the care plan." The DON was asked about the resident's continual refusal of breakfast and how they addressed that. She stated, "I don't know why he doesn't eat breakfast. I could ask the family." The DON and ADON was asked how the facility addressed the severe weight loss. Both of them stated, "I didn't know he had a weight loss." They were asked if there was any documentation in the clinical record that addressed the resident's weight loss. The DON stated, "The dietician talked about it but didn't recommend interventions." The DON was asked if the weight was avoidable or unavoidable. She stated, "I don't know without trying interventions." An interview was conducted on 08/02/12 at 8:45 a.m., with the QA nurse regarding the residents weight loss. She was asked if the family and physician had been notified on the severe weight loss for resident #6 . She stated, "Hospice notified the family of weight loss for resident #6." She was asked about the severe weight loss and interventions for the resident. She stated, "My system is broken." An interview was conducted on 08/02/12, with the resident's family. They were asked how they found about changes in the resident's condition. They indicated they only hear from Hospice about the changes. She was asked if the facility had notified them of the weight change the resident experienced. She stated only Hospice had notified them. 2. Resident #13 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan dated 03/15/12, documented, "Problem: maintaining body weight. Goal: consult with /c dietician or dietary supplement. Interventions: add house supplement (once) daily..." The "Monthly Patient Weight Record" for 2012, documented the following weights for the resident: 02/12: 124.0 pounds 03/12: 120.0 pounds 04/12: 116.4 pounds 05/12: 113.4 pounds The resident lost 10.6 pounds or 8.55 % (a severe) weight loss from February through July 2012. A physician's telephone order dated 04/24/12, documented, "...Healthy shots BID...DX wound healing..." "Dietary Progress Notes" dated 05/09/12, documented, "Wt 113.4# (arrow down) 3#/30 days. Unstg wound to (R) outer ankle noted & wound to (L) shin noted. Zinc, Vit C & healthy shot added 4/24. Suggest (arrow up) house supplement to BID." The progress note was signed by the licensed consulting dietician. There was no documentation to indicate the physician had been notified of the weight loss and of the recommendation to increase the house supplement to BID to aide in the prevention of further weight loss. There was no documentation the facility implemented the house supplement increase to BID. The resident's care plan had not been updated to address the resident's continual weight loss with interventions to prevent the weight loss. A quarterly assessment dated [DATE], documented the resident was severely impaired with cognitive skills for daily decision making, required supervision with meals, and had no weight loss of 5% or greater in the past month or 10% or greater in the past six months. The monthly physician's orders [REDACTED]. 04/12: 116.4 pounds 05/12: 113.4 pounds 06/12: 116.0 pounds 07/12: 104.8 pounds The resident lost 7 pounds or 9.97% (a severe) weight loss from April through July 2012. "Dietary Progress Notes" dated 07/11/12, documented, "Wt 109.4# (arrow down) 6.6#/30 days. Healthy shot d/cd d/t pt referral...suggest (arrow up) house supplement to BID..." The progress note was signed by the licensed consulting dietician. A physician's telephone order dated 07/13/12, documented, "(arrow up) house supplement to BID PO..." A care plan update dated 07/13/12, documented the resident had an added intervention of the house supplement BID. The facility implemented the July recommendation 64 days after the original recommendation was made on 05/09/12. The resident continued to have severe weight loss between May 2012 and July 2012. On 08/02/12, staff was observed weighing the resident. The resident's weight recorded 111.8 pounds, a weight gain of seven pounds since the house supplement was increased to BID. An interview was conducted on 08/02/12 at 1:50 p.m., with the DON, ADON, QA nurse, and MDS coordinator. They were asked what interventions were put into place to prevent further weight decline the resident experienced. The ADON stated, "Increased the house supplement to BID in July." The DON was asked if the intervention from May, increasing the house supplement to BID, was implemented. She stated, "The May was missed, the doctor was not notified." She was asked if there were any updated interventions on the care plan for the resident. The MDS coordinator stated, "The care plan had not been updated and there were no interventions attempted until the house supplement was increased in July."

Based on medical record review and staff interviews, it was determined neither the family nor the physician was notified when resident #2 did not receive her medications on the A.M. of 06/08/12, as ordered by the physician. Findings: A nursing assessment dated [DATE], documented resident #2 had memory problems, showed inattention, had unclear speech, rarely understood and was rarely able to understand; was total assistance for dressing and bathing and was always incontinent. The resident had [DIAGNOSES REDACTED]. During the review of the medication record, it was determined all of the resident's 8:00 A.M. medications were held on 06/08/12. The medication held was: [MEDICATION NAME] 50/200 mg for [MEDICAL CONDITION] Klor-Con oral solutions for Potassium replacement [MEDICATION NAME] 75 mg for [MEDICAL CONDITION] [MEDICATION NAME]'s Aspirin 81mg for a [DIAGNOSES REDACTED]. [MEDICATION NAME] 2.5mg for hypertension [MEDICATION NAME] 25/37.5mg for [MEDICAL CONDITION] of the legs and [MEDICATION NAME] 0.5mg for increased anxiety At 3:00 P.M., the DON, LPN #3 and LPN #5 were interviewed in regard to the medication not being given. They verified during the interview the medication was held by the CMA (#9), who stated when questioned by the DON, he felt the resident was, "over sedated." When the DON was asked if the CMA had talked to a nurse to assess the resident before not giving the medication, the DON stated, "No." When the DON was asked if the physician or the family were notified of the CMA holding the resident's medication when he felt the resident was over sedated, she stated, "No. They were not notified." When asked when she was made aware of the medication being held, the DON stated she was not made aware until 06/11/12. The DON stated she had received written notification from the evening nurse (LPN #10) on June 11, documenting she had sent the resident to the emergency room (ER) on the evening of the 8th, due to change in condition. The LPN documented she was not aware of the resident's medication being held that A.M., until after she had sent the resident to the ER. She also documented the CMA did not report the, "over-sedation" to a nurse before holding the medication. When the nurse's note were reviewed for 06/08/12, no notes could be found for the mentioned day until 7:20 P.M. The notes for 7:20 P.M., documented the resident was, "shaking and stiffening up." The resident was sent to the ER at that time and returned at 10:40 P.M. with a [DIAGNOSES REDACTED]. There was no evidence of any change of condition for this resident or over-sedation on the morning of the 8th of June. When the DON was asked about remembering the condition of the resident that A.M., she stated she did work that morning and did not remember the resident acting any different that A.M. She stated she was not aware of the resident being over sedated on 06/08/12.

Based on record review and staff interview, it was determined the facility failed to assess, monitor and intervene, for constipation and/or fecal impaction for one (#3) of six sampled residents who had a [DIAGNOSES REDACTED]. Findings: The facility policy for "Bowel and Bladder Retraining Program" documented, "...To develop regular bowel habits and prevent fecal... incontinence, impaction and irregularity." Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. A facility form for "Evaluation For Bowel and Bladder Training" dated 05/24/10, documented the resident was continent of bowel and bladder and was able to take self to BR. A physician's orders [REDACTED]. DX: Constipation." A physician's orders [REDACTED]. DX: Constipation." A quarterly assessment dated [DATE], documented the resident was independent with ambulation and transfers, required supervision with toileting, was occasionally incontinent of bowel and frequently incontinent of bladder. The resident's care plan dated 03/06/12, documented: "Problem: (Resident) said she was having a baby then had a lg BM. Goal: Will have BM q 3 days during next 90 days. Approach: ... Encourage fluids. Laxative as ordered. Report no BM p 3 days to charge nurse. Observe for signs of constipation: decreased appetite, distended abdomen, decreased bowel sounds... " Review of the ADL Flowsheets revealed the following: January 2012: No documented BM either continent or incontinent, from 01/19/12 through 01/24/12. The resident was not administered the order for [MEDICATION NAME] or the soap suds enema during the six day period of no BM. The only documented time the resident received the [MEDICATION NAME] was on 01/05/12, when the resident c/o constipation. February 2012: No documented BM either continent or incontinent, from 02/01/12 through 02/04/12, 02/06/12 through 02/10/12, from 02/18/12 through 02/21/12 and 02/26/12 through 02/28/12. The resident was administered the [MEDICATION NAME] one time on 02/11/12, when the resident c/o constipation. The soap suds enema was never administered. March 2012: No documented BM either continent or incontinent, from 03/01/12 through 03/04/12, from 03/10/12 through 03/16/12 and from 03/22/12 through 03/25/12. The resident was administered [MEDICATION NAME] on 03/04/12, 03/05/12, 03/10/12, 03/23/12 and 03/29/12, when the resident c/o constipation. The soap suds enema was never administered. April 2012: No documented BM either continent or incontinent, from 04/04/12 through 04/07/12. The resident was not administered the [MEDICATION NAME] during the four days of no BM. The soap suds enema was never administered. Review of the nurses' notes for the resident documented the following: 11/10/11 at 9:30 p.m., "Up on commode trying to move bowels unable to push BM out very anxious agitated tried manipulating around stool but res screaming trying to jump up very uncooperative n/o rec'd for soap suds enema administered approx 500 cc fluid in rectum res not holding well up to bedside commode only passed 1 sm piece of stool back to bed other 1/2 enema given not held at all did pass a couple more pieces of stool." 11/11/11 at 11:00 a.m., "Resident amb with therapy to shower room on ramp when she need to use restroom, c/o constipation, had large firm stool. Moans and groans the entire time, would not walk very well with staff. 11/11/11 at 11:45 a.m., "c/o not being able to walk. keeps leaning backwards. Staff walked her to D/R with 3 staff members where she refused to eat." 12/10/11 at 10:00 a.m., "...Communicated recent hospital (stay) R/T constipation/res. Advised resident to continue with prune juice PRN to preclude future episode..." 12/11/11 at 8:45 a.m., "...Resident stated she has been drinking prune juice to preclude constipation but would like something stronger. CMA advised to give meds/orders..." 01/27/12 (no documented time), "...c/o constipation request prune juice 120 cc given." 01/29/12 at 10:00 a.m., "...Stated prune juice (highly) effective this am and she feels very well..." 02/11/12 at 11:15 a.m., "Res requested prune juice to preclude constipation-(N/A) gave [MEDICATION NAME] with extra cup of H2O/order. Informed res she needed to ask for this med as it was prn. Res voiced understanding." 03/08/12 at 7:54 a.m., a fax request was sent to the resident's physician. The request documented, "Resident having lots of problems with constipation. [MEDICATION NAME] is ordered PRN and resident doesn't seem to be able to request before she has problems. Daughter wants her to have daily and mix with coffee. Can she have daily?" The physician responded back, "This has to be PRN No daily or it can be taken with coffee if she wants that." 03/08/12 at 1:00 p.m., "...Had large loose stool @ noon d/t med given last pm for constipation. Resident has been yelling, screaming, frantic today due to not be (ing) able to have BM. After initial stool resident calmed down. 03/10/12 at 8:30 p.m., "Res called family member (Name withheld) from nurse's station phone and was telling him over and over that she was constipated and no one here would do anything about it. She stated "no one here cares and I'm going to be in real trouble if my bowels don't move today." After she hung up I assisted her back to bed and tried to tell her she had a large BM Thurs..." 04/14/12 at 9:30 a.m., "Res ambulates with no walker ad lib thru facility. C/O "stomach pain" believes shes constipated. Prune juice given and [MEDICATION NAME]/orders/CMA. Resident states "stomach feels better..." 04/15/12 at 3:45 a.m., "Res sent out to ER D/T c/o ABD pain, chest pain, increased confusion... c/o ABD pain. Asked her when last BM was stated earlier today. ABD soft and non tender to touch... " On 04/15/12 a CT scan of the thorax abdomen pelvis wo contrast was obtained at the (Name withheld) hospital. The results of the scan indicated, "...Descending and sigmoid colon [DIAGNOSES REDACTED]. Moderate to prominent stool noted within the cecum, ascending and [MEDICATION NAME] colons." Another CT scan of the abdomen and pelvis was obtained at (Name withheld) hospital. The results indicated, "...Large amount of solid stool distends the cecum to 7.7 cm x 10 cm in [MEDICATION NAME] and AP dimensions. Moderate-small amount of gas and stool the remainder of the colon to the rectum." On 04/26/12 at 2:35 p.m., an interview was conducted with the DON regarding the resident's problem with constipation. The Don was asked if the resident should have been monitored better for when she had a BM, the consistency, etc. and if the facility staff should have asked the resident daily if she was having constipation problems and if she needed the [MEDICATION NAME]. She stated, "Yes." When shown the BM documentation on the monthly ADL sheets and the CT scans, she stated the documentation was consistent with the tests for impaction. On 04/27/12 at 11:20 a.m., the DON, QA nurse and RN #1 were interviewed regarding the resident's fecal impaction. The DON was asked if there was documentation to show the resident's BMs were being monitored and interventions implemented to prevent the impaction. She stated staff documented whether the resident had a BM in the toilet or was incontinent of BM. She stated the documentation was inconsistent if the resident had a BM in the toilet. She stated she didn't think the resident was administered the [MEDICATION NAME] as frequently as needed. She stated the nurses should have administered the PRN [MEDICATION NAME] more frequently when the resident went more than 3 days without a BM, especially due to the resident being on meds that could constipate her. This actual harm was determined to be past non-compliance due to no other current residents were found to have untreated constipation and/or fecal impaction and were being administered the ordered laxative medications.

Based on record review and staff interview, it was determined the facility failed to assess the individualized toileting schedule and implement a bladder training program for one (#3) sampled resident who was continent at admission to the facility and who had become incontinent during her stay, which resulted in the resident having numerous falls while attempting to self-toilet. This had the potential to affect an additional six residents identified by the facility as being able to self-toilet and who had fallen in the bathroom. Findings: A facility policy documented, "Nursing Services - Bowel and Bladder Observation" documented, "...Assessment. Prior to the initiation of the bowel and bladder program, the nurse should have assessed the incontinent resident's ability to participate in the benefit from a bowel and bladder retraining program. There should be some indication of the circumstances under which the resident voids or defecates ( e.g, incontinence with no awareness; aware of urge; and usual times, weekly chart, of incontinence)." Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. An "Evaluation For Bowel and Bladder Training" dated 05/24/10, documented the resident was continent of bowel and bladder and was able to "take self to BR." The resident's care plan dated 06/05/11, documented: "Problem: Elimination-Incontinence-Urinary At risk for altered skin integrity R/T dribbling of urine/incontinence. Risk for infection. Goal: (Resident's) skin will remain intact by 06/05/12. Will have no infections during (not completed). Approach: Staff may provide incontinent care PRN to ensure that skin is clean and dry QS... Monitor skin for redness, irritation, or breakdown when showering and PRN. Report to the nurse/physician as needed QS... Monitor for decreased mobility and decreased ability to change positions, assist as needed to ensure pressure relief PRN... Encourage fluids... Problem: At risk for altered fluid balance R/T diuretic use. Goal: (Resident) will maintain adequate fluid balance by 06/05/12. Approach: Administer [MEDICATION NAME]/HCTZ (medications) as ordered QD... Monitor for S/SX of dehydration: dry mucous membranes, poor skin turgor, decreased output. Report S/SX to the nurse/physician as needed QS... Record amount of fluids consumed with meals on dietary flow sheet TIDM... (8:00 AM, 12:00 PM, 5:00 PM). Record amount of fluids consumed outside of meals on ADL sheet QS... (6-2, 2-10, 10-6).... " Review of a "History and Physical" dated 11/03/11, documented, "...complaining of urinary frequency... [MEDICATION NAME] 20 mg daily... [MEDICATION NAME] 25 mg in am... patient reports painful urination, excessive night time urination, urinary frequency and hesitancy... Assessment and Plan: ...UTI Admit to hospital [MEDICATION NAME] 1 gr IV bid... " A "Physical Examination" by the resident's physician dated 11/09/11, documented the resident ambulated without difficulty and had discharge [DIAGNOSES REDACTED]. A "Resident Assessment-Data Collection Form" dated 11/09/11, was completed when the resident returned to the facility from a hospital stay. The assessment documented the resident required one person assistance with transfers and ambulation, used the toilet and was continent of bowel and bladder. The comprehensive 5 day Medicare assessment dated [DATE] and a quarterly assessment dated [DATE], documented the resident was independent with transfers, ambulation, was frequently incontinent of bladder and was independent with toileting. Facility incident reports reviewed documented the following falls which occurred as the resident attempted to go to the bathroom, while in the bathroom and/or upon return from the bathroom: 08/25/11- The resident had a fall with injury. She had ecchymosis and two superficial abrasions to the left mid back. The resident stated she hit her head on the toilet. No redness or bruising was noted. No corrective action was documented. 09/24/11- The resident had a fall with skin tears to the left hand. The corrective action was for staff to help her to the BR Q 2 hr and prn. 09/27/11- The resident had a fall with no injury. The corrective action was to remove the w/c from the BR. 10/31/11- The resident had a fall with a large amount of bruising to her left side. The fall was unwitnessed, but the resident told staff she fell in the BR but did not report it. She stated the floor was wet and she slipped. The corrective action was to tell the resident to always let someone know when she falls. The report documented they were going to obtain rib x-rays. The resident was also told staff would help her to the BR. 11/01/11- The resident had a fall with no injury due to her floor being wet with urine. The resident's clothing was also observed to be wet. The resident told staff she was trying to go to the BR. The corrective action was for staff to help resident to BR. 11/03/11- The resident had a fall and sustained bruising to the left buttock. The resident stated she also hit her head. She had been incontinent of urine. There was no corrective action documented. 11/14/11- The resident had a fall in the bathroom and sustained a skin tear to the right elbow. There was no corrective action documented. 12/03/11- The resident had a fall in the bathroom with no injury sustained. Documentation indicated the resident refused to ask for assistance and an alarm was needed. The was no documented corrective action. 12/21/11- The resident had a fall in the bathroom due to urine being on the floor. She sustained no injury. There was no corrective action documented. 12/26/11- The resident had a fall while going to the BR. She sustained no injury. No corrective action was documented. 01/01/12- The resident had a fall and sustained a skin tear to the left elbow when she slipped in urine. There was no documented corrective action. There was no corresponding nurse's note for this fall. 01/06/12- The resident had a fall in the BR and sustained a skin tear to the left leg. The documented corrective action was to remind resident to call for help and remind staff to help her. There was no corresponding nurse's note for this fall. 01/22/12- The resident had a fall in her room due to slipping in urine on the floor. The documented corrective action was to place a body alarm on the resident. There was no corresponding nurse's note for this fall. 01/31/12- The resident had a fall in her room when she lost her balance going to the BR. She sustained no injury. There was no documented corrective action. 02/10/12- The resident had a fall in her room and sustained redness and an abrasion to her right cheek and the top of her right lip. The documented corrective action was to instruct the resident to call for assistance and attache a body alarm on the resident. The staff were to check on the resident every 1-2 hours and take her to the BR. 02/17/12- A nurse's note documented the resident had a fall in her room coming back from the BR. She sustained no injury. There was no corresponding incident report for this fall. 02/22/12- The resident had a fall and sustained a head injury when going to the BR. She sustained a small quarter sized knot to the left side of her head. The documented corrective action was to remind the resident to use the call light and ask for assistance to prevent future falls. Neuro checks were initiated. 02/28/12 (6:58 a.m.)- The resident had a fall in the BR by the toilet. She sustained no injury. The documented corrective action was to check on the resident frequently and order a mat type pad to alert staff of unsafe transfers. A low bed was put in place for the resident. On 04/26/12 at 2:35 p.m., an interview was conducted with the DON regarding the facility's bladder program. She stated, "This doesn't help with this, but a bowel and bladder program has been implemented now. Every resident in the facility will be assessed to determine what type of bowel and bladder program they need." The DON was shown the numerous incident reports showing resident #3 frequently fell due to slipping in urine on the floor, while attempting to self-toilet. She was asked if the resident should have been assessed and if she might have benefited from a bladder program. She stated the resident should have been assessed for a bladder program. On 04/27/12 at 11:20 a.m., an interview was conducted with the DON, RN #1 and the QA nurse regarding how the facility assessed the resident's bladder capabilities. The DON stated a bladder assessment grid was used, but only on admission. She stated she could locate no evidence that an initial three day tracking of the resident's bladder schedule had been done. The DON was shown the resident's admission bowel and bladder evaluation, which indicated the resident was continent of bladder, and the most current MDS assessment dated (03/04/12) which indicated the resident was frequently incontinent of bladder. She was asked if she thought the resident had declined in bladder continence. She stated the resident had declined and should have been put on a toileting program. On 04/27/12 at 12:45 p.m., an interview was conducted with the DON and QA nurse regarding the resident's frequent falls while attempting to go to the BR. The DON stated, "Facts don't lie. There was no bowel and bladder program, no tracking and trending of falls, appropriate interventions not implemented." The QA nurse stated a new bowel and bladder system has been implemented. She stated they had evaluated all the residents to see what their incontinence needs were and according to their score they would then proceed with a three day program to see what their toileting habits/needs were then they would make a decision whether the resident would be on a check and change type program or promoted to a scheduled toileting program. A list was provided showing residents' bowel and bladder potential from the grids. The list indicated 15 residents scored high for a scheduled toileting program, 17 scored good, 25 scored fair and 2 scored poor. This actual harm was determined to be past non-compliance due to facility assessing and implementing a current bladder program to identify current residents who would benefit from a scheduled bladder program.

Based on interview and record review, the facility failed to follow a physician's recommendation upon discharge from the hospital for one (#5) of seven sampled residents. The administrator identified 30 residents who had been to the hospital and returned to the facility from 01/01/12 through 03/28/12. Findings: Resident #5 was admitted with [DIAGNOSES REDACTED]. His comprehensive assessment, dated 03/06/12, documented his cognitive status was severely impaired. He was dependent on the staff for transfers, dressing, eating and bathing. He was always incontinent of bowel and had an indwelling Foley catheter. A hospital discharge summary dated 08/30/11, documented, "He (resident) will follow up with Dr. (Name Withheld) for possible endoscopy. Call for an appointment. The discharge summary was dictated by the attending physician that had cared for the resident during a hospital stay. There was no documentation to indicate the facility scheduled the appointments as recommended by the hospital discharge summary. On 03/28/12 at 2:05 p.m., RN #1 and LPN #1 were interviewed regarding the order not being followed. They both stated, "it was overlooked."

On 01/31/12, an immediate jeopardy was determined to exist for the facility's failure to implement their abuse policy and procedure for thoroughly investigating allegations of abuse; protecting residents from abuse during the investigation; not acting upon the findings of an investigation and protecting residents from resident to resident abuse. At 10:10 a.m., the Oklahoma State Department of Health (OSDH)confirmed the existence of the immediate jeopardy situation. At 10:20 a.m., the administrator and director of nurses were informed an immediate jeopardy situation existed. On 01/31/12 at 1:30 p.m., an acceptable plan of removal was provided by the administrator. The plan of removal was as followed: "Abuse includes, but is not limited to: verbal, physical abuse, neglect or misappropriation. Allegations of abuse of any type will be reported according to facility policy and regulation. Facility staff will follow the "Freedom from abuse policies" set theirin. (sic) 1. Facility staff will be in-serviced on facility "Freedom from abuse policies" on 01/31/2012 by 11:00 p.m. 2. Facility staff will be in-serviced on facility policy and regulation as it pertains to reporting requirements on 01/31/2012 by 11:00 p.m. 3. Individual of who abuse is alleged, facility policy was followed on 01/31/2012 10:15 a.m., terminating their employment duties. 4. Facility will provide report of investigation and outcome as required by regulation to appropriate department (s) and/or agencies on 01/31/2012 by 5:00 PM. The above actions will be completed by 11:00 PM 1/31/2012. Employees not physically present for in-service education will be educated via phone in-service, employees will not return to duties until receiving the above education. Any staff with alleged abuse will be suspended until investigation is complete. Allegations of abuse will be investigated by interviewing alleged resident if applicable. Any staff they was present at that time will be interview and asked for statements in witting. Any resident that might have been present will also be interviewed and statements taken. Policy and procedure will be amended and all words of relocate will be removed. Any employees that are not reached today will not be allowed back to work until they are inserviced on abuse policy and procedure. The administration will follow the above investigation protocol and report per state and federal regulations. Administrator and Director of Nursing will review and sign incident reports and ensure any appropriate actions against an employee with alleged allegations have been taken. The Abuse Investigation Protocol will be followed as stated in the policy. There are currently 56 employees working for Wadley Care Center they will all be inserviced on abuse policy before being allowed to return to work." On 02/01/12 at 2:00 p.m., the OSDH confirmed the continued existence of the immediate jeopardy situation and expanded it to include resident to resident abuse and the failure to protect residents from such abuse. On 02/01/12 at 3:35 p.m., an addendum was provided by the facility for the plan of removal to include resident to resident abuse. The following was the addendum: "All resident to Resident and Resident to staff allegations of abuse will have an incident report completed and facility will investigate. 1. Facility staff will be inserviced today on resident to resident and resident to staff abuse policy and procedure. This includes correctly and accurately filling out incident report and making documentation in resident's clinical record with intervention being put in place. 2. Care plan for (resident #7) will be updated by 5:00 p.m. and staff will be inserviced on interventions put into place. 3. All staff will be inserviced by 11:00 p.m. on the above policies. 4. facility policy will follow and implemented to protect residents having an occurrence of resident to resident abuse." On 02/02/12 at 1:30 p.m., after reviewing all inservice's, care plan updates, and interviews with staff, the administrator was informed the immediacy had been lifted at 8:00 a.m. (02/02/12), after all inservice's had been completed. The deficient practice remained at a scope of actual harm at a pattern, until the facility is able to ensure a system is in place to prevent the deficient practice from reoccurring. Based on observation, record review, and interviews, it was determined the facility failed to follow their abuse policy and procedure for protecting residents from abuse; investigating and reporting allegations of abuse; protecting residents during abuse investigations; acting upon the findings of an investigation and protecting residents from resident to resident abuse. This resulted in an actual harm and an immediate jeopardy situation. This deficient practice had the potential to affect 62 of 62 residents at the facility. The 'Freedom from Abuse Policies' documented, "Resident abuse and neglect policy: If any person observes or becomes aware of an incident of resident abuse and/or neglect, whether alleged, suspected, or observed, that person must report the incident to the nursing supervisor immediately..." 'Abuse Prevention Program Policy Statement' documented, our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion...Policy interpretation and Implementation...Wadley Care Center is committed to protecting our residents from abuse by anyone including, but not necessarily limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents...Wadley Care Center has developed policies and procedures to aid us in preventing abuse, neglect or mistreatment of [REDACTED]. 'Abuse Investigation Protocol Policy Statement' documented, "Wadley Care Center management promptly and thoroughly investigate all reports of resident abuse...resident to resident and resident to staff abuse. Police (policy) Interpretation and Implementation...the individual conducting the investigation will, as a minimum...interview the person (s) reporting the incident...interview any witnesses to the incident...interview the resident (as medically appropriate)...interview staff members (on all shifts ) who have had contact with the resident during the 48-hour period prior to the time of the incident...employees of this facility who have been accused of resident abuse will be suspended or terminated from duty until the administrator has reviewed the results of the investigation..." 'Investigating Allegations of Resident-to-Resident Abuse' documented, "Policy statement: all incidents of resident-to-resident abuse must be reported to the administrator or his/her designee. Policy interpretation and Implication...should a resident be observed/accused of abusing another resident, implement the following protocol...remove the aggressor from the situation the aggressor is still in the area in which the incident occurred...temporarily separate the resident from other residents as a therapeutic intervention to help reduce the agitation until the interdisciplinary care planning team can develop a plan of care to meet the needs of the resident...develop a care plan that includes interventions to prevent to prevent the reoccurrence of such incidents...inform all staff involved in the care of the resident of the care plan and to promptly report behavioral changes to the charge nurse...document in the resident's clinical record all interventions and their effectiveness...consult psychiatric services for assistance in assessing the resident and developing a care plan for interventions and management as necessary or as may be recommended by the attending physician or interdisciplinary care planning team...complete an incident report and document the incident, findings, and any corrective measures taken in the resident's medical/clinical record...transfer the resident if deemed by the interdisciplinary care planning team and the medical director as being a danger to him/herself or to others for psychiatric evaluation; and report incidents, findings, and corrective measures to appropriate agencies..." 'Protection of Residents During Abuse Investigations' documented, "Policy Statement our facility will protect residents from harm during investigations of abuse allegations. Policy Interpretation and Implementation: During abuse investigations, residents will be protected from harm by the following measures: employees accused of participating in the alleged abuse will be immediately suspended until the findings of the investigation have been reviewed by the administrator...if the alleged abuse involves another resident, the accused resident's representative (sponsors) and attending physician will be informed of the alleged abuse incident and that the accused resident will not be permitted to make visits to other residents rooms unattended...upon completion of the investigation, the resident, the resident's representative, the Oklahoma Health Department...will be provided a written report of the findings of the investigation and a summary of corrective action taken to prevent such incident from reoccuring...should the results of the investigation indicate abuse occurred, the administrator will notify appropriate authorities..." 'Reporting Abuse to State Agencies and Other Entities/Individuals' documented, "Policy Statement: All alleged/suspected violations and all substantiated incidents of abuse will be promptly reported to appropriate state agencies and other entities or individuals as may be required by law...should an alleged suspected violation or substantiated incident of mistreatment, neglect...or abuse (including resident-to-resident and resident to staff abuse incidents) be reported, the facility administrator or his/her designee, will promptly notify the following persons or agencies (verbally or written) of such incident...the state licensing/certification agency responsible for surveying/licensing the facility...notices to the above agencies...shall be made within 24 hours after the occurrence of the incident or when the facility learns of the abuse...The administrator...will provide the appropriate agencies...a written report of the findings of the investigation within 5 days of the occurrence of the incident...appropriate professional and licensing boards will be notified when an employee is found to have committed abuse..." Findings: a.) A review of the investigation of the incident which occurred during the breakfast meal on 01/23/12, between LPN #1 and Resident #1, documented the administrator was made aware of the allegation on the same day the incident occurred. A signed statement dated 01/24/12, from dietary aide #1 documented, "I (dietary aide) witnessed the nurse (LPN #1) abuse (resident #1) during breakfast time. She was rude and hateful to her. The resident was screaming telling her she didn't want to eat. So (LPN #1) shoved her head back and made her eat and drink. To me I think that's abuse no matter how you look at it!! This particular nurse is mean to other residents also. This facility is the residents home and they should be treated with respect. We're here to take care of them to best of our ability. P.S. That's resident abuse!!" A signed statement dated 01/24/12, from dietary aide #2 documented, "I (dietary aide) witnessed what I feel was abuse against a resident (Resident #1). I was asked by a nurse, (LPN #1) to make a tray for her so she can feed. A few minutes later the resident screamed. I saw her spitting up milk and saying no cause she did not want to eat. Then she gently pulled the resident back to her seat. The resident continued to refuse to eat and that when I saw the nurse shove her head back 3 X and told her to swallow and that she needed to eat. I felt she was using much force on someone that age. Around 8:30 (a.m.) my supervisor (CDM) walked in and let her know what happened." A signed statement dated 01/30/12, from CNA #6 documented, "This incident happened at 01/24/12 at 7:40 a.m. I (CNA) is writing this to report that I witnessed (LPN #1) feeding (Resident #1) at the table against the wall under the clock. It would be the middle table against the wall to be exact. As I was serving trays to the feeding table closer to the door. I was waiting on a tray as I heard (Resident) claiming that she didn't want to eat. I looked over towards (Resident) as she took a bite leaned down and proceeded to spit it out onto a plate. (LPN) reached her right hand out over (Resident) forehead and pushed her up and back with force. If it wasn't for (Resident) being in a chair she would have fell backwards." An undated statement by a family member documented, "I was sitting at a table in the dining room and I witnessed (LPN #1) feeding a patient aggressively telling her to swallow her food before she could go to her room. I did not see (LPN) touch the patient physically. She was just being verbally aggressive." All statements were part of the facility's investigation provided by the administrator. Included in the investigation were handouts the administrator identified as training material on [MEDICATION NAME] care for LPN #1 to read on her scheduled days off. A review of the time record for the month of January 2012, for LPN #1, verified the nurse continued working on the following days after the allegation of abuse was reported to the administrator and an investigation had been started: 01/24/12: 6:12 a.m. through 10:56 p.m. for a total of 15 hours and 44 minutes; 01/25/12: 6:18 a.m. through 6:33 p.m. for a total of 12 hours and 15 minutes; 01/28/12: 6:15 a.m. through 3:01 p.m. for a total of 8 hours and 46 minutes; 01/29/12: 6:12 a.m. through 2:47 p.m. for a total of 8 hours and 35 minutes; 01/30/12: 6:08 a.m. through 6:24 p.m. for a total of 12 hours and 16 minutes; and 01/31/12: 6:13 a.m. through 10:28 a.m. for a total of 4 hours and 15 minutes. On 01/31/12 at 7:50 a.m., the breakfast meal service was observed. LPN #1 was observed in the dining room assisting residents with their meals. She was observed assisting residents in the dining room from 7:50 a.m. through 8:45 a.m.. An interview was conducted on 01/31/12 at 8:25 a.m., with CNA #6, regarding the abuse that occurred with resident #1 and LPN #1. She was asked if she had witnessed any abuse between any staff and residents. She stated one day resident #1 had been brought down for her breakfast and she did not want to eat. The resident had spit her food out. She stated, "(LPN #1) then grabbed and pushed her back very forcibly three times." She then stated the resident's head snapped backwards and the resident would have have fallen back to the ground, if she had not been seated in a chair. She was asked what happened to employees who were accused of abuse. She stated, "It varies on what happens. They should be suspended but she (LPN#1) continues to work." She was asked if this was reported to anyone. She stated she and other aides did not report it because the nurse is "close" with the administrator and DON and nothing would happen. She then stated she told another worker about it and they went to the administrator and a statement was taken on 01/30/12, regarding the incident. She was asked when the other employee reported it to the administrator. She stated, "on the same day it occurred, 01/23/12." She was asked when the incident occurred. She stated, "01/23/12, about a week ago." She was asked if anyone other then herself witnessed the incident. She stated dietary aide #1, dietary aide #2, the dietary manager, CNA #2, CNA #3, and CMA #2. An interview was conducted on 01/31/12 at 9:09 a.m., with CMA #2. She was asked to describe the incident that occurred between LPN #1 and resident #1. She stated, "CNA #3 and CNA #6 came to her with an allegation of abuse on 01/23/12." She was asked what they had told her. She stated, "(LPN #1) was forcing the resident to stay and eat when she wanted to go back to her room." She then stated the CNA's told her the nurse pushed on the resident's head very hard so it "thrashed back." She also stated the CNA's did not tell anyone because nothing would happen to the employee. She was asked if she had reported it to anyone. She stated she reported it on the same day in the afternoon. She was asked what happened to the employee. She stated, "No one had done anything about it. You can see she is still working." An interview was conducted on 01/31/12 at 9:30 a.m., with CNA #3 regarding the incident that occurred on 01/23/12. She was asked to identify what she saw. She stated, "(LPN #1) was assisting (Resident #1) in the morning." She then stated, "(Resident #1) didn't want to eat and wanted to go to bed." She was asked if the resident was allowed to return to her room. She stated, "She was continued to be fed even though she didn't want it. She was forced to stay." An interview was conducted on 01/31/12 at 9:30 a.m., with dietary aide #1 regarding the incident between LPN #1 and resident #1 on 01/23/12. She was asked what she witnessed. She stated, "The nurse (LPN #1) was feeding the resident, but the resident didn't want to eat." She then stated, "Staff insisted and forced food into her. The resident spit the food back out." She was asked what happened next. She stated, "(LPN) pushed the resident's head back forcibly. I had never seen staff do that before." She was asked if she reported the incident to anyone. She stated, "My supervisor." She was asked what she thought about the incident. She stated, "I consider it abusive and offensive." She was asked what happened to the employee that was involved in the incident. She stated, "Nothing, she is still here." An interview was conducted on 01/31/12 at 9:45 a.m., with the certified dietary manager (CDM) regarding the incident that occurred on 01/23/12. She was asked what had occurred. She stated, " (LPN #1) asked for the resident's tray. The resident yelled and was observed spitting out her food." She then stated the LPN sat the resident back up and pushed the resident's head back forcefully. The CDM was asked if she reported it to anyone. She stated, "I went to the administrator and reported it on the same day." She then stated her staff had to write out a statement on what was witnessed and the statements were provided to the administrator. She was asked what happened to the employees who had allegations of abuse against them. She stated, "Sometimes on a leave of absence or suspended." The CDM was asked to identify the employees who reported the abuse to her. She stated she had talked with dietary aide #1 and dietary aide #2, who both provided the same story at different times. She stated that was how she knew she had to report it. An interview was conducted on 01/31/12 at 10:05 a.m., with the administrator regarding the incident which had occurred with the resident. She was asked when the investigation was started following the incident which had occurred during the breakfast meal on 01/23/12. She stated, "01/24/12." She was asked what the facility policy was for protecting residents during an investigation. She stated, "I don't know verbatim, but I think relocate the employee away from the resident abused or not have any unwitnessed contact with the resident." She was asked how she protected the residents from the employee who had an allegation of abuse filled against her. She stated, "I screwed up. I didn't protect all the residents." She was asked if LPN#1 had been suspended, as their policy required, after the allegation was made against her. She stated, "She only had her regular two days off Thursday and Friday. She was not suspended." She then added she gave the employee articles to read on her day off related to [MEDICATION NAME] care. An interview was conducted on 02/01/12 at 10:00 a.m., with the DON. She was asked what the job title was for LPN #1. She stated, "Charge Nurse." She was asked what the responsibilities were for the charge nurse. She stated, "She is responsible for the hall and the residents." She was asked how many residents the charge nurse was responsible for while assisting in the dining room. She stated, "She was responsible for all the residents in the dining room and those who are eating." She was asked how many residents LPN #1 had contact with during meal times. She stated, "She had contact with all residents by walking around and supervising." An interview was conducted on 02/01/12 at 11:50 a.m., with resident #9, regarding the way residents were treated by LPN #1. He was asked to describe the nurses interaction with other residents. He stated, "Oh my gosh, she was a terror, always yelling at the girls and the little old ladies." An interview was conducted on 02/01/12 at 12:15 p.m., with resident #8, regarding the way residents were treated by LPN #1. She was asked to describe the nurses interaction with other residents. She stated, "She was quite the mean one." The fax transmittal sheets to the Oklahoma State Department of Health (OSDH) attached with the investigation, documented the facility failed to notify the nursing board of the incident until 01/25/12 at 5:22 p.m. and failed to notify OSDH until 01/25/12 at 5:09 p.m. b.) Resident # 3 was admitted with [DIAGNOSES REDACTED]. A nurse's note dated 06/24/11 at 3:15 p.m., documented, "Resident (#3) wandered into another female residents room (Resident #7). Per other resident was asked to leave but instead of leaving hit other resident in the face; which agitated other female and she began attempting to kick (Resident #3). Residents separated. This resident noted to have multiple dark bruises to bilateral arms. Resident c/o bruises on R arm in particular being sore. Padded dressing of 4 x 4' s', gauze roll and tape applied to prevent bumping, et provided comfort......" A quarterly assessment dated 07/14/12, documented the resident was severely impaired in cognitive skills in daily decision making, was hard of hearing, had tendency to hit and fight, scream, and curse at others. It also documented the resident ambulated freely. A nurse's note dated 08/04/11 at 7:20 p.m., documented, "Resident has been amb all over building looking for the door out she's going back to Arkansas, looking for her kids yelling at other res inquiring where the door is. Went into another residents rm (Resident #7) & poured her bowl of potpouri (sic) on the floor. Other resident was yelling & cussing @ her & she was yelling & cussing at other resident when trying to calm her down....." A nurse's note dated 08/08/11 at 10:25 a.m., documented, "Staff heard loud yelling screaming. Charge nurse got there in time to lower resident to the floor /p (after) another resident (Resident #7) pushed her backward (Resident #3) was in another residents doorway & other res claimed hit her on the forehead with remote control, denied pushing her. (Resident #3) noted to have 5 cm x 4 cm hemorrhage area with 3.9 x 3.0 cm skin tear (c-shaped) on L forearm. R wrist /c 5.2 x 3.8 hemorrhagic area. L forearm /c 4.0 cm x 3.1 cm hemorrhagic area /c C-shaped skin tear 2.8 cm x 2.5 cm....skin tears cleaned /c NS steri strips applied covered /c [MEDICATION NAME]/roll gauze & tape....." A nurse's note dated 10/04/11 at 6:00 p.m., documented, "Res entered another res room (Resident #7). The other resident attempted to forceably (sic) remove her & grabbed her (left) hand causing a ST approx 0.25 cm in length to back of (left) hand. Cleansed area /c NS & applied TAO & covered /c band-aid 0 swelling, bruising or bleeding noted to area..." The resident's care plan dated 10/12/11, documented "Problem: cognitive loss r/t [MEDICAL CONDITION] AEB short and long term memory loss. Moderately impaired decision making. Approaches: reorient (Resident) as needed, speak to (Resident) at eye level in a moderate tone of voice, redirect (Resident) as necessary PRN." The care plan did not address the resident's wandering or the resident to resident altercations. A nurse's note dated 11/26/11 at 9:00 a.m., documented, "Was called to ramp by CNA, she - resident- noted 9 x 6 cm area to R forearm /c skin missing. Was told by staff & another residents family member that (Resident) and another resident (Resident #7)were arguing at other residents door Other resident reached out & grabbed skin on R forearm causing the injury. Staff tried to get to her & even told other resident she was coming to get her (Resident #3), but she grabbed her anyway......." A review of the facility's incident report book did not contain a corresponding incident report for the nurses' notes dated 06/24/11, 08/04/11, 08/08/11 or 11/26/11. The care plan did not address interventions for the residents wandering to keep her out of other residents rooms and/or protecting her from other residents' abuse. Resident #7 was admitted with [DIAGNOSES REDACTED]. An annual assessment dated [DATE], documented the resident's cognition was intact. The resident's care plan last updated on 05/07/11, documented, "Problem: Cognition-Decision Making Inadequate Cognitive loss with Behaviors and some impaired decision making r/t closed head injury. Goal: (Resident) will maintain her current level of cognition with fewer behaviors by 05/07/2012. Approach...Encourage (Resident) and give praise for positive behaviors CONT...Administer (Resident's) medication(s) per physician(s) order(s) BID Every day (8:00 AM, 8:00 PM)...Allow (Resident) to vocalize feelings when needed PRN (as needed)... Ensure that decisions made for (Resident) are appropriate PRN (as needed)...Allow (Resident) to make own decisions and choices that do not put her or other residents at risk for harm CONT(continuos)." A nurse's note dated 06/24/11 at 3:15 p.m., documented, "Res involved in an altercation /c another female res. when other resident entered this res. room. This res reports nicely asking other res to leave but other res hit this res in the face. This agitated this res and she began attempting to kick other res. Residents separated and education/therapeutic communication provided /c this res. Does have slight reddened area to left cheek. Ice provided to place on cheek." The incident report in regard to this incident verified the other resident involved was Resident #3. Another entry under the notes section documented, "(Resident) was told to go to her room or separate herself from the person who had made her angry. She stated she just got 'very mad' but would try going away from the person she was angry at." A nurse's note dated 08/04/11 at 7:20 p.m., documented, "Another resident (Resident #3) came into her rm. & poured her bowl of potpouri (sic) on the floor Res yelling & cussing at the top of the ramp screaming and cussing @ the other res finally got her quieted and back in her own rm. Stated she wasn't going to apologize & that she would like to kick the other residents 'ass' but did agree that would be inappropriate & would cause her to be in trouble. Calmed quickly /c no further incident." A nurse's note dated 08/08/11, documented, "10:25 staff heard loud yelling screaming Another res was @ res's doorway Charge nurse got there just in time to lower other res to floor after res pushed her backward. Resident very loud screaming & cussing Stated other resident hit her on the left side of forehead, twice. (No) inj noted Neuro vs wnl. Mother made aware, Dr. notified." The incident report for this incident indicated the other resident involved was Resident #3 and she had sustained no injury during the altercation. A nurse's note dated 10/04/11 at 6:00 p.m., documented, "Res was in her own room when a fell ow res. entered her room & res became upset & attempted to forceably (sic) remove from her doorway. (No) inj noted to this res. Notified family (mom) and phys..." The incident report for this incident indicated the other resident involved was Resident #3 and she had received a skin tear. An untimed nurse's note dated 10/05/11, documented, "Res was out in hall started yelling cussing @ another resident Easily redirected." The other resident was not identified in the nurse's note. No incident report was available for this incident. A nurse's note on 11/28/11, documented, "9:45: res went to rm across the hall & told (another) res to turn down her TV. Other res told her (Resident #7) her TV was down. (Resident) told her to close her door if she didn't turn TV down. When other resident refused (Resident #7) went out & closed the door. Other res is [MEDICAL CONDITION] & likes her door open but /p (Resident) got back into her own rm she kept yelling '[***] ' at other res several x's...." There was no documentation to indicate who the second resident was. A quarterly assessment dated [DATE], documented the resident had no cognitive problems. The assessment further documented the resident hit, scratched, screamed, cursed, pushed and grabbed at other residents. An interview was conducted on 02/01/12 at 2:40 p.m., with the DON regarding the resident's care plan and assessment. Current care plan problems and approaches were read aloud to the DON. She was asked if she knew of any problems or approaches addressing the resident's outburst of temper, pushing and/or kicking of other residents. She replied, "If its not there, no." An interview was conducted on 02/01/12 at 11:15 a.m., with RN #2 regarding incident reports. She was asked about the missing incident reports. The RN asked two other people, including the administrator, about places to look for incident reports. She stated she was told there were no other places to store incident reports other than the incident report book. An interview was conducted with CMA # 2 on 02/02/12 at 9:45 a.m. She was asked if she had witnessed any resident to resident altercations. She stated, "(Resident #7) and (Resident #3) fight all the time. (Resident #7) doesn't like (Resident #3)." An interview was conducted with CMA #1 on 02/02/12 at 9:48 a.m. She was asked if she had witnessed any resident to resident altercations. She stated, "(Resident #7) and (Resident #3) don't get along. (Resident #7) is mean to her." There were no documented interventions on the incident reports or in the residents' care plans to address prevention of future altercations between the residents. A request was made for the missing incident reports and documentation to verify the facility notified OSDH of the resident to resident altercations. No further documentation was provided. A review of the facility reported allegations of abuse at OSDH indicated no resident to resident altercations had been reported with resident #7 as the alleged perpetrator since 06/04/11.

On 01/31/12, an immediate jeopardy was determined to exist for the facility's failure to protect residents from physical and verbal abuse. At 10:10 a.m., the Oklahoma State Department of Health confirmed the existence of the immediate jeopardy situation. At 10:20 a.m., the administrator and director of nurses were informed an immediate jeopardy situation existed. On 01/31/12 at 1:30 p.m., an acceptable plan of removal was provided by the administrator. The plan of removal was as followed: "Abuse includes, but is not limited to: verbal, physical abuse, neglect or misappropriation. Allegations of abuse of any type will be reported according to facility policy and regulation. Facility staff will follow the "Freedom from abuse policies" set theirin. (sic) 1. Facility staff will be in-serviced on facility "Freedom from abuse policies" on 01/31/2012 by 11:00 p.m. 2. Facility staff will be in-serviced on facility policy and regulation as it pertains to reporting requirements on 01/31/2012 by 11:00 p.m. 3. Individual of who abuse is alleged, facility policy was followed on 01/31/2012 10:15 a.m., terminating their employment duties. 4. Facility will provide report of investigation and outcome as required by regulation to appropriate department (s) and/or agencies on 01/31/2012 by 5:00 PM. The above actions will be completed by 11:00 PM 1/31/2012. Employees not physically present for in-service education will be educated via phone in-service, employees will not return to duties until receiving the above education. Any staff with alleged abuse will be suspended until investigation is complete. Allegations of abuse will be investigated by interviewing alleged resident if applicable. Any staff that was present at that time will be interview and asked for statements in witting. Any resident that might have been present will also be interviewed and statements taken. Policy and procedure will be amended and all words of relocate will be removed. Any employees that are not reached today will not be allowed back to work until they are inserviced on abuse policy and procedure. The administration will follow the above investigation protocol and report per state and federal regulations. Administrator and Director of Nursing will review and sign incident reports and ensure any appropriate actions against an employee with alleged allegations have been taken. The Abuse Investigation Protocol will be followed as stated in the policy. There are currently 56 employees working for Wadley Care Center. They will all be inserviced on abuse policy before being allowed to return to work." On 02/01/12 at 2:00 p.m., the Oklahoma State Department of Health confirmed the continued existence of the immediate jeopardy situation and expanded it to include resident to resident abuse and the failure to protect residents from such abuse. On 02/01/12 at 3:35 p.m., an addendum was provided for the facility's plan of removal to include resident to resident abuse. The following was the addendum: "All resident to Resident and Resident to staff allegations of abuse will have an incident report completed and facility will investigate. 1. Facility staff will be inserviced today on resident to resident and resident to staff abuse policy and procedure. This includes correctly and accurately filling out incident report and making documentation in resident's clinical record with intervention being put in place. 2. Care plan for (resident #7) will be updated by 5:00 p.m. and staff will be inserviced on interventions put into place. 3. All staff will be inserviced by 11:00 p.m. on the above policies. 4. Facility policy will follow and implemented to protect residents having an occurrence of resident to resident abuse." On 02/02/12 at 1:30 p.m., after reviewing all inservices, care plan updates, and interviews with staff, the administrator was informed the immediacy had been lifted at 8:00 a.m. (02/02/12), after all inservices had been completed. The deficient practice remained at a scope of actual harm at a pattern, until the facility is able to ensure a system is in place to prevent the deficient practice from reoccurring. Based on observation, record review, and interviews, it was determined the facility failed to ensure residents were: a.) protected and free from staff abuse for one (#1) of one sampled resident, who had been forcibly kept in the dining room for breakfast and had her head shoved back during eating. This resulted in an Immediate Jeopardy situation. This had the potential to affect 62 of 62 facility residents. b.) protected from the physical and verbal abuse of resident #7, for one (#3) of one sampled residents. This resulted in actual harm and an Immediate Jeopardy situation. This had the potential to affect 62 of 62 facility residents. The 'Freedom from Abuse Policies' documented, "Resident abuse and neglect policy: If any person observes or becomes aware of an incident of resident abuse and/or neglect, whether alleged, suspected, or observed, that person must report the incident to the nursing supervisor immediately..." 'Abuse Prevention Program Policy Statement' documented, our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion...Policy interpretation and Implementation...Wadley Care Center is committed to protecting our residents from abuse by anyone including, but not necessarily limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents...Wadley Care Center has developed policies and procedures to aid us in preventing abuse, neglect or mistreatment of [REDACTED]. 'Abuse Investigation Protocol Policy Statement' documented, "...employees of this facility who have been accused of resident abuse will be suspended or terminated from duty until the administrator has reviewed the results of the investigation..." 'Investigating Allegations of Resident-to-Resident Abuse' documented, "...temporarily separate the resident from other residents as a therapeutic intervention to help reduce the agitation until the interdisciplinary care planning team can develop a plan of care to meet the needs of the resident...develop a care plan that includes interventions to prevent to prevent the reoccurrence of such incidents..." 'Protection of Residents During Abuse Investigations' documented, "Policy Statement our facility will protect residents from harm during investigations of abuse allegations. Policy Interpretation and Implementation: During abuse investigations, residents will be protected from harm by the following measures: employees accused of participating in the alleged abuse will be immediately suspended until the findings of the investigation have been reviewed by the administrator..." Findings: a.) A review of the investigation of the incident which occurred during the breakfast meal on 01/23/12, between LPN #1 and Resident #1, documented the administrator was made aware of the allegation on the same day the incident occurred. A signed statement dated 01/24/12, from dietary aide #1 documented, "I (dietary aide) witnessed the nurse (LPN #1) abuse (resident #1) during breakfast time. She was rude and hateful to her. The resident was screaming telling her she didn't want to eat. So (LPN #1) shoved her head back and made her eat and drink. To me I think that's abuse no matter how you look at it!! This particular nurse is mean to other residents also. This facility is the residents home and they should be treated with respect. We're here to take care of them to best of our ability. P.S. That's resident abuse!!" A signed statement dated 01/24/12, from dietary aide #2 documented, "I (dietary aide) witnessed what I feel was abuse against a resident (Resident #1). I was asked by a nurse, (LPN #1) to make a tray for her so she can feed. A few minutes later the resident screamed. I saw her spitting up milk and saying no cause she did not want to eat. Then she gently pulled the resident back to her seat. The resident continued to refuse to eat and that when I saw the nurse shove her head back 3 X and told her to swallow and that she needed to eat. I felt she was using much force on someone that age. Around 8:30 (a.m.) my supervisor (CDM) walked in and let her know what happened." A signed statement dated 01/30/12, from CNA #6 documented, "This incident happened at 01/24/12 at 7:40 a.m. I (CNA) is writing this to report that I witnessed (LPN #1) feeding (Resident #1) at the table against the wall under the clock. It would be the middle table against the wall to be exact. As I was serving trays to the feeding table closer to the door. I was waiting on a tray as I heard (Resident) claiming that she didn't want to eat. I looked over towards (Resident) as she took a bite leaned down and proceeded to spit it out onto a plate. (LPN) reached her right hand out over (Resident) forehead and pushed her up and back with force. If it wasn't for (Resident) being in a chair she would have fell backwards." An undated statement by a family member documented, "I was sitting at a table in the dining room and I witnessed (LPN #1) feeding a patient aggressively telling her to swallow her food before she could go to her room. I did not see (LPN) touch the patient physically. She was just being verbally aggressive." All statements were part of the facility's investigation provided by the administrator. Included in the investigation were handouts the administrator identified as training material on [MEDICATION NAME] care for LPN #1 to read on her scheduled days off. A review of the time record for the month of January 2012, for LPN #1, verified the nurse continued working on the following days after the allegation of abuse was reported to the administrator and an investigation had been started: 01/24/12: 6:12 a.m. through 10:56 p.m. for a total of 15 hours and 44 minutes; 01/25/12: 6:18 a.m. through 6:33 p.m. for a total of 12 hours and 15 minutes; 01/28/12: 6:15 a.m. through 3:01 p.m. for a total of 8 hours and 46 minutes; 01/29/12: 6:12 a.m. through 2:47 p.m. for a total of 8 hours and 35 minutes; 01/30/12: 6:08 a.m. through 6:24 p.m. for a total of 12 hours and 16 minutes; and 01/31/12: 6:13 a.m. through 10:28 a.m. for a total of 4 hours and 15 minutes. On 01/31/12 at 7:50 a.m., the breakfast meal service was observed. LPN #1 was observed in the dining room assisting residents with their meals. She was observed assisting residents in the dining room from 7:50 a.m. through 8:45 a.m.. An interview was conducted on 01/31/12 at 8:25 a.m., with CNA #6, regarding the abuse that occurred with resident #1 and LPN #1. She was asked if she had witnessed any abuse between any staff and residents. She stated one day resident #1 had been brought down for her breakfast and she did not want to eat. The resident had spit her food out. She stated, "(LPN #1) then grabbed and pushed her back very forcibly three times." She then stated the resident's head snapped backwards and the resident would have have fallen back to the ground, if she had not been seated in a chair. She was asked what happened to employees who were accused of abuse. She stated, "It varies on what happens. They should be suspended but she (LPN#1) continues to work." She was asked if this was reported to anyone. She stated she and other aides did not report it because the nurse is "close" with the administrator and DON and nothing would happen. She then stated she told another worker about it and they went to the administrator and a statement was taken on 01/30/12, regarding the incident. She was asked when the other employee reported it to the administrator. She stated, "on the same day it occurred, 01/23/12." She was asked when the incident occurred. She stated, "01/23/12, about a week ago." She was asked if anyone other then herself witnessed the incident. She stated dietary aide #1, dietary aide #2, the dietary manager, CNA #2, CNA #3, and CMA #2. An interview was conducted on 01/31/12 at 9:09 a.m., with CMA #2. She was asked to describe the incident that occurred between LPN #1 and resident #1. She stated, "CNA #3 and CNA #6 came to her with an allegation of abuse on 01/23/12." She was asked what they had told her. She stated, "(LPN #1) was forcing the resident to stay and eat when she wanted to go back to her room." She then stated the CNA's told her the nurse pushed on the resident's head very hard so it "thrashed back." She also stated the CNA's did not tell anyone because nothing would happen to the employee. She was asked if she had reported it to anyone. She stated she reported it on the same day in the afternoon. She was asked what happened to the employee. She stated, "No one had done anything about it. You can see she is still working." An interview was conducted on 01/31/12 at 9:30 a.m., with CNA #3 regarding the incident that occurred on 01/23/12. She was asked to identify what she saw. She stated, "(LPN #1) was assisting (Resident #1) in the morning." She then stated, "(Resident #1) didn't want to eat and wanted to go to bed." She was asked if the resident was allowed to return to her room. She stated, "She was continued to be fed even though she didn't want it. She was forced to stay." An interview was conducted on 01/31/12 at 9:30 a.m., with dietary aide #1 regarding the incident between LPN #1 and resident #1 on 01/23/12. She was asked what she witnessed. She stated, "The nurse (LPN #1) was feeding the resident, but the resident didn't want to eat." She then stated, "Staff insisted and forced food into her. The resident spit the food back out." She was asked what happened next. She stated, "(LPN) pushed the resident's head back forcibly. I had never seen staff do that before." She was asked if she reported the incident to anyone. She stated, "My supervisor." She was asked what she thought about the incident. She stated, "I consider it abusive and offensive." She was asked what happened to the employee that was involved in the incident. She stated, "Nothing, she is still here." An interview was conducted on 01/31/12 at 9:45 a.m., with the certified dietary manager (CDM) regarding the incident that occurred on 01/23/12. She was asked what had occurred. She stated, " (LPN #1) asked for the resident's tray. The resident yelled and was observed spitting out her food." She then stated the LPN sat the resident back up and pushed the resident's head back forcefully. The CDM was asked if she reported it to anyone. She stated, "I went to the administrator and reported it on the same day." She then stated her staff had to write out a statement on what was witnessed and the statements were provided to the administrator. She was asked what happened to the employees who had allegations of abuse against them. She stated, "Sometimes on a leave of absence or suspended." The CDM was asked to identify the employees who reported the abuse to her. She stated she had talked with dietary aide #1 and dietary aide #2, who both provided the same story at different times. She stated that was how she knew she had to report it. An interview was conducted on 01/31/12 at 10:05 a.m., with the administrator regarding the incident which had occurred with the resident. She was asked when the investigation was started following the incident which had occurred during the breakfast meal on 01/23/12. She stated, "01/24/12." She was asked what the facility policy was for protecting residents during an investigation. She stated, "I don't know verbatim, but I think relocate the employee away from the resident abused or not have any unwitnessed contact with the resident." She was asked how she protected the residents from the employee who had an allegation of abuse filled against her. She stated, "I screwed up. I didn't protect all the residents." She was asked if LPN#1 had been suspended, as their policy required, after the allegation was made against her. She stated, "She only had her regular two days off Thursday and Friday. She was not suspended." She then added she gave the employee articles to read on her day off related to [MEDICATION NAME] care. An interview was conducted on 02/01/12 at 10:00 a.m., with the DON. She was asked what the job title was for LPN #1. She stated, "Charge Nurse." She was asked what the responsibilities were for the charge nurse. She stated, "She is responsible for the hall and the residents." She was asked how many residents the charge nurse was responsible for while assisting in the dining room. She stated, "She was responsible for all the residents in the dining room and those who are eating." She was asked how many residents LPN #1 had contact with during meal times. She stated, "She had contact with all residents by walking around and supervising." An interview was conducted on 02/01/12 at 11:50 a.m., with resident #9, regarding the way residents were treated by LPN #1. He was asked to describe the nurses interaction with other residents. He stated, "Oh my gosh, she was a terror, always yelling at the girls and the little old ladies." An interview was conducted on 02/01/12 at 12:15 p.m., with resident #8, regarding the way residents were treated by LPN #1. She was asked to describe the nurses interaction with other residents. She stated, "She was quite the mean one." The fax transmittal sheets to the Oklahoma State Department of Health (OSDH) attached with the investigation, documented the facility failed to notify the nursing board of the incident until 01/25/12 at 5:22 p.m. and failed to notify OSDH until 01/25/12 at 5:09 p.m. b.) Resident # 3 was admitted with [DIAGNOSES REDACTED]. A nurse's note dated 06/24/11 at 3:15 p.m., documented, "Resident (#3) wandered into another female residents room (Resident #7). Per other resident was asked to leave but instead of leaving hit other resident in the face; which agitated other female and she began attempting to kick (Resident #3). Residents separated. This resident noted to have multiple dark bruises to bilateral arms. Resident c/o bruises on R arm in particular being sore. Padded dressing of 4 x 4' s', gauze roll and tape applied to prevent bumping, et provided comfort......" A quarterly assessment dated 07/14/12, documented the resident was severely impaired in cognitive skills in daily decision making, was hard of hearing, had tendency to hit and fight, scream, and curse at others. It also documented the resident ambulated freely. A nurse's note dated 08/04/11 at 7:20 p.m., documented, "Resident has been amb all over building looking for the door out she's going back to Arkansas, looking for her kids yelling at other res inquiring where the door is. Went into another residents rm (Resident #7) & poured her bowl of potpouri (sic) on the floor. Other resident was yelling & cussing @ her & she was yelling & cussing at other resident when trying to calm her down....." A nurse's note dated 08/08/11 at 10:25 a.m., documented, "Staff heard loud yelling screaming. Charge nurse got there in time to lower resident to the floor /p (after) another resident (Resident #7) pushed her backward (Resident #3) was in another residents doorway & other res claimed hit her on the forehead with remote control, denied pushing her. (Resident #3) noted to have 5 cm x 4 cm hemorrhage area with 3.9 x 3.0 cm skin tear (c-shaped) on L forearm. R wrist /c 5.2 x 3.8 hemorrhagic area. L forearm /c 4.0 cm x 3.1 cm hemorrhagic area /c C-shaped skin tear 2.8 cm x 2.5 cm....skin tears cleaned /c NS steri strips applied covered /c [MEDICATION NAME]/roll gauze & tape....." A nurse's note dated 10/04/11 at 6:00 p.m., documented, "Res entered another res room (Resident #7). The other resident attempted to forceably (sic) remove her & grabbed her (left) hand causing a ST approx 0.25 cm in length to back of (left) hand. Cleansed area /c NS & applied TAO & covered /c band-aid 0 swelling, bruising or bleeding noted to area..." The resident's care plan dated 10/12/11, documented "Problem: cognitive loss r/t [MEDICAL CONDITION] AEB short and long term memory loss. Moderately impaired decision making. Approaches: reorient (Resident) as needed, speak to (Resident) at eye level in a moderate tone of voice, redirect (Resident) as necessary PRN." The care plan did not address the resident's wandering or the resident to resident altercations. A nurse's note dated 11/26/11 at 9:00 a.m., documented, "Was called to ramp by CNA, she - resident- noted 9 x 6 cm area to R forearm /c skin missing. Was told by staff & another residents family member that (Resident) and another resident (Resident #7)were arguing at other residents door Other resident reached out & grabbed skin on R forearm causing the injury. Staff tried to get to her & even told other resident she was coming to get her (Resident #3), but she grabbed her anyway......." A review of the facility's incident report book did not contain a corresponding incident report for the nurses' notes dated 06/24/11, 08/04/11, 08/08/11 or 11/26/11. The care plan did not address interventions for the residents wandering to keep her out of other residents rooms and/or protecting her from other residents' abuse. Resident #7 was admitted with [DIAGNOSES REDACTED]. An annual assessment dated [DATE], documented the resident's cognition was intact. The resident's care plan last updated on 05/07/11, documented, "Problem: Cognition-Decision Making Inadequate Cognitive loss with Behaviors and some impaired decision making r/t closed head injury. Goal: (Resident) will maintain her current level of cognition with fewer behaviors by 05/07/2012. Approach...Encourage (Resident) and give praise for positive behaviors CONT...Administer (Resident's) medication(s) per physician(s) order(s) BID Every day (8:00 AM, 8:00 PM)...Allow (Resident) to vocalize feelings when needed PRN (as needed)... Ensure that decisions made for (Resident) are appropriate PRN (as needed)...Allow (Resident) to make own decisions and choices that do not put her or other residents at risk for harm CONT(continuos)." A nurse's note dated 06/24/11 at 3:15 p.m., documented, "Res involved in an altercation /c another female res. when other resident entered this res. room. This res reports nicely asking other res to leave but other res hit this res in the face. This agitated this res and she began attempting to kick other res. Residents separated and education/therapeutic communication provided /c this res. Does have slight reddened area to left cheek. Ice provided to place on cheek." The incident report in regard to this incident verified the other resident involved was Resident #3. Another entry under the notes section documented, "(Resident) was told to go to her room or separate herself from the person who had made her angry. She stated she just got 'very mad' but would try going away from the person she was angry at." A nurse's note dated 08/04/11 at 7:20 p.m., documented, "Another resident (Resident #3) came into her rm. & poured her bowl of potpouri (sic) on the floor Res yelling & cussing at the top of the ramp screaming and cussing @ the other res finally got her quieted and back in her own rm. Stated she wasn't going to apologize & that she would like to kick the other residents 'ass' but did agree that would be inappropriate & would cause her to be in trouble. Calmed quickly /c no further incident." A nurse's note dated 08/08/11, documented, "10:25 staff heard loud yelling screaming Another res was @ res's doorway Charge nurse got there just in time to lower other res to floor after res pushed her backward. Resident very loud screaming & cussing Stated other resident hit her on the left side of forehead, twice. (No) inj noted Neuro vs wnl. Mother made aware, Dr. notified." The incident report for this incident indicated the other resident involved was Resident #3 and she had sustained no injury during the altercation. A nurse's note dated 10/04/11 at 6:00 p.m., documented, "Res was in her own room when a fell ow res. entered her room & res became upset & attempted to forceably (sic) remove from her doorway. (No) inj noted to this res. Notified family (mom) and phys..." The incident report for this incident indicated the other resident involved was Resident #3 and she had received a skin tear. An untimed nurse's note dated 10/05/11, documented, "Res was out in hall started yelling cussing @ another resident Easily redirected." The other resident was not identified in the nurse's note. No incident report was available for this incident. A nurse's note on 11/28/11, documented, "9:45: res went to rm across the hall & told (another) res to turn down her TV. Other res told her (Resident #7) her TV was down. (Resident) told her to close her door if she didn't turn TV down. When other resident refused (Resident #7) went out & closed the door. Other res is [MEDICAL CONDITION] & likes her door open but /p (Resident) got back into her own rm she kept yelling '[***] ' at other res several x's...." There was no documentation to indicate who the second resident was. A quarterly assessment dated [DATE], documented the resident had no cognitive problems. The assessment further documented the resident hit, scratched, screamed, cursed, pushed and grabbed at other residents. An interview was conducted on 02/01/12 at 2:40 p.m., with the DON regarding the resident's care plan and assessment. Current care plan problems and approaches were read aloud to the DON. She was asked if she knew of any problems or approaches addressing the resident's outburst of temper, pushing and/or kicking of other residents. She replied, "If its not there, no." An interview was conducted on 02/01/12 at 11:15 a.m., with RN #2 regarding incident reports. She was asked about the missing incident reports. The RN asked two other people, including the administrator, about places to look for incident reports. She stated she was told there were no other places to store incident reports other than the incident report book. An interview was conducted with CMA # 2 on 02/02/12 at 9:45 a.m. She was asked if she had witnessed any resident to resident altercations. She stated, "(Resident #7) and (Resident #3) fight all the time. (Resident #7) doesn't like (Resident #3)." An interview was conducted with CMA #1 on 02/02/12 at 9:48 a.m. She was asked if she had witnessed any resident to resident altercations. She stated, "(Resident #7) and (Resident #3) don't get along. (Resident #7) is mean to her." There were no documented interventions on the incident reports or in the residents' care plans to address prevention of future altercations between the residents.

On 01/31/12, an immediate jeopardy was determined to exist in regard to the facility's failure to protect a resident (#1) by allowing a nurse to continue to work in the facility who had been witnessed to verbally and physically abuse the resident. The facility also failed to thoroughly investigate and immediately report the incident between the resident and the nurse. At 10:10 a.m., the Oklahoma State Department of Health (OSDH)confirmed the existence of the immediate jeopardy situation. At 10:20 a.m., the administrator and director of nurses were informed an immediate jeopardy situation existed due to the facility's failure to protect residents from physical and verbal abuse during investigations of alleged abuse; thoroughly investigate allegations of staff to resident and resident to resident abuse; act upon the findings of the investigations to protect residents from further abuse; and intervene and protect residents from other resident abuse. On 01/31/12 at 1:30 p.m., an acceptable plan of removal was provided by the administrator. The plan of removal was as followed: "Abuse includes, but is not limited to: verbal, physical abuse, neglect or misappropriation. Allegations of abuse of any type will be reported according to facility policy and regulation. Facility staff will follow the "Freedom from abuse policies" set therein. (sic) 1. Facility staff will be in-serviced on facility "Freedom from abuse policies" on 01/31/2012 by 11:00 p.m. 2. Facility staff will be in-serviced on facility policy and regulation as it pertains to reporting requirements on 01/31/2012 by 11:00 p.m. 3. Individual of who abuse is alleged, facility policy was followed on 01/31/2012 10:15 a.m., terminating their employment duties. 4. Facility will provide report of investigation and outcome as required by regulation to appropriate department (s) and/or agencies on 01/31/2012 by 5:00 PM. The above actions will be completed by 11:00 PM 1/31/2012. Employees not physically present for in-service education will be educated via phone in-service, employees will not return to duties until receiving the above education. Any staff with alleged abuse will be suspended until investigation is complete. Allegations of abuse will be investigated by interviewing alleged resident if applicable. Any staff they was present at that time will be interview and asked for statements in witting. Any resident that might have been present will also be interviewed and statements taken. Policy and procedure will be amended and all words of relocate will be removed. Any employees that are not reached today will not be allowed back to work until they are inserviced on abuse policy and procedure. The administration will follow the above investigation protocol and report per state and federal regulations. Administrator and Director of Nursing will review and sign incident reports and ensure any appropriate actions against an employee with alleged allegations have been taken. The Abuse Investigation Protocol will be followed as stated in the policy. There are currently 56 employees working for Wadley Care Center they will all be inserviced on abuse policy before being allowed to return to work." On 02/01/12 at 2:00 p.m., the Oklahoma State Department of Health confirmed the continued existence of the immediate jeopardy situation and expanded it to include resident to resident abuse and the failure to protect residents from such abuse. On 02/01/12 at 3:35 p.m., an addendum was provided for the facility's plan of removal to include resident to resident abuse. The following was the addendum: "All resident to Resident and Resident to staff allegations of abuse will have an incident report completed and facility will investigate. 1. Facility staff will be inserviced today on resident to resident and resident to staff abuse policy and procedure. This includes correctly and accurately filling out incident report and making documentation in resident's clinical record with intervention being put in place. 2. Care plan for (resident #7) will be updated by 5:00 p.m. and staff will be inserviced on interventions put into place. 3. All staff will be inserviced by 11:00 p.m. on the above policies. 4. facility policy will follow and implemented to protect residents having an occurrence of resident to resident abuse." On 02/02/12 at 1:30 p.m., after reviewing all inservice's, care plan updates, and interviews with staff, the administrator was informed the immediacy had been lifted at 8:00 a.m. (02/02/12) following completion of all inservices. The deficient practice remained at a scope of actual harm at a pattern, until the facility is able to ensure a system is in place to prevent the deficient practice from reoccurring. Based on observation, record review, and interviews, it was determined the facility failed to: a.) ensure residents were protected from abuse during investigations, by suspending employees as their policy required, pending the outcome of the investigation; thoroughly investigating allegations of abuse and acting upon findings from abuse investigations. This deficient practice resulted in an immediate jeopardy situation. b.) investigate resident to resident altercations, implement interventions which protected residents from other residents abuse and report allegations of resident to resident abuse to the Oklahoma State Department of Health for two (#3 and #7) of three sampled residents reviewed for resident to resident abuse. This resulted in an actual harm and an immediate jeopardy situation. This deficient practice had the potential to affect 62 of 62 residents at the facility. The 'Freedom from Abuse Policies' documented, "Resident abuse and neglect policy: If any person observes or becomes aware of an incident of resident abuse and/or neglect, whether alleged, suspected, or observed, that person must report the incident to the nursing supervisor immediately..." 'Abuse Prevention Program Policy Statement' documented, our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion...Policy interpretation and Implementation...Wadley Care Center is committed to protecting our residents from abuse by anyone including, but not necessarily limited to, facility staff, other residents...Wadley Care Center has developed policies and procedures to aid us in preventing abuse, neglect or mistreatment of [REDACTED]. 'Abuse Investigation Protocol Policy Statement' documented, "Wadley Care Center management promptly and thoroughly investigate all reports of resident abuse...resident to resident and resident to staff abuse. Police (policy) Interpretation and Implementation...the individual conducting the investigation will...interview the person (s) reporting the incident...interview any witnesses to the incident...interview the resident (as medically appropriate)...interview staff members (on all shifts)... employees of this facility who have been accused of resident abuse will be suspended or terminated from duty until the administrator has reviewed the results of the investigation..." 'Investigating Allegations of Resident-to-Resident Abuse' documented, "Policy statement: all incidents of resident-to-resident abuse must be reported to the administrator or his/her designee. Policy interpretation and Implication...should a resident be observed/accused of abusing another resident, implement the following protocol...temporarily separate the resident from other residents as a therapeutic intervention to help reduce the agitation until the interdisciplinary care planning team can develop a plan of care to meet the needs of the resident...develop a care plan that includes interventions to prevent to prevent the reoccurrence of such incidents...inform all staff involved in the care of the resident of the care plan and to promptly report behavioral changes to the charge nurse...document in the resident's clinical record all interventions and their effectiveness...complete an incident report and document the incident, findings, and any corrective measures taken in the resident's medical/clinical record...and report incidents, findings, and corrective measures to appropriate agencies..." 'Protection of Residents During Abuse Investigations' documented, "Policy Statement our facility will protect residents from harm during investigations of abuse allegations. Policy Interpretation and Implementation: During abuse investigations, residents will be protected from harm by the following measures: employees accused of participating in the alleged abuse will be immediately suspended until the findings of the investigation have been reviewed by the administrator...if the alleged abuse involves another resident, the accused resident's representative (sponsors) and attending physician will be informed of the alleged abuse incident and that the accused resident will not be permitted to make visits to other residents rooms unattended...upon completion of the investigation, the resident, the resident's representative, the Oklahoma Health Department...will be provided a written report of the findings of the investigation and a summary of corrective action taken to prevent such incident from reoccuring...should the results of the investigation indicate abuse occurred, the administrator will notify appropriate authorities..." 'Reporting Abuse to State Agencies and Other Entities/Individuals' documented, "Policy Statement: All alleged/suspected violations and all substantiated incidents of abuse will be promptly reported to appropriate state agencies and other entities or individuals as may be required by law...should an alleged suspected violation or substantiated incident of mistreatment, neglect...or abuse (including resident-to-resident and resident to staff abuse incidents) be reported, the facility administrator or his/her designee, will promptly notify the following persons or agencies (verbally or written) of such incident...the state licensing/certification agency responsible for surveying/licensing the facility...notices to the above agencies...shall be made within 24 hours after the occurrence of the incident or when the facility learns of the abuse...The administrator...will provide the appropriate agencies...a written report of the findings of the investigation within 5 days of the occurrence of the incident...appropriate professional and licensing boards will be notified when an employee is found to have committed abuse..." Findings: a.) A review of the investigation of the incident which occurred during the breakfast meal on 01/23/12, between LPN #1 and Resident #1, documented the administrator was made aware of the allegation on the same day the incident occurred. A signed statement dated 01/24/12, from dietary aide #1 documented, "I (dietary aide) witnessed the nurse (LPN #1) abuse (resident #1) during breakfast time. She was rude and hateful to her. The resident was screaming telling her she didn't want to eat. So (LPN #1) shoved her head back and made her eat and drink. To me I think that's abuse no matter how you look at it!! This particular nurse is mean to other residents also. This facility is the residents home and they should be treated with respect. We're here to take care of them to best of our ability. P.S. That's resident abuse!!" A signed statement dated 01/24/12, from dietary aide #2 documented, "I (dietary aide) witnessed what I feel was abuse against a resident (Resident #1). I was asked by a nurse, (LPN #1) to make a tray for her so she can feed. A few minutes later the resident screamed. I saw her spitting up milk and saying no cause she did not want to eat. Then she gently pulled the resident back to her seat. The resident continued to refuse to eat and that when I saw the nurse shove her head back 3 X and told her to swallow and that she needed to eat. I felt she was using much force on someone that age. Around 8:30 (a.m.) my supervisor (CDM) walked in and let her know what happened." A signed statement dated 01/30/12, from CNA #6 documented, "This incident happened at 01/24/12 at 7:40 a.m. I (CNA) is writing this to report that I witnessed (LPN #1) feeding (Resident #1) at the table against the wall under the clock. It would be the middle table against the wall to be exact. As I was serving trays to the feeding table closer to the door. I was waiting on a tray as I heard (Resident) claiming that she didn't want to eat. I looked over towards (Resident) as she took a bite leaned down and proceeded to spit it out onto a plate. (LPN) reached her right hand out over (Resident) forehead and pushed her up and back with force. If it wasn't for (Resident) being in a chair she would have fell backwards." An undated statement by a family member documented, "I was sitting at a table in the dining room and I witnessed (LPN #1) feeding a patient aggressively telling her to swallow her food before she could go to her room. I did not see (LPN) touch the patient physically. She was just being verbally aggressive." All statements were part of the facility's investigation provided by the administrator. Included in the investigation were handouts the administrator identified as training material on [MEDICATION NAME] care for LPN #1 to read on her scheduled days off. A review of the time record for the month of January 2012, for LPN #1, verified the nurse continued working on the following days after the allegation of abuse was reported to the administrator and an investigation had been started: 01/24/12: 6:12 a.m. through 10:56 p.m. for a total of 15 hours and 44 minutes; 01/25/12: 6:18 a.m. through 6:33 p.m. for a total of 12 hours and 15 minutes; 01/28/12: 6:15 a.m. through 3:01 p.m. for a total of 8 hours and 46 minutes; 01/29/12: 6:12 a.m. through 2:47 p.m. for a total of 8 hours and 35 minutes; 01/30/12: 6:08 a.m. through 6:24 p.m. for a total of 12 hours and 16 minutes; and 01/31/12: 6:13 a.m. through 10:28 a.m. for a total of 4 hours and 15 minutes. On 01/31/12 at 7:50 a.m., the breakfast meal service was observed. LPN #1 was observed in the dining room assisting residents with their meals. She was observed assisting residents in the dining room from 7:50 a.m. through 8:45 a.m.. An interview was conducted on 01/31/12 at 8:25 a.m., with CNA #6, regarding the abuse that occurred with resident #1 and LPN #1. She was asked if she had witnessed any abuse between any staff and residents. She stated one day resident #1 had been brought down for her breakfast and she did not want to eat. The resident had spit her food out. She stated, "(LPN #1) then grabbed and pushed her back very forcibly three times." She then stated the resident's head snapped backwards and the resident would have have fallen back to the ground, if she had not been seated in a chair. She was asked what happened to employees who were accused of abuse. She stated, "It varies on what happens. They should be suspended but she (LPN#1) continues to work." She was asked if this was reported to anyone. She stated she and other aides did not report it because the nurse is "close" with the administrator and DON and nothing would happen. She then stated she told another worker about it and they went to the administrator and a statement was taken on 01/30/12, regarding the incident. She was asked when the other employee reported it to the administrator. She stated, "on the same day it occurred, 01/23/12." She was asked when the incident occurred. She stated, "01/23/12, about a week ago." She was asked if anyone other then herself witnessed the incident. She stated dietary aide #1, dietary aide #2, the dietary manager, CNA #2, CNA #3, and CMA #2. An interview was conducted on 01/31/12 at 9:09 a.m., with CMA #2. She was asked to describe the incident that occurred between LPN #1 and resident #1. She stated, "CNA #3 and CNA #6 came to her with an allegation of abuse on 01/23/12." She was asked what they had told her. She stated, "(LPN #1) was forcing the resident to stay and eat when she wanted to go back to her room." She then stated the CNA's told her the nurse pushed on the resident's head very hard so it "thrashed back." She also stated the CNA's did not tell anyone because nothing would happen to the employee. She was asked if she had reported it to anyone. She stated she reported it on the same day in the afternoon. She was asked what happened to the employee. She stated, "No one had done anything about it. You can see she is still working." An interview was conducted on 01/31/12 at 9:30 a.m., with CNA #3 regarding the incident that occurred on 01/23/12. She was asked to identify what she saw. She stated, "(LPN #1) was assisting (Resident #1) in the morning." She then stated, "(Resident #1) didn't want to eat and wanted to go to bed." She was asked if the resident was allowed to return to her room. She stated, "She was continued to be fed even though she didn't want it. She was forced to stay." An interview was conducted on 01/31/12 at 9:30 a.m., with dietary aide #1 regarding the incident between LPN #1 and resident #1 on 01/23/12. She was asked what she witnessed. She stated, "The nurse (LPN #1) was feeding the resident, but the resident didn't want to eat." She then stated, "Staff insisted and forced food into her. The resident spit the food back out." She was asked what happened next. She stated, "(LPN) pushed the resident's head back forcibly. I had never seen staff do that before." She was asked if she reported the incident to anyone. She stated, "My supervisor." She was asked what she thought about the incident. She stated, "I consider it abusive and offensive." She was asked what happened to the employee that was involved in the incident. She stated, "Nothing, she is still here." An interview was conducted on 01/31/12 at 9:45 a.m., with the certified dietary manager (CDM) regarding the incident that occurred on 01/23/12. She was asked what had occurred. She stated, " (LPN #1) asked for the resident's tray. The resident yelled and was observed spitting out her food." She then stated the LPN sat the resident back up and pushed the resident's head back forcefully. The CDM was asked if she reported it to anyone. She stated, "I went to the administrator and reported it on the same day." She then stated her staff had to write out a statement on what was witnessed and the statements were provided to the administrator. She was asked what happened to the employees who had allegations of abuse against them. She stated, "Sometimes on a leave of absence or suspended." The CDM was asked to identify the employees who reported the abuse to her. She stated she had talked with dietary aide #1 and dietary aide #2, who both provided the same story at different times. She stated that was how she knew she had to report it. An interview was conducted on 01/31/12 at 10:05 a.m., with the administrator regarding the incident which had occurred with the resident. She was asked when the investigation was started following the incident which had occurred during the breakfast meal on 01/23/12. She stated, "01/24/12." She was asked what the facility policy was for protecting residents during an investigation. She stated, "I don't know verbatim, but I think relocate the employee away from the resident abused or not have any unwitnessed contact with the resident." She was asked how she protected the residents from the employee who had an allegation of abuse filled against her. She stated, "I screwed up. I didn't protect all the residents." She was asked if LPN#1 had been suspended, as their policy required, after the allegation was made against her. She stated, "She only had her regular two days off Thursday and Friday. She was not suspended." She then added she gave the employee articles to read on her day off related to [MEDICATION NAME] care. An interview was conducted on 02/01/12 at 10:00 a.m., with the DON. She was asked what the job title was for LPN #1. She stated, "Charge Nurse." She was asked what the responsibilities were for the charge nurse. She stated, "She is responsible for the hall and the residents." She was asked how many residents the charge nurse was responsible for while assisting in the dining room. She stated, "She was responsible for all the residents in the dining room and those who are eating." She was asked how many residents LPN #1 had contact with during meal times. She stated, "She had contact with all residents by walking around and supervising." An interview was conducted on 02/01/12 at 11:50 a.m., with resident #9, regarding the way residents were treated by LPN #1. He was asked to describe the nurses interaction with other residents. He stated, "Oh my gosh, she was a terror, always yelling at the girls and the little old ladies." An interview was conducted on 02/01/12 at 12:15 p.m., with resident #8, regarding the way residents were treated by LPN #1. She was asked to describe the nurses interaction with other residents. She stated, "She was quite the mean one." The fax transmittal sheets to the Oklahoma State Department of Health (OSDH) attached with the investigation, documented the facility failed to notify the nursing board of the incident until 01/25/12 at 5:22 p.m. and failed to notify OSDH until 01/25/12 at 5:09 p.m. b.) Resident # 3 was admitted with [DIAGNOSES REDACTED]. A nurse's note dated 06/24/11 at 3:15 p.m., documented, "Resident (#3) wandered into another female residents room (Resident #7). Per other resident was asked to leave but instead of leaving hit other resident in the face; which agitated other female and she began attempting to kick (Resident #3). Residents separated. This resident noted to have multiple dark bruises to bilateral arms. Resident c/o bruises on R arm in particular being sore. Padded dressing of 4 x 4' s', gauze roll and tape applied to prevent bumping, et provided comfort......" A quarterly assessment dated 07/14/12, documented the resident was severely impaired in cognitive skills in daily decision making, was hard of hearing, had tendency to hit and fight, scream, and curse at others. It also documented the resident ambulated freely. A nurse's note dated 08/04/11 at 7:20 p.m., documented, "Resident has been amb all over building looking for the door out she's going back to Arkansas, looking for her kids yelling at other res inquiring where the door is. Went into another residents rm (Resident #7) & poured her bowl of potpouri (sic) on the floor. Other resident was yelling & cussing @ her & she was yelling & cussing at other resident when trying to calm her down....." A nurse's note dated 08/08/11 at 10:25 a.m., documented, "Staff heard loud yelling screaming. Charge nurse got there in time to lower resident to the floor /p (after) another resident (Resident #7) pushed her backward (Resident #3) was in another residents doorway & other res claimed hit her on the forehead with remote control, denied pushing her. (Resident #3) noted to have 5 cm x 4 cm hemorrhage area with 3.9 x 3.0 cm skin tear (c-shaped) on L forearm. R wrist /c 5.2 x 3.8 hemorrhagic area. L forearm /c 4.0 cm x 3.1 cm hemorrhagic area /c C-shaped skin tear 2.8 cm x 2.5 cm....skin tears cleaned /c NS steri strips applied covered /c [MEDICATION NAME]/roll gauze & tape....." A nurse's note dated 10/04/11 at 6:00 p.m., documented, "Res entered another res room (Resident #7). The other resident attempted to forceably (sic) remove her & grabbed her (left) hand causing a ST approx 0.25 cm in length to back of (left) hand. Cleansed area /c NS & applied TAO & covered /c band-aid 0 swelling, bruising or bleeding noted to area..." The resident's care plan dated 10/12/11, documented "Problem: cognitive loss r/t [MEDICAL CONDITION] AEB short and long term memory loss. Moderately impaired decision making. Approaches: reorient (Resident) as needed, speak to (Resident) at eye level in a moderate tone of voice, redirect (Resident) as necessary PRN." The care plan did not address the resident's wandering or the resident to resident altercations. A nurse's note dated 11/26/11 at 9:00 a.m., documented, "Was called to ramp by CNA, she - resident- noted 9 x 6 cm area to R forearm /c skin missing. Was told by staff & another residents family member that (Resident) and another resident (Resident #7)were arguing at other residents door Other resident reached out & grabbed skin on R forearm causing the injury. Staff tried to get to her & even told other resident she was coming to get her (Resident #3), but she grabbed her anyway......." A review of the facility's incident report book did not contain a corresponding incident report for the nurses' notes dated 06/24/11, 08/04/11, 08/08/11 or 11/26/11. The care plan did not address interventions for the residents wandering to keep her out of other residents rooms and/or protecting her from other residents' abuse. Resident #7 was admitted with [DIAGNOSES REDACTED]. An annual assessment dated [DATE], documented the resident's cognition was intact. The resident's care plan last updated on 05/07/11, documented, "Problem: Cognition-Decision Making Inadequate Cognitive loss with Behaviors and some impaired decision making r/t closed head injury. Goal: (Resident) will maintain her current level of cognition with fewer behaviors by 05/07/2012. Approach...Encourage (Resident) and give praise for positive behaviors CONT...Administer (Resident's) medication(s) per physician(s) order(s) BID Every day (8:00 AM, 8:00 PM)...Allow (Resident) to vocalize feelings when needed PRN (as needed)... Ensure that decisions made for (Resident) are appropriate PRN (as needed)...Allow (Resident) to make own decisions and choices that do not put her or other residents at risk for harm CONT(continuos)." A nurse's note dated 06/24/11 at 3:15 p.m., documented, "Res involved in an altercation /c another female res. when other resident entered this res. room. This res reports nicely asking other res to leave but other res hit this res in the face. This agitated this res and she began attempting to kick other res. Residents separated and education/therapeutic communication provided /c this res. Does have slight reddened area to left cheek. Ice provided to place on cheek." The incident report in regard to this incident verified the other resident involved was Resident #3. Another entry under the notes section documented, "(Resident) was told to go to her room or separate herself from the person who had made her angry. She stated she just got 'very mad' but would try going away from the person she was angry at." A nurse's note dated 08/04/11 at 7:20 p.m., documented, "Another resident (Resident #3) came into her rm. & poured her bowl of potpouri (sic) on the floor Res yelling & cussing at the top of the ramp screaming and cussing @ the other res finally got her quieted and back in her own rm. Stated she wasn't going to apologize & that she would like to kick the other residents 'ass' but did agree that would be inappropriate & would cause her to be in trouble. Calmed quickly /c no further incident." A nurse's note dated 08/08/11, documented, "10:25 staff heard loud yelling screaming Another res was @ res's doorway Charge nurse got there just in time to lower other res to floor after res pushed her backward. Resident very loud screaming & cussing Stated other resident hit her on the left side of forehead, twice. (No) inj noted Neuro vs wnl. Mother made aware, Dr. notified." The incident report for this incident indicated the other resident involved was Resident #3 and she had sustained no injury during the altercation. A nurse's note dated 10/04/11 at 6:00 p.m., documented, "Res was in her own room when a fell ow res. entered her room & res became upset & attempted to forceably (sic) remove from her doorway. (No) inj noted to this res. Notified family (mom) and phys..." The incident report for this incident indicated the other resident involved was Resident #3 and she had received a skin tear. An untimed nurse's note dated 10/05/11, documented, "Res was out in hall started yelling cussing @ another resident Easily redirected." The other resident was not identified in the nurse's note. No incident report was available for this incident. A nurse's note on 11/28/11, documented, "9:45: res went to rm across the hall & told (another) res to turn down her TV. Other res told her (Resident #7) her TV was down. (Resident) told her to close her door if she didn't turn TV down. When other resident refused (Resident #7) went out & closed the door. Other res is [MEDICAL CONDITION] & likes her door open but /p (Resident) got back into her own rm she kept yelling '[***] ' at other res several x's...." There was no documentation to indicate who the second resident was. A quarterly assessment dated [DATE], documented the resident had no cognitive problems. The assessment further documented the resident hit, scratched, screamed, cursed, pushed and grabbed at other residents. An interview was conducted on 02/01/12 at 2:40 p.m., with the DON regarding the resident's care plan and assessment. Current care plan problems and approaches were read aloud to the DON. She was asked if she knew of any problems or approaches addressing the resident's outburst of temper, pushing and/or kicking of other residents. She replied, "If its not there, no." An interview was conducted on 02/01/12 at 11:15 a.m., with RN #2 regarding incident reports. She was asked about the missing incident reports. The RN asked two other people, including the administrator, about places to look for incident reports. She stated she was told there were no other places to store incident reports other than the incident report book. An interview was conducted with CMA # 2 on 02/02/12 at 9:45 a.m. She was asked if she had witnessed any resident to resident altercations. She stated, "(Resident #7) and (Resident #3) fight all the time. (Resident #7) doesn't like (Resident #3)." An interview was conducted with CMA #1 on 02/02/12 at 9:48 a.m. She was asked if she had witnessed any resident to resident altercations. She stated, "(Resident #7) and (Resident #3) don't get along. (Resident #7) is mean to her." There were no documented interventions on the incident reports or in the residents' care plans to address prevention of future altercations between the residents. A request was made for the missing incident reports and documentation to verify the facility notified OSDH of the resident to resident altercations. No further documentation was provided. A review of the facility reported allegations of abuse at OSDH indicated no resident to resident altercations had been reported with resident #7 as the alleged perpetrator since 06/04/11.

On 01/31/12, an immediate jeopardy was determined to exist due to the facility's failure to have an effective administration who implemented the abuse policy and procedure for investigating allegations of abuse, protecting residents from abuse, protecting residents during investigations of abuse, acting upon the findings of an abuse investigation, and protecting residents from other resident abuse. At 10:10 a.m., the Oklahoma State Department of Health confirmed the existence of the immediate jeopardy situation. At 10:20 a.m., the administrator and director of nurses were informed an immediate jeopardy situation existed. On 01/31/12 at 1:30 p.m., an acceptable plan of removal was provided by the administrator. The plan of removal was as followed: "Abuse includes, but is not limited to: verbal, physical abuse, neglect or misappropriation. Allegations of abuse of any type will be reported according to facility policy and regulation. Facility staff will follow the "Freedom from abuse policies" set theirin. (sic) 1. Facility staff will be in-serviced on facility "Freedom from abuse policies" on 01/31/2012 by 11:00 p.m. 2. Facility staff will be in-serviced on facility policy and regulation as it pertains to reporting requirements on 01/31/2012 by 11:00 p.m. 3. Individual of who abuse is alleged, facility policy was followed on 01/31/2012 10:15 a.m., terminating their employment duties. 4. Facility will provide report of investigation and outcome as required by regulation to appropriate department (s) and/or agencies on 01/31/2012 by 5:00 PM. The above actions will be completed by 11:00 PM 1/31/2012. Employees not physically present for in-service education will be educated via phone in-service, employees will not return to duties until receiving the above education. Any staff with alleged abuse will be suspended until investigation is complete. Allegations of abuse will be investigated by interviewing alleged resident if applicable. Any staff they was present at that time will be interview and asked for statements in witting. Any resident that might have been present will also be interviewed and statements taken. Policy and procedure will be amended and all words of relocate will be removed. Any employees that are not reached today will not be allowed back to work until they are inserviced on abuse policy and procedure. The administration will follow the above investigation protocol and report per state and federal regulations. Administrator and Director of Nursing will review and sign incident reports and ensure any appropriate actions against an employee with alleged allegations have been taken. The Abuse Investigation Protocol will be followed as stated in the policy. There are currently 56 employees working for Wadley Care Center they will all be inserviced on abuse policy before being allowed to return to work." On 02/01/12 at 2:00 p.m., the OSDH confirmed the continued existence of the immediate jeopardy situation and expanded it to include resident to resident abuse and the failure to protect residents from such abuse. On 02/01/12 at 3:35 p.m., an addendum was provided for the facility's plan of removal to include resident to resident abuse. The following was the addendum: "All resident to Resident and Resident to staff allegations of abuse will have an incident report completed and facility will investigate. 1. Facility staff will be inserviced today on resident to resident and resident to staff abuse policy and procedure. This includes correctly and accurately filling out incident report and making documentation in resident's clinical record with intervention being put in place. 2. Care plan for (resident #7) will be updated by 5:00 p.m. and staff will be inserviced on interventions put into place. 3. All staff will be inserviced by 11:00 p.m. on the above policies. 4. facility policy will follow and implemented to protect residents having an occurrence of resident to resident abuse." On 02/02/12 at 1:30 p.m., after reviewing all inservice's, care plan updates, and interviews with staff, the administrator was informed the immediacy had been lifted at 8:00 a.m. (02/02/12), after all inservice's had been completed. The deficient practice remained at a scope of actual harm at a pattern, until the facility is able to ensure a system is in place to prevent the deficient practice from reoccurring. Based on observation, record review, and interviews, it was determined the facility failed to have an effective administration who ensured their abuse policy and procedure was followed by suspending employees during an investigation pending the outcome, acting upon the findings of an investigation, protecting resident from abuse, protecting residents from other resident abuse and reporting resident to resident abuse to OSDH. This resulted in an actual harm and an immediate jeopardy. This had the potential to affect 62 of 62 residents. The 'Freedom from Abuse Policies' documented, "Resident abuse and neglect policy: If any person observes or becomes aware of an incident of resident abuse and/or neglect, whether alleged, suspected, or observed, that person must report the incident to the nursing supervisor immediately..." 'Abuse Prevention Program Policy Statement' documented, our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion...Policy interpretation and Implementation...Wadley Care Center is committed to protecting our residents from abuse by anyone including, but not necessarily limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents...Wadley Care Center has developed policies and procedures to aid us in preventing abuse, neglect or mistreatment of [REDACTED]. 'Abuse Investigation Protocol Policy Statement' documented, "Wadley Care Center management promptly and thoroughly investigate all reports of resident abuse...resident to resident and resident to staff abuse. Police (policy) Interpretation and Implementation...the individual conducting the investigation will, as a minimum...interview the person (s) reporting the incident...interview any witnesses to the incident...interview the resident (as medically appropriate)...interview staff members (on all shifts ) who have had contact with the resident during the 48-hour period prior to the time of the incident...employees of this facility who have been accused of resident abuse will be suspended or terminated from duty until the administrator has reviewed the results of the investigation..." 'Investigating Allegations of Resident-to-Resident Abuse' documented, "Policy statement: all incidents of resident-to-resident abuse must be reported to the administrator or his/her designee. Policy interpretation and Implication...should a resident be observed/accused of abusing another resident, implement the following protocol...remove the aggressor from the situation the aggressor is still in the area in which the incident occurred...temporarily separate the resident from other residents as a therapeutic intervention to help reduce the agitation until the interdisciplinary care planning team can develop a plan of care to meet the needs of the resident...develop a care plan that includes interventions to prevent to prevent the reoccurrence of such incidents...inform all staff involved in the care of the resident of the care plan and to promptly report behavioral changes to the charge nurse...document in the resident's clinical record all interventions and their effectiveness...consult psychiatric services for assistance in assessing the resident and developing a care plan for interventions and management as necessary or as may be recommended by the attending physician or interdisciplinary care planning team...complete an incident report and document the incident, findings, and any corrective measures taken in the resident's medical/clinical record...transfer the resident if deemed by the interdisciplinary care planning team and the medical director as being a danger to him/herself or to others for psychiatric evaluation; and report incidents, findings, and corrective measures to appropriate agencies..." 'Protection of Residents During Abuse Investigations' documented, "Policy Statement our facility will protect residents from harm during investigations of abuse allegations. Policy Interpretation and Implementation: During abuse investigations, residents will be protected from harm by the following measures: employees accused of participating in the alleged abuse will be immediately suspended until the findings of the investigation have been reviewed by the administrator...if the alleged abuse involves another resident, the accused resident's representative (sponsors) and attending physician will be informed of the alleged abuse incident and that the accused resident will not be permitted to make visits to other residents rooms unattended...upon completion of the investigation, the resident, the resident's representative, the Oklahoma Health Department...will be provided a written report of the findings of the investigation and a summary of corrective action taken to prevent such incident from reoccuring...should the results of the investigation indicate abuse occurred, the administrator will notify appropriate authorities..." 'Reporting Abuse to State Agencies and Other Entities/Individuals' documented, "Policy Statement: All alleged/suspected violations and all substantiated incidents of abuse will be promptly reported to appropriate state agencies and other entities or individuals as may be required by law...should an alleged suspected violation or substantiated incident of mistreatment, neglect...or abuse (including resident-to-resident and resident to staff abuse incidents) be reported, the facility administrator or his/her designee, will promptly notify the following persons or agencies (verbally or written) of such incident...the state licensing/certification agency responsible for surveying/licensing the facility...notices to the above agencies...shall be made within 24 hours after the occurrence of the incident or when the facility learns of the abuse...The administrator...will provide the appropriate agencies...a written report of the findings of the investigation within 5 days of the occurrence of the incident...appropriate professional and licensing boards will be notified when an employee is found to have committed abuse..." Findings: a.) A review of the investigation of the incident which occurred during the breakfast meal on 01/23/12, between LPN #1 and Resident #1, documented the administrator was made aware of the allegation on the same day the incident occurred. A signed statement dated 01/24/12, from dietary aide #1 documented, "I (dietary aide) witnessed the nurse (LPN #1) abuse (resident #1) during breakfast time. She was rude and hateful to her. The resident was screaming telling her she didn't want to eat. So (LPN #1) shoved her head back and made her eat and drink. To me I think that's abuse no matter how you look at it!! This particular nurse is mean to other residents also. This facility is the residents home and they should be treated with respect. We're here to take care of them to best of our ability. P.S. That's resident abuse!!" A signed statement dated 01/24/12, from dietary aide #2 documented, "I (dietary aide) witnessed what I feel was abuse against a resident (Resident #1). I was asked by a nurse, (LPN #1) to make a tray for her so she can feed. A few minutes later the resident screamed. I saw her spitting up milk and saying no cause she did not want to eat. Then she gently pulled the resident back to her seat. The resident continued to refuse to eat and that when I saw the nurse shove her head back 3 X and told her to swallow and that she needed to eat. I felt she was using much force on someone that age. Around 8:30 (a.m.) my supervisor (CDM) walked in and let her know what happened." A signed statement dated 01/30/12, from CNA #6 documented, "This incident happened at 01/24/12 at 7:40 a.m. I (CNA) is writing this to report that I witnessed (LPN #1) feeding (Resident #1) at the table against the wall under the clock. It would be the middle table against the wall to be exact. As I was serving trays to the feeding table closer to the door. I was waiting on a tray as I heard (Resident) claiming that she didn't want to eat. I looked over towards (Resident) as she took a bite leaned down and proceeded to spit it out onto a plate. (LPN) reached her right hand out over (Resident) forehead and pushed her up and back with force. If it wasn't for (Resident) being in a chair she would have fell backwards." An undated statement by a family member documented, "I was sitting at a table in the dining room and I witnessed (LPN #1) feeding a patient aggressively telling her to swallow her food before she could go to her room. I did not see (LPN) touch the patient physically. She was just being verbally aggressive." All statements were part of the facility's investigation provided by the administrator. Included in the investigation were handouts the administrator identified as training material on [MEDICATION NAME] care for LPN #1 to read on her scheduled days off. A review of the time record for the month of January 2012, for LPN #1, verified the nurse continued working on the following days after the allegation of abuse was reported to the administrator and an investigation had been started: 01/24/12: 6:12 a.m. through 10:56 p.m. for a total of 15 hours and 44 minutes; 01/25/12: 6:18 a.m. through 6:33 p.m. for a total of 12 hours and 15 minutes; 01/28/12: 6:15 a.m. through 3:01 p.m. for a total of 8 hours and 46 minutes; 01/29/12: 6:12 a.m. through 2:47 p.m. for a total of 8 hours and 35 minutes; 01/30/12: 6:08 a.m. through 6:24 p.m. for a total of 12 hours and 16 minutes; and 01/31/12: 6:13 a.m. through 10:28 a.m. for a total of 4 hours and 15 minutes. On 01/31/12 at 7:50 a.m., the breakfast meal service was observed. LPN #1 was observed in the dining room assisting residents with their meals. She was observed assisting residents in the dining room from 7:50 a.m. through 8:45 a.m.. An interview was conducted on 01/31/12 at 8:25 a.m., with CNA #6, regarding the abuse that occurred with resident #1 and LPN #1. She was asked if she had witnessed any abuse between any staff and residents. She stated one day resident #1 had been brought down for her breakfast and she did not want to eat. The resident had spit her food out. She stated, "(LPN #1) then grabbed and pushed her back very forcibly three times." She then stated the resident's head snapped backwards and the resident would have have fallen back to the ground, if she had not been seated in a chair. She was asked what happened to employees who were accused of abuse. She stated, "It varies on what happens. They should be suspended but she (LPN#1) continues to work." She was asked if this was reported to anyone. She stated she and other aides did not report it because the nurse is "close" with the administrator and DON and nothing would happen. She then stated she told another worker about it and they went to the administrator and a statement was taken on 01/30/12, regarding the incident. She was asked when the other employee reported it to the administrator. She stated, "on the same day it occurred, 01/23/12." She was asked when the incident occurred. She stated, "01/23/12, about a week ago." She was asked if anyone other then herself witnessed the incident. She stated dietary aide #1, dietary aide #2, the dietary manager, CNA #2, CNA #3, and CMA #2. An interview was conducted on 01/31/12 at 9:09 a.m., with CMA #2. She was asked to describe the incident that occurred between LPN #1 and resident #1. She stated, "CNA #3 and CNA #6 came to her with an allegation of abuse on 01/23/12." She was asked what they had told her. She stated, "(LPN #1) was forcing the resident to stay and eat when she wanted to go back to her room." She then stated the CNA's told her the nurse pushed on the resident's head very hard so it "thrashed back." She also stated the CNA's did not tell anyone because nothing would happen to the employee. She was asked if she had reported it to anyone. She stated she reported it on the same day in the afternoon. She was asked what happened to the employee. She stated, "No one had done anything about it. You can see she is still working." An interview was conducted on 01/31/12 at 9:30 a.m., with CNA #3 regarding the incident that occurred on 01/23/12. She was asked to identify what she saw. She stated, "(LPN #1) was assisting (Resident #1) in the morning." She then stated, "(Resident #1) didn't want to eat and wanted to go to bed." She was asked if the resident was allowed to return to her room. She stated, "She was continued to be fed even though she didn't want it. She was forced to stay." An interview was conducted on 01/31/12 at 9:30 a.m., with dietary aide #1 regarding the incident between LPN #1 and resident #1 on 01/23/12. She was asked what she witnessed. She stated, "The nurse (LPN #1) was feeding the resident, but the resident didn't want to eat." She then stated, "Staff insisted and forced food into her. The resident spit the food back out." She was asked what happened next. She stated, "(LPN) pushed the resident's head back forcibly. I had never seen staff do that before." She was asked if she reported the incident to anyone. She stated, "My supervisor." She was asked what she thought about the incident. She stated, "I consider it abusive and offensive." She was asked what happened to the employee that was involved in the incident. She stated, "Nothing, she is still here." An interview was conducted on 01/31/12 at 9:45 a.m., with the certified dietary manager (CDM) regarding the incident that occurred on 01/23/12. She was asked what had occurred. She stated, " (LPN #1) asked for the resident's tray. The resident yelled and was observed spitting out her food." She then stated the LPN sat the resident back up and pushed the resident's head back forcefully. The CDM was asked if she reported it to anyone. She stated, "I went to the administrator and reported it on the same day." She then stated her staff had to write out a statement on what was witnessed and the statements were provided to the administrator. She was asked what happened to the employees who had allegations of abuse against them. She stated, "Sometimes on a leave of absence or suspended." The CDM was asked to identify the employees who reported the abuse to her. She stated she had talked with dietary aide #1 and dietary aide #2, who both provided the same story at different times. She stated that was how she knew she had to report it. An interview was conducted on 01/31/12 at 10:05 a.m., with the administrator regarding the incident which had occurred with the resident. She was asked when the investigation was started following the incident which had occurred during the breakfast meal on 01/23/12. She stated, "01/24/12." She was asked what the facility policy was for protecting residents during an investigation. She stated, "I don't know verbatim, but I think relocate the employee away from the resident abused or not have any unwitnessed contact with the resident." She was asked how she protected the residents from the employee who had an allegation of abuse filled against her. She stated, "I screwed up. I didn't protect all the residents." She was asked if LPN#1 had been suspended, as their policy required, after the allegation was made against her. She stated, "She only had her regular two days off Thursday and Friday. She was not suspended." She then added she gave the employee articles to read on her day off related to [MEDICATION NAME] care. An interview was conducted on 02/01/12 at 10:00 a.m., with the DON. She was asked what the job title was for LPN #1. She stated, "Charge Nurse." She was asked what the responsibilities were for the charge nurse. She stated, "She is responsible for the hall and the residents." She was asked how many residents the charge nurse was responsible for while assisting in the dining room. She stated, "She was responsible for all the residents in the dining room and those who are eating." She was asked how many residents LPN #1 had contact with during meal times. She stated, "She had contact with all residents by walking around and supervising." An interview was conducted on 02/01/12 at 11:50 a.m., with resident #9, regarding the way residents were treated by LPN #1. He was asked to describe the nurses interaction with other residents. He stated, "Oh my gosh, she was a terror, always yelling at the girls and the little old ladies." An interview was conducted on 02/01/12 at 12:15 p.m., with resident #8, regarding the way residents were treated by LPN #1. She was asked to describe the nurses interaction with other residents. She stated, "She was quite the mean one." The fax transmittal sheets to the Oklahoma State Department of Health (OSDH) attached with the investigation, documented the facility failed to notify the nursing board of the incident until 01/25/12 at 5:22 p.m. and failed to notify OSDH until 01/25/12 at 5:09 p.m. b.) Resident # 3 was admitted with [DIAGNOSES REDACTED]. A nurse's note dated 06/24/11 at 3:15 p.m., documented, "Resident (#3) wandered into another female residents room (Resident #7). Per other resident was asked to leave but instead of leaving hit other resident in the face; which agitated other female and she began attempting to kick (Resident #3). Residents separated. This resident noted to have multiple dark bruises to bilateral arms. Resident c/o bruises on R arm in particular being sore. Padded dressing of 4 x 4' s', gauze roll and tape applied to prevent bumping, et provided comfort......" A quarterly assessment dated 07/14/12, documented the resident was severely impaired in cognitive skills in daily decision making, was hard of hearing, had tendency to hit and fight, scream, and curse at others. It also documented the resident ambulated freely. A nurse's note dated 08/04/11 at 7:20 p.m., documented, "Resident has been amb all over building looking for the door out she's going back to Arkansas, looking for her kids yelling at other res inquiring where the door is. Went into another residents rm (Resident #7) & poured her bowl of potpouri (sic) on the floor. Other resident was yelling & cussing @ her & she was yelling & cussing at other resident when trying to calm her down....." A nurse's note dated 08/08/11 at 10:25 a.m., documented, "Staff heard loud yelling screaming. Charge nurse got there in time to lower resident to the floor /p (after) another resident (Resident #7) pushed her backward (Resident #3) was in another residents doorway & other res claimed hit her on the forehead with remote control, denied pushing her. (Resident #3) noted to have 5 cm x 4 cm hemorrhage area with 3.9 x 3.0 cm skin tear (c-shaped) on L forearm. R wrist /c 5.2 x 3.8 hemorrhagic area. L forearm /c 4.0 cm x 3.1 cm hemorrhagic area /c C-shaped skin tear 2.8 cm x 2.5 cm....skin tears cleaned /c NS steri strips applied covered /c [MEDICATION NAME]/roll gauze & tape....." A nurse's note dated 10/04/11 at 6:00 p.m., documented, "Res entered another res room (Resident #7). The other resident attempted to forceably (sic) remove her & grabbed her (left) hand causing a ST approx 0.25 cm in length to back of (left) hand. Cleansed area /c NS & applied TAO & covered /c band-aid 0 swelling, bruising or bleeding noted to area..." The resident's care plan dated 10/12/11, documented "Problem: cognitive loss r/t [MEDICAL CONDITION] AEB short and long term memory loss. Moderately impaired decision making. Approaches: reorient (Resident) as needed, speak to (Resident) at eye level in a moderate tone of voice, redirect (Resident) as necessary PRN." The care plan did not address the resident's wandering or the resident to resident altercations. A nurse's note dated 11/26/11 at 9:00 a.m., documented, "Was called to ramp by CNA, she - resident- noted 9 x 6 cm area to R forearm /c skin missing. Was told by staff & another residents family member that (Resident) and another resident (Resident #7)were arguing at other residents door Other resident reached out & grabbed skin on R forearm causing the injury. Staff tried to get to her & even told other resident she was coming to get her (Resident #3), but she grabbed her anyway......." A review of the facility's incident report book did not contain a corresponding incident report for the nurses' notes dated 06/24/11, 08/04/11, 08/08/11 or 11/26/11. The care plan did not address interventions for the residents wandering to keep her out of other residents rooms and/or protecting her from other residents' abuse. Resident #7 was admitted with [DIAGNOSES REDACTED]. An annual assessment dated [DATE], documented the resident's cognition was intact. The resident's care plan last updated on 05/07/11, documented, "Problem: Cognition-Decision Making Inadequate Cognitive loss with Behaviors and some impaired decision making r/t closed head injury. Goal: (Resident) will maintain her current level of cognition with fewer behaviors by 05/07/2012. Approach...Encourage (Resident) and give praise for positive behaviors CONT...Administer (Resident's) medication(s) per physician(s) order(s) BID Every day (8:00 AM, 8:00 PM)...Allow (Resident) to vocalize feelings when needed PRN (as needed)... Ensure that decisions made for (Resident) are appropriate PRN (as needed)...Allow (Resident) to make own decisions and choices that do not put her or other residents at risk for harm CONT(continuos)." A nurse's note dated 06/24/11 at 3:15 p.m., documented, "Res involved in an altercation /c another female res. when other resident entered this res. room. This res reports nicely asking other res to leave but other res hit this res in the face. This agitated this res and she began attempting to kick other res. Residents separated and education/therapeutic communication provided /c this res. Does have slight reddened area to left cheek. Ice provided to place on cheek." The incident report in regard to this incident verified the other resident involved was Resident #3. Another entry under the notes section documented, "(Resident) was told to go to her room or separate herself from the person who had made her angry. She stated she just got 'very mad' but would try going away from the person she was angry at." A nurse's note dated 08/04/11 at 7:20 p.m., documented, "Another resident (Resident #3) came into her rm. & poured her bowl of potpouri (sic) on the floor Res yelling & cussing at the top of the ramp screaming and cussing @ the other res finally got her quieted and back in her own rm. Stated she wasn't going to apologize & that she would like to kick the other residents 'ass' but did agree that would be inappropriate & would cause her to be in trouble. Calmed quickly /c no further incident." A nurse's note dated 08/08/11, documented, "10:25 staff heard loud yelling screaming Another res was @ res's doorway Charge nurse got there just in time to lower other res to floor after res pushed her backward. Resident very loud screaming & cussing Stated other resident hit her on the left side of forehead, twice. (No) inj noted Neuro vs wnl. Mother made aware, Dr. notified." The incident report for this incident indicated the other resident involved was Resident #3 and she had sustained no injury during the altercation. A nurse's note dated 10/04/11 at 6:00 p.m., documented, "Res was in her own room when a fell ow res. entered her room & res became upset & attempted to forceably (sic) remove from her doorway. (No) inj noted to this res. Notified family (mom) and phys..." The incident report for this incident indicated the other resident involved was Resident #3 and she had received a skin tear. An untimed nurse's note dated 10/05/11, documented, "Res was out in hall started yelling cussing @ another resident Easily redirected." The other resident was not identified in the nurse's note. No incident report was available for this incident. A nurse's note on 11/28/11, documented, "9:45: res went to rm across the hall & told (another) res to turn down her TV. Other res told her (Resident #7) her TV was down. (Resident) told her to close her door if she didn't turn TV down. When other resident refused (Resident #7) went out & closed the door. Other res is [MEDICAL CONDITION] & likes her door open but /p (Resident) got back into her own rm she kept yelling '[***] ' at other res several x's...." There was no documentation to indicate who the second resident was. A quarterly assessment dated [DATE], documented the resident had no cognitive problems. The assessment further documented the resident hit, scratched, screamed, cursed, pushed and grabbed at other residents. An interview was conducted on 02/01/12 at 2:40 p.m., with the DON regarding the resident's care plan and assessment. Current care plan problems and approaches were read aloud to the DON. She was asked if she knew of any problems or approaches addressing the resident's outburst of temper, pushing and/or kicking of other residents. She replied, "If its not there, no." An interview was conducted on 02/01/12 at 11:15 a.m., with RN #2 regarding incident reports. She was asked about the missing incident reports. The RN asked two other people, including the administrator, about places to look for incident reports. She stated she was told there were no other places to store incident reports other than the incident report book. An interview was conducted with CMA # 2 on 02/02/12 at 9:45 a.m. She was asked if she had witnessed any resident to resident altercations. She stated, "(Resident #7) and (Resident #3) fight all the time. (Resident #7) doesn't like (Resident #3)." An interview was conducted with CMA #1 on 02/02/12 at 9:48 a.m. She was asked if she had witnessed any resident to resident altercations. She stated, "(Resident #7) and (Resident #3) don't get along. (Resident #7) is mean to her." There were no documented interventions on the incident reports or in the residents' care plans to address prevention of future altercations between the residents. A request was made for the missing incident reports and documentation to verify the facility notified OSDH of the resident to resident altercations. No further documentation was provided. A review of the facility reported allegations of abuse at OSDH indicated no resident to resident altercations had been reported with resident #7 as the alleged perpetrator since 06/04/11.

Based on record review and staff interview, it was determined the facility failed to assess, monitor and intervene, for constipation and/or fecal impaction for one (#3) of six sampled residents who had a [DIAGNOSES REDACTED]. Findings: The facility policy for "Bowel and Bladder Retraining Program" documented, "...To develop regular bowel habits and prevent fecal... incontinence, impaction and irregularity." Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. A facility form for "Evaluation For Bowel and Bladder Training" dated 05/24/10, documented the resident was continent of bowel and bladder and was able to take self to BR. A physician's orders [REDACTED]. DX: Constipation." A physician's orders [REDACTED]. DX: Constipation." A quarterly assessment dated [DATE], documented the resident was independent with ambulation and transfers, required supervision with toileting, was occasionally incontinent of bowel and frequently incontinent of bladder. The resident's care plan dated 03/06/12, documented: "Problem: (Resident) said she was having a baby then had a lg BM. Goal: Will have BM q 3 days during next 90 days. Approach: ... Encourage fluids. Laxative as ordered. Report no BM p 3 days to charge nurse. Observe for signs of constipation: decreased appetite, distended abdomen, decreased bowel sounds... " Review of the ADL Flowsheets revealed the following: January 2012: No documented BM either continent or incontinent, from 01/19/12 through 01/24/12. The resident was not administered the order for [MEDICATION NAME] or the soap suds enema during the six day period of no BM. The only documented time the resident received the [MEDICATION NAME] was on 01/05/12, when the resident c/o constipation. February 2012: No documented BM either continent or incontinent, from 02/01/12 through 02/04/12, 02/06/12 through 02/10/12, from 02/18/12 through 02/21/12 and 02/26/12 through 02/28/12. The resident was administered the [MEDICATION NAME] one time on 02/11/12, when the resident c/o constipation. The soap suds enema was never administered. March 2012: No documented BM either continent or incontinent, from 03/01/12 through 03/04/12, from 03/10/12 through 03/16/12 and from 03/22/12 through 03/25/12. The resident was administered [MEDICATION NAME] on 03/04/12, 03/05/12, 03/10/12, 03/23/12 and 03/29/12, when the resident c/o constipation. The soap suds enema was never administered. April 2012: No documented BM either continent or incontinent, from 04/04/12 through 04/07/12. The resident was not administered the [MEDICATION NAME] during the four days of no BM. The soap suds enema was never administered. Review of the nurses' notes for the resident documented the following: 11/10/11 at 9:30 p.m., "Up on commode trying to move bowels unable to push BM out very anxious agitated tried manipulating around stool but res screaming trying to jump up very uncooperative n/o rec'd for soap suds enema administered approx 500 cc fluid in rectum res not holding well up to bedside commode only passed 1 sm piece of stool back to bed other 1/2 enema given not held at all did pass a couple more pieces of stool." 11/11/11 at 11:00 a.m., "Resident amb with therapy to shower room on ramp when she need to use restroom, c/o constipation, had large firm stool. Moans and groans the entire time, would not walk very well with staff. 11/11/11 at 11:45 a.m., "c/o not being able to walk. keeps leaning backwards. Staff walked her to D/R with 3 staff members where she refused to eat." 12/10/11 at 10:00 a.m., "...Communicated recent hospital (stay) R/T constipation/res. Advised resident to continue with prune juice PRN to preclude future episode..." 12/11/11 at 8:45 a.m., "...Resident stated she has been drinking prune juice to preclude constipation but would like something stronger. CMA advised to give meds/orders..." 01/27/12 (no documented time), "...c/o constipation request prune juice 120 cc given." 01/29/12 at 10:00 a.m., "...Stated prune juice (highly) effective this am and she feels very well..." 02/11/12 at 11:15 a.m., "Res requested prune juice to preclude constipation-(N/A) gave [MEDICATION NAME] with extra cup of H2O/order. Informed res she needed to ask for this med as it was prn. Res voiced understanding." 03/08/12 at 7:54 a.m., a fax request was sent to the resident's physician. The request documented, "Resident having lots of problems with constipation. [MEDICATION NAME] is ordered PRN and resident doesn't seem to be able to request before she has problems. Daughter wants her to have daily and mix with coffee. Can she have daily?" The physician responded back, "This has to be PRN No daily or it can be taken with coffee if she wants that." 03/08/12 at 1:00 p.m., "...Had large loose stool @ noon d/t med given last pm for constipation. Resident has been yelling, screaming, frantic today due to not be (ing) able to have BM. After initial stool resident calmed down. 03/10/12 at 8:30 p.m., "Res called family member (Name withheld) from nurse's station phone and was telling him over and over that she was constipated and no one here would do anything about it. She stated "no one here cares and I'm going to be in real trouble if my bowels don't move today." After she hung up I assisted her back to bed and tried to tell her she had a large BM Thurs..." 04/14/12 at 9:30 a.m., "Res ambulates with no walker ad lib thru facility. C/O "stomach pain" believes shes constipated. Prune juice given and [MEDICATION NAME]/orders/CMA. Resident states "stomach feels better..." 04/15/12 at 3:45 a.m., "Res sent out to ER D/T c/o ABD pain, chest pain, increased confusion... c/o ABD pain. Asked her when last BM was stated earlier today. ABD soft and non tender to touch... " On 04/15/12 a CT scan of the thorax abdomen pelvis wo contrast was obtained at the (Name withheld) hospital. The results of the scan indicated, "...Descending and sigmoid colon [DIAGNOSES REDACTED]. Moderate to prominent stool noted within the cecum, ascending and [MEDICATION NAME] colons." Another CT scan of the abdomen and pelvis was obtained at (Name withheld) hospital. The results indicated, "...Large amount of solid stool distends the cecum to 7.7 cm x 10 cm in [MEDICATION NAME] and AP dimensions. Moderate-small amount of gas and stool the remainder of the colon to the rectum." On 04/26/12 at 2:35 p.m., an interview was conducted with the DON regarding the resident's problem with constipation. The Don was asked if the resident should have been monitored better for when she had a BM, the consistency, etc. and if the facility staff should have asked the resident daily if she was having constipation problems and if she needed the [MEDICATION NAME]. She stated, "Yes." When shown the BM documentation on the monthly ADL sheets and the CT scans, she stated the documentation was consistent with the tests for impaction. On 04/27/12 at 11:20 a.m., the DON, QA nurse and RN #1 were interviewed regarding the resident's fecal impaction. The DON was asked if there was documentation to show the resident's BMs were being monitored and interventions implemented to prevent the impaction. She stated staff documented whether the resident had a BM in the toilet or was incontinent of BM. She stated the documentation was inconsistent if the resident had a BM in the toilet. She stated she didn't think the resident was administered the [MEDICATION NAME] as frequently as needed. She stated the nurses should have administered the PRN [MEDICATION NAME] more frequently when the resident went more than 3 days without a BM, especially due to the resident being on meds that could constipate her.

Based on record review and interviews, it was determined the facility failed to: a. provide dental care for a resident with a known dental problem in a timely manner for one (#15) of seven sampled residents whose records were reviewed. b. evaluate and treat a resident for persistent complaint of increased pain, observed swelling and elevated temperature for one (#15) of seven sampled residents whose records were reviewed. The director of nurses identified 46 residents who had a change in condition and required nursing intervention and assessments. This deficient practice resulted in an actual harm to the resident. Findings: A facility policy documented, "An individualized pain assessment shall be conducted for each resident at lease once every 30 days and more frequently if warranted by the resident's condition, including but not limited to...at admission...with onset of complaint of pain...any time pain is suspected...with any change in condition...the goal is to alleviate or minimize pain while assisting the resident to maintain as high a level of functioning as possible..." Resident #15 was admitted to the facility with [DIAGNOSES REDACTED]. A treatment note from a local dental facility dated 09/09/11, documented the following: "c/o generalized pain in [MEDICATION NAME], poss ANUG, heavy plaque and debris. Discussed NR teeth....Pt needs SC/RP to clear [MEDICATION NAME]. Will call in RX later today for ANUG, After AB regimen can proceed w/ext's/deep cleaning." The care plan dated 09/10/11, documented, "Cipro 500 mg, 1 BID x 7 days; dx URI." A quarterly assessment dated [DATE], documented the resident was moderately impaired in cognition, able to make her needs known, had a problem with her dental health and was on a scheduled pain medication program. The care plan had not been updated to include the resident's dental problems documented on the quarterly assessment dated [DATE]. An additional dental treatment note dated 12/13/11, documented, "severe ging, plaque mod, pt states some of her broken teeth are hurting..." An untimed nurse's note, dated 01/12/12, documented, "requested meal in room due to tooth pain..." The note was signed by LPN #3. A second entry, dated 01/12/12, documented, "pt also c/o toothache pain." The note was signed by LPN #6. A nurse's note, dated 01/13/12, documented, "ABT for toothache cont." A second entry documented, "L jaw neck area remains swollen and tender..." The note was signed by LPN #6. A nurse's note, dated 01/14/12 at 3:00 A.M., documented, "ABT for toothache...Ice pack in place neck swollen. No adverse reactions." The note was signed by LPN #3. A nurse's note dated 01/14/12 at 10:40 a.m., documented the following entry. "Called to res's room, by CN (name withheld). Res presented c s/s of [MEDICAL CONDITION] activity just prior to this nurse entering room. Per CMA recount- res experienced ~ 4 min of this activity. Res. has change in voice swollen neck w {increased} redness across neck and chin-cheeks flushed as well. Res stated 'it hurts'. Res is currently on ABT [MEDICATION NAME] for dental issue - has appt scheduled w dentist Mon in am.... Ambulance arrived to transport res to ER." The care plan last updated 01/14/12, documented: "send to (local hospital emergency room ) to eval and tx swelling in jaw area-[MEDICAL CONDITION] activity." The care plan did not contain specific goals, approach's or interventions planned to address the areas of pain and dental health as documented in the nurses' notes and the dental consult between 12/13/11 and 01/14/12. The resident was transferred to the hospital on [DATE]. A transfer form from the facility to Hospital #1, dated 01/14/12 at 11:15 a.m., documented: "Reason for transfer, increased [MEDICAL CONDITION] to throat area, change in vocalization, abscess tooth." An emergency room report from Hospital #1 at 11:19 a.m., documented, "Being treated for [REDACTED]. A CBC laboratory test completed at 11:58 a.m., documented the residents WBC to be 25.7 K/uL. Normal WBC values are 4.0 - 10.0 K/uL. (per hospital #1). A transfer form from Hospital #1 to Hospital #2 at 3:30 p.m., documented, "The individual has been stabilized...will be transferred by ambulance due to worsening symptoms for an increased level of care." An emergency room consult from Hospital #2 at 4:30 p.m., documented, "She is being treated for [REDACTED].I think this probably is some sort of an infection; at the very least, a [MEDICAL CONDITION] with an early abscess, ...says that if this started with the tooth, which I think that it did...The blood work does indicate infection. Diagnosis: [REDACTED]." A second physician's consult from Hospital #2, dated 01/15/12, documented, "She has multiple carious teeth in her mandible and appears that #19, which is the left mandibular first molar is grossly carious and then #'s 29 and 30 in the right mandible are grossly carious, #29 and 30 are the teeth that are painful to the patient." A third physician's consult from Hospital #2, dated 1/16/12, documented, "She has not had any history of sialoadenitis ( inflammation of a salivary gland) or issues with her submandibular gland, but she has had multiple issues with her teeth." On 02/02/12 at 9:55 a.m., LPN #4 was asked what had been done for the resident regarding her complaints of mouth pain. LPN #4 stated, "I assessed her and found her to have two abnormal appearing teeth on the (residents) right side of the mouth on her lower jaw. She had a tooth with a hole in it mid way back on her gum and another molar which was broken in half. She also had what appeared to be pus pockets in three different areas inside her mouth along the inner gum line." She was asked if any pain assessment were completed. She stated, "No, pain assessments are only done once a month." She was asked what was done for her additional complaints of pain. She stated the resident received pain medication every six hours. On 02/02/12 at 9:58 a.m., CNA #3 was asked if she knew of any complaints the resident had before being discharged to the hospital. She stated on 01/11/12, the resident wasn't feeling good and had complained that her teeth hurt. The CNA was asked who she had told about the residents complaints. She stated, "LPN #1 and #2." On 02/02/12 at 10:30 a.m., LPN #2 was interviewed regarding CNA #3's statement. She was asked what measures were taken to alleviate the residents pain after it was reported. She stated, "(LPN #1) assessed the resident immediately and reported she had not found any swelling or redness in the neck area, but that she was medicated for pain." The surveyor then asked LPN #2 if the resident was given additional pain medication for her increased complaints of pain. She stated she was not. The MAR, dated [DATE], documented, "[MEDICATION NAME] 5/500 mg PO 6 X A Day. dx: Pain." The medication was documented as given daily at 6:00 a.m., 10:00 a.m., 2:00 p.m., 6:00 p.m., 10:00 p.m. and 2:00 a.m. The medical record did not contain any additional orders for PRN pain medication to address the residents increased complaints of pain. When asked if the physician was ever made aware of the resident's increased pain and other complaints. She stated he was not. The surveyor asked LPN #2 if she felt the physician should have been notified of the increased pain, swallowing and redness. She stated, "No because the resident was already receiving scheduled pain medication, an antibiotic and was scheduled to see a dentist." On 02/02/12 at 11:30 a.m., the DON was asked what additional measures were taken to assist the resident with the increased complaints of pain and symptoms. She stated, "Since the resident was already scheduled to see a dentist on the following Monday, I thought that was enough."

Based on record review and interview, it was determined the facility to notify a physician of a resident's change in condition for one (#15) of one sampled residents whose records were reviewed. This resulted in an actual harm. The DON identified an additional 45 residents who experienced a change in condition during the month on January 2012. Findings: Resident #15 was admitted to the facility with [DIAGNOSES REDACTED]. A facility "Face Sheet" printed on 08/25/11, and 11/10/11, documented the resident had an allergy to [MEDICATION NAME]. A quarterly assessment dated [DATE], documented the resident was moderately impaired in cognition, but was able to make her needs known. An unsigned physician's telephone order dated 01/11/12, documented, " [MEDICATION NAME] 500 mg TID x 7 days." An untimed nurse's note dated 01/11/12, documented, "Recd order for [MEDICATION NAME] 500 mg, TID x 7 days initial dose began this P.M. dx toothache." The note was signed by LPN #3. An untimed nurse's note dated 01/12/12, documented, "requested meal in room due to tooth pain, ABT cont as ordered T 100.3, 152/92 (blood pressure), 98 ( pulse)." The note was signed by LPN #3. A second entry dated 01/12/12, documented," (8:40) temp @ this x 101.3 ...pt also c/o pain, toothache." The note was signed by LPN #6. A nurse's note dated 01/13/12, documented, "ABT for toothache cont." A second entry documented, " L jaw neck area remains swollen and tender T 101... ." The note was signed by LPN #6. A nurse's note dated 01/14/12 at 3:00 A.M., documented, "ABT for toothache...Ice pack in place neck swollen. No adverse reactions.. .....medicated for Temp and pain." The note was signed by LPN #3. There was no documentation to show the facility notified the physician of the resident's increased pain, swelling and elevated temperature. The January 2012 MAR, documented [MEDICATION NAME] was administered a total of eight times, with the last dose being administered at 8:00 a.m. on 01/14/11. A nurse's note dated 01/14/12 at 10:40 a.m., documented the following entry. "Called to res's room, by CN (name withheld). Res presented c s/s of [MEDICAL CONDITION] activity just prior to this nurse entering room. Per CMA recount- res experienced ~ 4 min of this activity. Res. has change in voice swollen neck w {increased} redness across neck and chin-cheeks flushed as well. Res stated 'it hurts.... Ambulance arrived to transport res to ER." A transfer form dated 01/14/12 at 11:15 a.m., documented: " Reason for transfer, increased [MEDICAL CONDITION] to throat area, change in vocalization, [MEDICAL CONDITION] activity x 4 mins." On 02/02/12 at 9:55 a.m., LPN #4 was asked about the resident in regard to her complaint of mouth pain. LPN #4 stated, "I assessed her and found her to have two abnormal appearing teeth on the (residents) right side of the mouth on her lower jaw. She had a tooth with a hole in it mid way back on her gum and another molar which was broken in half. She also had what appeared to be pus pockets in three different areas inside her mouth along the inner gum line." On 02/02/12 at 9:58 a.m., CNA #3 was asked if she knew of any complaints the resident made before being discharged to the hospital. She stated on 01/11/12, the resident wasn't feeling good and she had heard her complain that her teeth hurt. The CNA was asked who she had told about the residents complaints. She stated, "(LPN #1) and (#2). On 02/02/12 at 10:30 a.m. LPN #2 was interviewed regarding CNA #3's statement. She was asked what measures were taken to alleviate the residents pain after it was reported. She stated, "LPN #1 assessed the resident immediately, and reported she had not found any swelling or redness in the neck area, but that she was medicated for pain." When asked if the physician was ever notified of the resident's persistent fevers, swelling of the jaw, increased pain and the receiving of an antibiotic she was allergic to, she stated, " No. She was already on an antibiotic and pain medication. We thought she was covered."