Every finding on record at Radiant Nursing and Rehab at Palatka

Based on observation, record review, and interview the facility failed to ensure a physician's order was obtained to administer oxygen therapy per standard of practice for 1 of 3 residents, Resident #12, reviewed for respiratory care. Findings include: Review of Resident #12's clinical record documented an admission date of 5/3/2026 with diagnosis including but not limited to chronic obstructive pulmonary disease (block airflow in the lungs), heart failure (failure of heart to pump blood), and dependence on supplemental oxygen, During an observation on 6/15/2026 at 11:49 AM Resident #12 was lying in bed with oxygen being administered at 4 liter/minute via nasal cannula.During an interview on 6/15/2026 at 11:49 AM Resident #12 stated, I don't know the rate. I think it [oxygen] should be at 2 [liter/minute]. Review of the physician orders for Resident #12 documents no orders for oxygen. Review of the MDS (Minimum data set) dated 5/8/2026 section O- C1. A. On admission Oxygen therapy, Yes and B while a resident, yes. Review of Resident #12's care plan read, The resident has oxygen therapy related to ineffective gas exchange. Give medications as ordered by physician.During an interview on 6/16/2026 at 1:58 PM the Director of Nursing (DON) stated, She [Resident #12] is on oxygen. I don't know why there is no order. During the interview the DON reviewed Resident #12's physician orders and verified there is no order for oxygen in the record. The DON stated, The physician orders have to be written and followed. Review of the policy and procedure titled Documentation of Medication Administration with a last review date of 1/6/2026 read, Policy Statement: A medication administration record is used to document all medications administered. Policy Interpretation and Implementation: 1. A nurse or certified medication aide (where applicable) documents all medications administered to each resident on the resident's medication administration record (MAR). 3. Documentation of medication administration includes, as a minimum: h. resident response to the medication, if applicable (e.g., PRN, pain medication, etc.)Review of the policy and procedure titled Oxygen Administration and Documentation Policy and Procedure with a last review date of 1/6/2026 read, Purpose: To establish guidelines for the safe administration, monitoring, and documentation of oxygen therapy in accordance with physician orders, accepted standards of nursing practice, federal and state regulations, and resident-centered care principals. Policy: Oxygen shall be administered only upon the order of a licensed practitioner authorized to prescribe treatment. Oxygen therapy shall be administered, monitored, and documented by licensed nursing personnel in accordance with physician orders, facility policy, manufacturer recommendations, and applicable federal and state regulations. Oxygen is considered a medication and shall be treated with the same standards of accuracy, accountability, and documentation as all prescribed medications and treatments. Responsible Staff: The following personnel are responsible for implementation of this policy: Registered Nurse (RN); Licensed Practical Nurse (LPN); Respiratory Therapist (if applicable); Certified Nursing Assistant (CNA) for observation and reporting only.

Based on observation, interview, and record review, the facility failed to document oxygen administration on the medication administration record per policy and procedure for 2 of 3 residents, Resident #6 and #33, reviewed for respiratory care.Findings include: 1) During an observation on 6/15/2026 at approximately 11:00 AM Resident #6 was lying in bed. She was wearing a nasal canula that was attached to an oxygen concentrator administering oxygen at 2 liters per min (2L/Min). During an observation on 6/16/2026 at 12:00 PM Resident #6 was sitting up on the side of her bed. The nurse was at her bedside observing Resident #6 taking medications. Resident #6 was wearing a nasal canula attached to an oxygen concentrator administering oxygen at 2L/Min. During an interview on 6/16/2026 at 12:00 PM Resident #6 stated that she had a history of COPD (Chronic Obstructive Pulmonary Disease). She needed oxygen; it has been a life saver. Review of Resident #6's Census Data documented the resident was admitted on [DATE] with medical diagnoses to include chronic obstructive pulmonary disease, unspecified; heart failure, unspecified. Review of the physician's order for Resident #6 read, O2 (oxygen) via nasal prongs @ (at) 2 L PRN (2 liters per minute as needed) – May remove adlib (as much as one desires). During an interview on 6/16/2026 at 4:00 PM the ADM (Administrator) and ADON (Assistant Director of Nursing) stated since oxygen was ordered similarly to a medication, they would refer to the medication administration policy for guidance. During an interview on 6/17/2026 at 9:45 AM Resident #6 stated She puts on and takes off the oxygen herself. The nurse checks the rate once a week when they change the tubing. During an interview on 6/17/2026 at 9:50 AM Staff A, RN (Registered Nurse) stated that for a resident with a PRN (as needed) oxygen order the expectation was to document when the resident was wearing oxygen, what their oxygen saturation level was, and why they were wearing the oxygen (what symptoms they are having). Resident #6 should have her oxygen documented on her MAR. During an interview on 6/17/2026 at 10:30 AM the ADON stated that residents were to have their vital signs checked and documented every shift; their oxygen saturation level required the nurse to document whether the resident was receiving oxygen. If a resident was wearing oxygen the nurse was expected to check their O2 sat (oxygen saturation level), check the rate of administration (of the oxygen) and confirm that it is the correct rate, and document it on the resident's MAR. Review of Resident #6's Vital Sign form for the period of 4/01/2026 through 6/16/2026 documented multiple instances of oxygen saturation levels. Review of Resident #6's MAR/TAR (Medication Administration Record/Treatment Administration Record for the period of 4/01/2026 through 6/16/2026 did not provide documentation of the administration of oxygen. 2) During an observation on 06/15/2026 at 10:25 PM, an oxygen concentrator with nasal cannula tubing attached was observed in Resident #33's room. At the time of the observation, Resident #33 was not being administered oxygen. During an interview on 06/18/2026 at 9:42 AM, Staff B stated, He wears oxygen at night mostly. During an interview on 06/18/2026 at 9:44 AM, Resident #33 stated, I wear oxygen at night to help me breathe. Review of Resident #33's physician orders dated 01/07/2026 revealed an order for Oxygen at 2 liters per minute via nasal cannula PRN, may remove ad lib for ADLs [activities of daily living]. Review of Resident #33's oxygen saturation documentation dated 06/13/2026 at 11:21 AM documented an oxygen saturation of 97% with documentation indicating oxygen was being administered via nasal cannula. Review of Resident #33's oxygen saturation documentation dated 06/16/2026 at 3:33 AM revealed an oxygen saturation of 95% with documentation indicating oxygen was being administered via nasal cannula. Review of Resident #33's June 2026 Medication Administration Record (MAR) revealed no documentation of oxygen administration despite documentation elsewhere in the clinical record indicating oxygen was administered. Review of the policy and procedure titled Documentation of Medication Administration with a last review date of 1/6/2026 read, Policy Statement: A medication administration record is used to document all medications administered. Policy Interpretation and Implementation: 1. A nurse or certified medication aide (where applicable) documents all medications administered to each resident on the resident's medication administration record (MAR). 3. Documentation of medication administration includes, as a minimum: h. resident response to the medication, if applicable (e.g., PRN, pain medication, etc.) Review of the policy and procedure titled Oxygen Administration and Documentation Policy and Procedure with a last review date of 1/6/2026 read, Purpose: To establish guidelines for the safe administration, monitoring, and documentation of oxygen therapy in accordance with physician orders, accepted standards of nursing practice, federal and state regulations, and resident-centered care principals. Policy: Oxygen shall be administered only upon the order of a licensed practitioner authorized to prescribe treatment. Oxygen therapy shall be administered, monitored, and documented by licensed nursing personnel in accordance with physician orders, facility policy, manufacturer recommendations, and applicable federal and state regulations. Oxygen is considered a medication and shall be treated with the same standards of accuracy, accountability, and documentation as all prescribed medications and treatments. Responsible Staff: The following personnel are responsible for implementation of this policy: Registered Nurse (RN); Licensed Practical Nurse (LPN); Respiratory Therapist (if applicable); Certified Nursing Assistant (CNA) for observation and reporting only.

Based on interview and record review the facility failed to implement corrective actions to preserve 1 resident's, Resident #1, of 3 residents reviewed, dignity following an incident during which the resident expressed dissatisfaction following an interaction with a facility staff member. Findings include: Review of investigative files revealed a federal report that read Resident [Resident #1] reported to UM [Unit Manager] while visibly upset that she had a horrible night and that she was told by CNA [Certified Nursing Assistant] to void in her brief. Review of the facility document titled 1:1 Counseling/Education, dated 4/16/2026, revealed Staff A, Certified Nursing Assistant, had been identified as the aide that had upset Resident #1 and documented a Corrective/Monitoring Plan that included CNA [Certified Nursing Assistant] will be placed on heightened observation for 60 days Supervisory rounds will be conducted routinely Random observation audits will be implemented to monitor compliance Continued adherence to policies will be evaluated throughout the monitoring period Review of facility investigative files and Staff A's personnel records failed to reveal documentation the facility had implemented the corrective/monitoring plan. During an interview on 5/20/2026 at 11:58 AM, the Director of Nursing stated she periodically checked in with Staff A to see if she has any issues. The Director of Nursing reported she did not have documentation of random audits or monthly supervisor rounds as specified in Staff A's corrective/monitoring plan.

Based on record review and interview, the facility failed to ensure accuracy of Minimum Data Set (MDS) assessments for 1 (Resident #55) of 4 residents reviewed for discharge assessments. Findings include: Review of Resident #55's admission record documented that Resident #55 was admitted to the facility on [DATE] with diagnoses including: altered mental status, chronic obstructive pulmonary disease (COPD), seizures, cerebral infarction, transient cerebral ischemic attack, anxiety disorder, dysphagia and osteoarthritis. Review of Resident #55's Minimum Data Set (MDS) titled Discharge Return Not Anticipated dated 11/20/2024 showed the resident was discharged to acute hospital on 11/20/2024. Review of Resident #55's social services notes dated 11/14/2024 at 9:31 AM read, Met with resident and resident stated [Resident #55's Niece's name] came up here and talked to her about transferring and the resident stated she wanted to transfer where she [Social Services Director's name] was working. Referral process initiated. Review of Resident #55's social services note dated 11/15/2024 read, Received a call from [Facility name] who stated they approved the referral and will pick up the resident on 11/20/2024 at 10:00 AM. Review of Resident #55's Admission & Discharge Summary dated 11/20/2024 read, Resident [Resident #55's name] transferred to SNF [skilled nursing facility]. During an interview on 2/4/2025 at 1:50 PM, the MDS Coordinator confirmed Resident #55 was discharged to another skilled nursing facility and the MDS dated [DATE] was inaccurate. Review of the facility policy and procedure titled Resident Assessment Instruments (RAI) with the last review date of 1/25/2024 read, Policy: It is the policy of the facility to adhere to the following procedures related to the proper documentation and utilization of a resident's Minimum Data Set (MDS) to ensure a comprehensive and accurate assessment of residents will be completed in the format and in accordance with time frames stipulated by Department of Health and Human Services Center for Medicare and Medicaid Services. This assessment system will provide a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacities and assist staff to identify health problems for care plan development. Review of the facility form titled Certifying Accuracy of the Resident Assessment read, 2. Any person who completes any portion of the MDS assessment, tracking form, or correction request form is required to sign the assessment certifying the accuracy of that portion of that assessment . 4. The resident assessment coordinator is responsible for ensuring that an MDS assessment has been completed for each resident.

Based on observation, interview and record review, the facility failed to ensure the drugs and biologicals used in the facility were stored in accordance with currently accepted professional principle in 1 of 4 hallways. Findings include: During an observation on 2/3/2025 at 10:55 AM, Resident #15 was sleeping in bed and there was one bottle of Artificial Tears Ophthalmic Solution (Artificial Tear Solution) on the resident's beside table. Review of Resident #15's physician order dated 1/17/2024 read, Artificial Tears Ophthalmic Solution (Artificial Tear Solution), Instill 1 drop in both eyes four times a day for dry eyes and irritation. During an interview on 2/3/2025 at 10:58 AM, Staff A, Licensed Practical Nurse (LPN), stated Eye drops should not be at the bedside not secured. During an interview on 2/3/2025 at 11:08 AM, the Director of Nursing (DON) stated, Medications need to be secured and there are times when family members bring in eye drops we are not aware of. The medication has been brought to the patient. Review of the facility policy and procedure titled Medication Labeling and Storage with the last review date of 1/7/2025 read, Policy Statement: The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light control.

Based on record review and interview, the facility failed to inform the resident representative following a change in the resident's condition for 1 of 3 sampled residents, Resident #1. Findings include: Review of Resident #1's admission record revealed the resident was admitted to the facility on [DATE] with diagnoses including acute and chronic respiratory failure with hypercapnia, chronic obstructive pulmonary disease, type 2 diabetes mellitus, acute kidney failure, chronic kidney disease, major depressive disorder, generalized anxiety disorder, and muscle weakness. Review of Resident #1's progress note completed by Staff A, Licensed Practical Nurse (LPN), dated 4/2/2024 at 1:26 PM read, Resident was transferring from bedside commode to wheelchair, and she states her legs gave out and she slide [Sic.] to the floor. CNA [Certified Nursing Assistant] was in the room assisting resident with the transfer and was able to lower resident to the floor. No apparent injury noted at that time no cuts or bruises. [Medical Doctor's name] was notified and family member phone states the number could not be dialed. DON [Director of Nursing] was made aware of incident. Resident denies injury and pain, she said she couldn't breathe rescuer puffer given at that time. During an interview on 5/2/2024 at 12:58 PM, Staff A, LPN, stated, I was assigned to [Resident #1's name] when she fell . I completed an assessment, notified the doctor, and attempted the family but the call would not go through. I don't remember what the message said. I did not inform the resident that I could not get her daughter and did not follow through to obtain a correct number for the records. During an interview on 5/2/2024 at 12:18 PM, the Director of Nursing stated, I was aware that the daughter could not be reached by the phone number recorded, but the resident is responsible for herself, so I did not attempt to get the correct phone number. I didn't ask the resident if she wanted us to call her daughter because I didn't think I had to inform the family since she is responsible for herself. Review of the facility policy and procedures titled Change in a Resident's Condition or Status revised in February 2021 read, Policy Statement: Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and /or status (e.g., changes in level of care, billing/payments, resident rights, etc.) Policy Interpretation and Implementation . 4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: a. the resident is involved in any accident or incident that results in an injury including injuries of an unknown source; b. there is a significant change in the resident's physical, mental, or psychosocial status; c. there is a need to change the resident's room assignment.

Based on record review and interview, the facility failed to ensure resident assessments were transmitted within 14 days of completion for 5 of 6 residents reviewed for resident assessments, Residents #4, #28, #36, #42, and #48. Findings include: Review of Resident #4's MDS (Minimum Data Set) on 10/25/2023 showed the Assessment Reference Date (ARD) of 9/14/2023 and completion due date of 9/28/2023. The transmission was overdue for 28 days. Review of Resident #28's MDS on 10/25/2023 showed the ARD of 9/21/2023 and completion due date of 10/5/2023. The transmission was overdue for 20 days. Review of Resident #36's MDS on 10/25/2023 showed the 3rd quarter ARD of 8/17/2023 and completion due date of 8/31/2023. The transmission was overdue for 56 days. Review of Resident #42's MDS on 10/25/2023 showed the discharge ARD of 8/29/2023 and completion due date of 9/12/2023. The transmission was overdue for 43. Review of Resident #48's MDS on 10/25/2023 showed the discharge ARD of 8/19/2023 and complete due date of 9/2/2023. The transmission was overdue for 53 days. During an interview on 10/25/2023 at 3:15 PM, the Administrator stated, My expectation is that the MDS assessments should be submitted timely. During an interview on 10/26/2023 at 11:10 AM, the MDS Coordinator stated, I am the MDS Coordinator. Once a resident assessment is completed, you have 14 days to submit it. Review of the facility policy and procedure titled MDS Completion and Submission Timeframes last reviewed on 1/19/2023 reads, Policy Statement: Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes.

Based on observation, interview, and record review, the facility failed to ensure foods were stored in accordance with professional standards in the kitchen freezer and in 1 of 1 nourishment rooms. Findings include: During an initial tour of the facility kitchen on 10/23/2023 at 9:18 AM with the Kitchen Manager, there was a cake wrapped with no label or date in the kitchen freezer. During an observation of the nourishment room on 10/23/2023 at 9:30 AM with the Kitchen Manager, there was a box of blueberries in the nourishment room refrigerator with no label or date. During an interview on 10/23/2023 at 9:30 AM, the Kitchen Manager confirmed that the observed food items in the kitchen freezer and nourishment room refrigerator were not labeled and dated, and they should have been labeled and dated. Review of the facility policy and procedure titled Food Storage last reviewed on 1/19/2023 reads, Procedures . 5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination.

Based on record review and interview, the facility failed to ensure resident records were complete and accurate for 4 of 10 residents reviewed, Residents #12, #17, #24, and #110. Findings include: 1. Review of the admission record for Resident #12 documented the resident was admitted on [DATE] and readmitted on [DATE] with diagnosis that included pressure ulcers. Review of Resident #12's physician order dated 6/21/2023 reads, Wound care: cleans wound to RT [Right] Ischium with NS [Normal Saline]. Apply xeroform and up cover with borderless silicone foam. Change daily. Review of Resident #12's physician order dated 6/30/2023 reads, Wound care: cleans wound to right buttocks with NS. Apply xeroform and up cover with borderless silicone foam. Change daily. Review of Resident #12's physician order dated 8/20/2023 reads, Wound care cleanse Lt. [left] Lateral foot with Dakins. Apply Santyl and calcium alginate. Apply ABD [abdominal] and wrap and kerlix. Change M [Monday]/W [Wednesday]/F [Friday] every day shift Monday, Wednesday, Friday for neuropathic ulcer. Review of Resident #12's physician order dated 8/20/2023 reads, Wound care cleanse Lt. heel with Dakins. Apply Santyl and calcium alginate. Cover with silicone borderless foam. Change M/W/F every day shift Monday, Wednesday, Friday for neuropathic ulcer. Review of Resident #12's physician order dated 8/20/2023 reads, Wound care: cleanse RT [right] heel with Dakins. Apply Santyl and calcium alginate. Apply ABD and wrap and kerlix. Change M/W/F every day shift Monday, Wednesday, Friday for neuropathic ulcer. Review of Resident #12's physician order dated 8/20/2023 reads, Wound care cleanse Lt. plantar (foot) with Dakins. Apply Santyl and calcium alginate. Apply ABD and wrap and kerlix. Change M/W/F every day shift Monday, Wednesday, Friday for neuropathic ulcer. Review of Resident #12's physician order dated 9/8/2023 reads, Wound care: cleanse wound to Lt. Ischium with NS. Apply honey and calcium alginate. Cover with borderless silicone foam. Change daily, every day shift for pressure ulcer. Review of Resident #12's Treatment Administration Records (TARs) for September 2023 and October 2023 revealed no documentation that wound care was provided for the following: 1. Wound care cleanse Lt. Lateral foot with Dakins. Apply Santyl and calcium alginate. Apply ABD and wrap and kerlix. Change M/W/F every day shift Monday, Wednesday, Friday for neuropathic ulcer on 9/8/2023, 9/13/2023, 9/20/2023 or 9/27/2023; 2. Wound care cleanse Lt. heel with Dakins, apply Santyl and calcium alginate. Cover with silicone borderless foam. Change M/W/F every day shift Monday, Wednesday, Friday for neuropathic ulcer on 9/8/2023, 9/13/2023, 9/20/2023 or 9/27/2023; 3. Wound care: cleanse wound to Lt. Ischium with NS. Apply honey and calcium alginate. Cover with borderless silicone foam. Change daily, every day shift for pressure ulcer on 9/9/2023, 9/13/2023, 9/14/2023, 9/16/2023, 9/19/2023, 9/20/2023, 9/21/2023, 9/26/2023 or 9/27/2023; 4. Wound care cleanse Lt. plantar with Dakins. Apply Santyl and calcium alginate. Apply ABD and wrap and kerlix. Change M/W/F every day shift Monday, Wednesday, Friday for neuropathic ulcer on 9/5/2023 and 9/8/2023; 5. Wound care: cleans wound to right buttocks with NS. Apply xeroform and up cover with borderless silicone foam. Change daily on 9/5/2023, 9/8/2023, 9/9/2023, 9/13/2023, 9/14/2023, 9/16/2023, 9/20/2023, 9/21/2023, 9/26/2023,9/27/2023; 6. Wound care: cleanse RT heel with Dakins. Apply Santyl and calcium alginate. Apply ABD and wrap and kerlix. Change M/W/F every day shift Monday, Wednesday, Friday for neuropathic ulcer on 9/8/2023, 9/13/2023, 9/20/2023 or 9/27/2023; 7. Wound care: cleans wound to RT Ischium with NS. Apply xeroform and up cover with borderless silicone foam. Change daily on 9/5/2023 and 9/8/2023. Review of Resident # 12's TAR for October 2023 revealed no documentation for wound care was provided for 1)Wound care cleanse Lt. Lateral foot with Dakins. Apply Santyl and calcium alginate. Apply ABD and wrap and kerlix. Change M/W/F every day shift Monday, Wednesday, Friday for neuropathic ulcer. No documentation on 10/6/2023. 2)Wound care cleanse Lt. heel with Dakins. Apply Santyl and calcium alginate. Cover with silicone borderless foam. Change M/W/F every day shift Monday, Wednesday, Friday for neuropathic ulcer. No documentation on 10/6/2023 and 10/16/2023. 3) Wound care: cleanse wound to Lt. Ischium with NS. Apply honey and calcium alginate. Cover with borderless silicone foam. Change daily, every day shift for pressure ulcer. Wound care cleanse Lt. plantar foot with Dakins. Apply Santyl and calcium alginate. Apply ABD and wrap and kerlix. Change M/W/F every day shift Monday, Wednesday, Friday for neuropathic ulcer. No documentation on 10/6/2023 and 10/16/2023. 4) Wound care: cleans wound to right buttocks with NS. Apply xeroform and up cover with borderless silicone foam. Change daily. Wound care: cleanse RT heel with Dakins. Apply Santyl and calcium alginate. Apply ABD and wrap and kerlix. Change M/W/F every day shift Monday, Wednesday, Friday for neuropathic ulcer. No documentation on 10/6/2023 and 10/16/2023. 5) Wound care: Cleanse wound to ischium with 1/2 strength Dakins. Apply moistened 1/2 strength Dakins and cover with borderless silicone foam. Change daily No documentation on 10/5/2023 , 10/6/2023, 10/16/2023, 10/21/2023. 6) Wound care: cleanse wound to right lateral leg with Dakins. Apply Santyl and Ca Alginate. Cover with silicone borderless foam. Wrap kerlix. Change M/W/F every day shift every Mon, Wed, Fri for wound care. No documentation on 10/16/2023 During an interview on 10/26/2023 at 1:55 PM, the Director of Nursing confirmed all dates that were blank were documentation error and that wound care was provided, and each area should have been signed by the nurse providing the wound care. 39185 2. Review of the admission record for Resident #17 showed the resident was admitted on [DATE] with the diagnoses including peripheral vascular disease, type 2 diabetes mellitus with diabetic neuropathy, non-pressure chronic ulcer of left calf with other specified severity, acute kidney failure, unspecified dementia, neuromuscular dysfunction of bladder, essential (primary) hypertension, major depressive disorder, muscle weakness, benign prostatic hyperplasia without lower urinary tract symptoms, left knee contracture, and repeated falls. Review of Resident #17's TAR for August 2023 revealed no entries documented for head-to-toe skin assessment on Saturdays on Saturday 8/19/2023, no entries for left heel wound care on Monday, Wednesday and Friday on Monday 8/21/2023 and Friday 8/25/2023, no entries for bilateral calf wound care 8/8/2023, 8/21/2023 and 8/25/2023. Review of Resident #17's TAR for September 2023 revealed no entries documented for applying A&D ointment for dry skin on 9/14/2023 and 9/19/2023, no entries for changing catheter drainage bag on 9/19/2023, no entries for head-to-toe skin assessment on Saturdays on Saturday 9/16/2023, no entries for urinary output from foley catheter every shift on 9/25/2023, 9/26/2023, 9/17/2023, and 9/28/2023 at 7:00 PM to 7:00 AM shift, and on 9/26/2023 at 7:00 AM to 7:00 PM shift. Review of Resident #17's TAR for October 2023 revealed no entries documented for applying A&D ointment for dry skin on 10/5/2023, no entries for changing catheter drainage bag on 10/25/2023, no entries for assessment of level of pain on 10/2023 at 7:00 AM to 7:00 PM shift and on 10/15/2023 at 7:00 PM to 7:00 AM shift, no entries for documenting bowel movement on 10/15/2023 at 7:00 PM to 7:0 AM shift, no entries for documenting urinary output on 10/2/2023 and 10/5/2023 at 7:00 AM to 7:00 PM shift and on 10/1/2023, 1015/2023, and 10/20/2023 at 7:00 PM to 7:00 AM shift, AND no entries for catheter care on 105/2023 at 7:00 AM to 7:00 PM shift and on 10/15/2023 at 7:00 PM to 7:00 AM shift. Review of the admission record for Resident #24 showed the resident was admitted on [DATE] with the diagnoses including chronic kidney disease, unspecified atrial fibrillation, peripheral vascular disease, morbid (severe) obesity due to excess calories, end stage renal disease, anemia, atherosclerotic heart disease of native coronary artery without angina pectoris, hypothyroidism, bilateral primary osteoarthritis of knee, unspecified diastolic (congestive) heart failure, need for assistance with personal care, encounter for immunization, muscle weakness (generalized), congenital malformation of ear causing impairment of hearing, essential (primary) hypertension, gastroesophageal reflux disease without esophagitis, difficulty in walking. Review of Resident #24's TAR for September 2023 revealed no entries documented for providing wound care for right hand on Monday, Wednesday and Friday on Monday 9/11/2023, Wednesday 9/13/2023, Monday 9/18/2023, and Wednesday 9/20/2023, no entries for applying Ammonium Lactate external lotion for dry skin every shift on 9/11/2023, 9/14/2023, 9/19/2023, and 9/28/2023 at 7:00 AM to 7:00 PM shift, and on 9/6/2023 and 9/16/2023 at 7:00 PM to 7:00 AM shift, no entries for assessment of level of pain on 9/11/2023, 9/14/2023, 9/19/2023 and 9/26/2023 at 7:00 AM to 7:00 PM shift, and on 9/6/2023 and 9/16/2023 at 7:00 PM to 7:00 AM shift, no entries for monitoring shunt to left upper extremity on 9/11/2023, 9/14/2023, 9/19/2023 and 9/26/2023 at 7:00 AM to 7:00 PM shift, and on 9/6/2023 and 9/16/2023 at 7:00 PM to 7:00 AM shift, and no entries for monitoring dialysis catheter dressing on 9/11/2023, 9/14/2023, 9/19/2023 and 9/26/2023 at 7:00 AM to 7:00 PM shift and on 9/6/2023 and 9/16/2023 at 7:00 PM to 7:00 AM shift. Review of Resident #24's TAR for October 2023 revealed no entries documented for obtaining vital signs every shift on Tuesday, Thursday and Saturday on Thursday 10/19/2023 and Tuesday 10/24/2023, no entries for providing wound care for right hand on Monday, Wednesday and Friday on Monday 10/2/2023, Friday 10/6/2023, and 10/16/2023, no entries for applying Ammonium Lactate external lotion for dry skin every shift on 10/19/2023 at 7:00 AM to 7:00 PM shift, no entries for assessment of level of pan on 10/2/2023 at 7:00 PM to 7:00 AM shift, no entries for assessment of level of pai on 10/5/2023 and 10/19/2023 at 7:00 AM to 7:00 PM shift, no entries for documenting bowel movement on 10/19/2023 at 7:00 AM to 7:00 PM shift, and on 10/15/2023 at 7:00 PM to 7:00 SM shift, no entries for monitoring shunt to left upper extremity on 10/5/2023 and 10/19/2023 at 7:00 AM to 7:00 PM shift, no entries for monitoring dialysis catheter dressing on 10/5/2023 and 10/19/2023 at 7:00 AM to 7:00 PM shift. Review of the admission record for Resident #110 showed the resident was admitted on [DATE] with the diagnoses including malignant neoplasm of prostate, urinary tract infection, anemia, acute posthemorrhagic anemia, acute embolism and thrombosis of deep veins of left upper extremity, obstructive and reflux uropathy, hyperlipidemia, hydronephrosis with renal and urethral calculous obstruction, chronic kidney disease, vitamin D deficiency, localized swelling, mass and lump, inflammatory disorders of scrotum, other artificial openings of urinary tract status, intra-abdominal and pelvic swelling, mass and lump, acute kidney failure, hypothyroidism, gastroesophageal reflux disease, and muscle weakness. Review of Resident #110's TAR for October 2023 revealed no entries documented for changing the dressing to bilateral nephrostomy tube sites every 3 days on 10/15/2023, 10/24/2023, and 10/27/2023, no entries for non-skid footwear on 10/15/2023, no entries for assessment of level of pain on 10/3/2023 at 7:00 AM to 7:00 PM shift, no entries for documenting bowel movement on 10/15/2023 at 7:00 PM to 7:00 AM shift, no entries for emptying bilateral nephrostomy bags on 10/15/2023 and 10/20/2023 at 7:00 PM to 7:00 AM shift and 10/18/2023 at 7:00 AM to 7:00 PM shift, no entries for vital signs on 10/15/2023 at 7:00 AM to 7:00 PM shift and 7:00 PM to 7:00 AM shift, and on 10/18/2023 and 10/19/2023 at 7:00 PM to 7:00 AM shift. During an interview on 10/26/2023 at 1:45 PM, the Director of Nursing (DON) confirmed that the TARs had blanks Residents #17, #24, and #110 and stated that they were documentation issues, and she knew that the care was provided, and the staff did not document them. Review of the facility policy and procedure titled Charting and Documentation last reviewed on 1/19/2023 reads, Policy Statement: All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. Policy Interpretation and Implementation: 1. All observations, medications administered, services performed, etc., must be documented in the resident's clinical records . 6. Documentation of procedures and treatments shall include care-specific details and shall include at a minimum: 1. The date and time the procedure/treatment was provided; b. the name and title of the individual(s) who provided the care.

Based on observation, interview, and record review, the facility failed to ensure staff followed infection control standards of practice specific to hand hygiene during medication administration and cleansing of automated blood pressure wrist cuff and oxygen saturation probe monitor during direct care. Findings include: During medication administration observation on 10/24/2023 beginning at 9:23 AM, Staff A, License Practical Nurse (LPN), did not complete hand hygiene before preparing Resident #110's medication. Staff A entered Resident #110's room and applied an automated blood pressure wrist cuff on the resident's left wrist to obtain blood pressure and finger probe on the right finger to obtain oxygen saturation. Staff A removed the blood pressure cuff and oxygen saturation probe from the resident and returned to the medication cart. Staff A began preparing medications for Resident #110. Staff A did not clean the blood pressure cuff and the finger probe. Staff A popped one Bicalutamide Oral tablet 50 mg (Bicalutamide), one Tamsulosin HCL Oral Capsule 0.4 mg, and one Metronidazole 250 mg tablet into her non-gloved hand and placed the tablets into the medication cup. Staff A, then, returned to Resident #110 and administered the oral medications. Staff A left Resident #110's room and returned to the medication cart. Staff A collected the blood pressure cuff and oxygen saturation probe and went to Resident #13's room and obtained his blood pressure and oxygen saturation. Staff A returned to the medication cart and began preparing medications for Resident #13. Staff A popped one Amlodipine Besylate 10 mg tablet, one Amiodarone HCL 200 mg tablet, and one Thiamine HCL 100 mg tablet into her non-gloved hand and placed them into the medication cup. Staff A returned to Resident #13's room and administered the medications. Staff A left Resident #13's room and returned to the medication cart. Staff A proceeded to Resident #9's room and applied the automated blood pressure wrist cuff on the resident's wrist and finger probe on his finger and obtained the readings and returned to the medication cart to prepare medications for Resident #9. Staff A began preparing medications for Resident #9. Staff A popped one Ferrous Fumarate 324 mg tablet, one Apixaban tablet, one Glipizide 5 mg tablet, one Losartan 100 mg tablet into her non-gloved hand and then placed the tablets into the medication cup. Staff A proceeded to Resident #9's room and administered Brimonidine Tartrate Ophthalmic solution 0.2% (Brimonidine Tartrate) eyedrop in the resident's both eyes. Staff A administered Brinzolamide Ophthalmic suspension 1% (Brinzolamide) eyedrop in the resident's both eyes and then administered all oral medications prepared. Staff A did not perform hand hygiene. Staff A placed the oxygen saturation probe in her pocket and left the blood pressure cuff on top of the medication cart. During an interview on 10/24/2023 at 9:55 AM, Staff A, LPN, stated, I do not clean the blood pressure cuff or oxygen saturation probe before or after each patient. I clean it at the end of the day. I don't want to use those bleach wipes and I don't know what to clean it with. I do not know what the policy and procedure for the facility is related to cleaning items used between patients such as the blood pressure cuff and oxygen saturation probe. I did hand hygiene earlier before I started medication pass and after I completed several patients. I usually use gel. I miss the cup when I try to pop the medication out of the packet directly into the medication cup, so to save time, I pop the medication in my hand. During an interview on 10/24/2023 at 12:24 PM, the Director of Nursing stated, Hand hygiene is expected before and after each patient contact and before medication preparation and administration. All Resident equipment is cleaned and disinfected after each use. The blood pressure cuff and the oxygen saturation probe are to be cleaned after each patient's use. During an interview on 10/25/2023 at 10:00 AM, the Unit Manager stated, It is my expectation that hand hygiene is used before and after each patient contact and before all medication deliveries. Blood pressure cuffs and oxygen saturation probes are to be cleaned before and after each patient's use. Staff should never be popping medication into their hands and then administering the medication to patients. Review of the facility policy and procedure titled Cleaning and Disinfection of Resident-Care Items and Equipment last reviewed on 1/19/2023 reads, Policy Statement: Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC [Centers for Disease Control and Prevention] recommendations for disinfection and the OSHA [Occupational Safety and Health Administration] Bloodborne Pathogens Standard. Policy Interpretation and Implementation: 1. The following categories are used to distinguish the levels of sterilization/ disinfection necessary for items used in resident care . 4. Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes durable medical equipment). Review of facility policy and procedure titled Handwashing/Hand Hygiene last reviewed on 1/19/2023 reads, Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation . 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . When to Wash Hands. 5. Employees must wash their hands for at least fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions . c. Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice) . i. Upon and after coming in contact with a resident's intact skin. (e.g., when taking a pulse or blood pressure, and lifting a resident) . When to Use Alcohol-Based Hand Rub. 6 In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% ethanol or isopropanol for all the following situations: a. Before and after direct contact with residents . d. Before preparing or handling medications . g. After contact with a resident's intact skin . i. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident.

Based on record review and interview, the facility failed to ensure the resident assessment accurately reflected the resident's status for 1 of 3 sampled residents, Resident #58. Findings include: Review of the admission record for Resident #58 showed the resident was admitted on [DATE] with the diagnoses including cerebral infection, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, peripheral vascular disease, dysarthria following cerebral infarction, occlusion and stenosis of right carotid artery, other low back pain, paroxysmal atrial fibrillation, transient cerebral ischemic attached, major depressive disorder, gastroesophageal reflux disease, essential (primary) hypertension, dementia, atherosclerotic heart disease of native coronary artery with unspecified angina pectoris, and hyperlipidemia. Review of Resident #58's physician order dated 8/31/2023 reads, May discharged [Sic.] resident to home with [Home Health Agency's name] with SN [skilled nursing], PT [physical therapy], OT [occupational therapy], [Pharmacy's name] for prescriptions and [Home Medical Equipment Provider's name] for DME [Durable Medical Equipment] equipment. Review of Section A (Identification Information) of Resident #58's Discharge Return Not Anticipated Minimum Data Set (MDS) dated [DATE] showed the resident was discharged to acute hospital. During an interview on 10/25/2023 at 2:45 PM, the Director of Nursing (DON) stated that the resident was discharged home and the MDS was inaccurate. During an interview on 10/26/2023 at 11:10 AM, the MDS Coordinator stated that the MDS information needed to be accurate. Review of the facility policy and procedure titled MDS Completion and Submission Timeframes last reviewed on 1/19/2023 reads, Policy Interpretation and Implementation: 1. The Assessment Coordinator or designee shall be responsible for ensuring that resident assessments are submitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current federal and state guidelines.

Based on observation, interview, and record review, the facility failed to ensure the residents who were unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 1 of 3 residents sampled for activities of daily living, Resident #110. Findings include: During an observation on 10/23/2023 at 11:25 AM, Resident #110 was in bed. The resident's fingernails were long and untrimmed with dark substance underneath the nailbeds of both hands. During an observation on 10/24/2023 at 2:07 PM, Resident #110 was in bed. The resident's fingernails were long and untrimmed with dark substance under the nailbeds of both hands. During an observation on 10/25/2023 at 9:28 AM, Resident #110 was in bed with long and untrimmed fingernails and dark substance under the nailbeds of both hands. Review of the admission record for Resident #110 showed the resident was admitted on [DATE] with the diagnose including malignant neoplasm of prostate, urinary tract infection, anemia, acute posthemorrhagic anemia, acute embolism and thrombosis of deep veins of left upper extremity, obstructive and reflux uropathy, hyperlipidemia, hydronephrosis with renal and urethral calculous obstruction, chronic kidney disease, vitamin D deficiency, localized swelling, mass and lump, inflammatory disorders of scrotum, other artificial openings of urinary tract status, intra-abdominal and pelvic swelling, mass and lump, acute kidney failure, hypothyroidism, gastroesophageal reflux disease, and muscle weakness. Review of Resident #110's care plan dated 10/6/2023 reads, Focus: Resident has ADL [Activities of Daily Living] Self-Care Deficit AEB [As Evidenced By]: Resident requires: Assist of one with ADL's . assist with Personal Hygiene At risk of developing complications associated with decreased ADL self-performance r/t [related to] Disease Process/condition . Date Initiated: 10/15/2023. During an observation on 10/25/2023 at 3:37 PM accompanied with the Director of Nursing (DON), Resident #110 had long and untrimmed fingernails with dark substance under the nailbeds. During an interview on 10/25/2023 at 3:37 PM, the DON confirmed the fingernails were long and untrimmed with black substance under nailbeds. The DON stated, I do have a concierge CNA [Certified Nursing Assistant] takes care of it. Review of the facility policy and procedure titled Care of Fingernails last reviewed on 1/19/2023 reads, Purpose: The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections . General Guidelines . 2- Nail care includes cleaning and trimming, weekly and as needed.

Based on observation, record review, and interview, the facility failed to ensure the residents received Midline intravenous catheter site dressing care and services in accordance with professional standards of practice for 1 of 1 resident receiving intravenous therapy, Resident #12 (photographic evidence obtained). Findings include: During an observation on 10/23/2023 at 10:08 AM, Resident #12's transparent dressing covering a midline intravenous catheter located on the right upper arm was dated 9/29/2023. The edges of the top and bottom of the dressing were pulled away from the skin. During an interview on 10/23/2023 at 10:08 AM, Resident #12 stated, The dressing has not been changed in a long time, not weekly and I have not refused to have it changed. The wound care nurse is the only nurse that has changed the dressing for me, and she is gone. During an observation on 10/23/2023 at 3:11 PM, accompanied with the Director of Nursing (DON), Resident #12's transparent dressing covering a midline intravenous catheter located on right upper arm was dated 9/29/2023. During an interview on 10/23/2023 at 3:11 PM, the DON stated, The dressing has not been changed since 9/29/2023. Physician orders need to be followed and the dressings are to be changed every 7 days to decrease the risk of infection. When the dressing was changed, the staff will place their initials, the date and time that the dressing was changed on the dressing. I do not know why it is documented on the TAR [Treatment Administration Record] as being completed on October 5th and 19th because the dressing has not been changed since 9/29/2023. During an interview on 10/23/2023 at 3:15 PM, the Physician stated, The dressing should be changed as ordered every 7 days. A midline dressing can go between 15-30 days without being changed without increasing the risk of infection if the dressing is intact and clean. Staff need to document if the patient refuses to have a dressing changed. During an interview on 10/24/2023 at 8:42 AM, the Wound Care License Practical Nurse (LPN) stated, The midline dressing is to be changed every 7 days or when soiled to decrease the risk of infection and the dressing change is documented in the TAR. During an interview on 10/24/2023 at 9:00 AM, the Nurse Manager stated, The wound care nurse normally completes dressing changes for wound or intravenous lines, but nurses can also do the dressing changes. Whoever completes the dressing change will initial, date and time the dressing change and document the dressing change in the TAR. The TAR should be completed when the dressing is changed or refused. The dressing has not been changed since 9/29/2023. During an interview on 10/24/2023 at 3:43 PM, the Infectious Disease Physician stated, The dressing for the midline needs to be changed as ordered and if the patient refuses, the refusal needs to be documented. During an interview on 10/25/2023 at 8:34 AM, Staff C, LPN, stated, I have never changed a midline or PICC [Peripherally Inserted Central Catheter] line dressing. I was told by previous wound care nurse and previous DON that LPNs could not do dressing changes for midlines or PICC catheters. [Resident #12's name] would refuse wound care frequently, but I never attempted to change his midline dressing because I was told that I was not allowed to. I do an assessment of IV [intravenous] line for signs of infection which is redness, drainage, pain and dressing intact. I never pay attention to the date because I don't change the dressing. The documentation of the TAR for 10/5, 10/12 and 10/19 was an error on my part. I must have just been clicking complete on all the task and in error clicked that I changed the dressing on 10/5 and 10/19 and that he refused the dressing change on 10/12. Review of the facility policy and procedure titled Midline Dressing Changes last reviewed on 1/19/2023 reads, Purpose: The purpose of this procedure is to prevent catheter-related infections associated with contaminated, loosened, or soiled catheter-site dressings. General Guidelines: 1. Change midline catheter dressing 24 hours after catheter insertion, every 5-7 days, or if it is wet, dirty, not intact, or compromised in any way.

Based on observation, record review, and interview, the facility failed to ensure the medication error rate was not 5% or greater. The medication error rate was 34.38%. Findings include: During medication administration observation on [DATE] beginning at 9:23 AM, Staff A, License Practical Nurse (LPN), began preparing medications for Resident #110. Staff A administered one Metronidazole tablet 250 mg (milligrams) by mouth for diarrhea. The resident had no current order for Metronidazole tablet 250 mg. The original order was for 7 days, which expired on [DATE]. During medication administration observation on [DATE] beginning at 9:36 AM, Staff A, LPN, began preparing medications for Resident #13. Staff A omitted administering Folic Acid oral tablet 1 mg as ordered for anemia. During medication administration observation on [DATE] beginning at 9:48 AM, Staff A, LPN, began preparing medications for Resident #9. Staff A administered one drop of Brimonidine Tartrate Ophthalmic Solution 0.2% (Brimonidine Tartrate) in each eye related to glaucoma. At 9:48 AM, Staff A administered one drop of Brinzolamide Ophthalmic Suspension 1% (Brinzolamide) in each eye. Staff A did not wait for 5 minutes between eye drop administration for additional eye drops. Staff A did not administer Senokot S oral tablet 8XXX,d+[DATE] mg (Sennosides -Docusate Sodium) for constipation and Polyethylene Glycol 3350 Powder (Polyethylene Glycol 3350 (Bulk) 17 grams by mouth for constipation as ordered. During medication administration observation on [DATE] at 9:11 AM, the Unit Manager, LPN, crushed medications for Resident #215 and administered all at one time, which included Aspirin 81 mg related to cerebrovascular disease, Amlodipine Besylate oral tablet 10 mg related to hypertension, Apixaban oral tablet 5 mg related to cerebrovascular disease, Metoprolol Tartrate oral tablet 25 mg related to hypertension, and Lacosamide oral solution 10 mg/ml [milliliter], 20 ml related to seizures. Review of Resident #110 's physician order dated [DATE] reads, Metronidazole Tablet 250 mg. Give 1 tablet by mouth three times daily for diarrhea for 7 days. Review of Resident #13's physician order dated [DATE] reads, Folic Acid oral Tablet 1 mg (Folic Acid). Give 1 tablet by mouth one time a day related to anemia. Review of Resident #9's physician order dated [DATE] reads, Brinzolamide Ophthalmic Suspension 1% (Brinzolamide). Instill 1 drop in both eyes two times a day related to glaucoma. Review of Resident #9's physician order dated [DATE] reads, Senokot S oral tablet 8XXX,d+[DATE] mg (Sennosides -Docusate Sodium). Give 1 tablet by mouth two times a day for constipation. Review of Resident #9's physician order dated [DATE] reads, Brimonidine Tartrate Ophthalmic Solution 0.2% (Brimonidine Tartrate). Instill 1 drop in both eyes two times a day related to glaucoma. Review of Resident #9's physician order dated [DATE] reads, Polyethylene Glycol 3350 Powder (Polyethylene Glycol 3350 (Bulk). Give 17 grams by mouth two times a day for constipation. Review of Resident #215's physician order dated [DATE] reads, Metoprolol Tartrate Oral Tablet 25 mg. Give 1 tablet via PEG [Percutaneous Endoscopic Gastrostomy] Tube every morning and at bedtime related to hypertension. Review of Resident #215's physician order dated [DATE] reads, Lacosamide oral solution 10 mg/ml. Give 20 ml via PG-Tube every morning and at bedtime related to seizures. Via G Tube. Review of Resident #215's physician order dated [DATE] reads, Aspirin 81 (oral tablet chewable aspirin). Give 1 tablet via PEG (Percutaneous endoscopic gastrostomy) Tube one time a day related to cerebrovascular disease. Via G-tube (Gastric Tube). Review of Resident #215's physician order dated [DATE] reads, Amlodipine Besylate oral tablet 10 mg. Give 1 tablet via PEG tube one time a day related hypertension. Review of Resident #215's physician order dated [DATE] reads, Apixaban oral Tablet 5 mg. Give 1 tablet via PEG-Tube every morning and at bedtime related to cerebrovascular disease. During an interview on [DATE] at 9:55 AM, Staff A, LPN, stated, I do not wait for the suggested 5 minutes between administration of eye drop medication unless it is written as an order. I don't think I have to wait. I do not know what the policy and procedure is here at our facility. During an interview on [DATE] at 12:24 PM, the Director of Nursing stated, Medications are to be administered as ordered and if not given should be documented on the MAR [Medication Administration Record] as not given. During an interview on [DATE] at 10:00 AM, the Unit Manager, LPN, stated, I have always administered the medication via G-tube all at one time. I was not aware that the medications had to be administered one medication at a time with a flush before and after. I am not aware of what our policy and procedure is related to medication administration via G-tubes. During an interview on [DATE] 3:10 PM with the Director of Nursing stated It is the standard and our policy and procedure for a 5-minute delay between administering eye drop medications, All medications via a G-tube are to be give one at a time with flush before and after each medication administered. Review of the facility policy and procedures titled Administering Medications last reviewed on [DATE] reads, Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation . 4. Medications are administered in accordance with prescriber orders including any required timeframe. 5. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. Enhancing optimal therapeutic effect of the medication . 21. 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. 22. The individual administering the medication initials the Resident's MAR on the appropriate line after giving each medication and before administering the next ones. Review of the policy and procedure titled Guideline for Administration of Ophthalmics in Long Term Care Facilities reads, 9) Allow ,d+[DATE] minutes before administration of another drop of any medication is administered to the same eye. Review of facility policy and procedure titled Administering Medications through an Enteral Tube last reviewed on [DATE] reads, Purpose: The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube . General Guidelines . 3. Do not mix medications together prior to administering through an enteral tube. Administer each medication separately . Steps in the Procedure . 27. When the last of the medication begins to drain from the tubing, flush the tubing with ,d+[DATE] mL of warm sterile water (or prescribed amount).

Based on record review and interview, the facility failed to obtain laboratory service ordered by the physician for 1 of 3 residents reviewed for laboratory services, Resident #2. Findings include: Review of Resident's #2's physician order dated 9/18/2023 showed CBC (Complete Blood Count), BMP (Complete Metabolic Panel), and ProBNP (Pro-brain Natriuretic Peptide) in 1 week. Review of Resident #2's medical records revealed no lab results for CBC, BMP, and ProBMP. During an interview on 10/25/2023 at 12:17 PM, the Director of Nursing stated, The order was written on 9/18/2023 but it was never obtained or completed. Nursing did not complete their 24-hour check and the test was missed. Review of the facility policy and procedure titled Lab and Diagnostic Test results- Clinical Protocol last reviewed on 1/19/2023 reads, Assessment and Recognition: 1. The physician will identify and order diagnostic and lab testing based on diagnostic and monitoring needs. 2. The staff will process test requisitions and arrange for tests. 3. The laboratory, diagnostic radiology provider, or other testing source will report test results to the facility.

Based on interview and record review, the facility failed to ensure the medical records related to meal intake percentages were complete for 2 of 3 residents reviewed for nutrition, Resident #3, and Resident #20. Findings Include: Review of Resident #3's care plan, initiated on 9/14/2021, revealed the resident had chronic pain related to arthritis and diabetic [CONDITION(S)]. Resident #3's care plan documented nutritional interventions that included monitor/record/report to nurse loss of appetite, refusal to eat and weight loss. Review of Resident #3's clinical records revealed a Point of Care Response History for Eating Meal Percentage dated 3/30/22- 4/26/22 failed to reveal completed documentation of the amount of the meal Resident #3 had eaten each meal. Documentation of the percentage of the meal Resident #3 had eaten was missing for 3 meals on 5 days, 2 meals on 5 days and 1 meal on 15 days during the period reviewed. Review of Resident #20's clinical record revealed Resident #20 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #20's care plan, initiated on 4/11/2020, revealed the resident was at nutritional risk related to a history of weight loss, refusals of meals and history of leaving more than 25% of most meals uneaten. Resident #20's care plan documented nutritional care interventions that included record intake. Review of Resident #20's clinical record revealed a Point of Care Response History for Eating Meal Percentage dated 4/4/22- 4/26/22 failed to reveal completed documentation of the amount of the meal Resident #20 had eaten each meal. Documentation of the percentage of the meal Resident #3 had eaten was missing for 3 meals on 5 days, 2 meals on 3 days and 1 meal on 14 days during the period reviewed. During an interview on 4/7/2022 at 9:03 AM, the Director of Nursing verified that the amount eaten percentage data had not been entered for Resident #3 and Resident #20. She stated, I don't know if we have a policy, but they are supposed to do it [enter the percentage eaten data].

Based on observation, interview, and record review, the facility failed to ensure nurse staffing information was posted on a daily basis. Findings Include: Observation of the posted nurse staffing information on 4/26/2022 at 9:28 AM revealed the posted nurse staffing information was dated 4/25/2022. During an interview on 4/26/2022 at 9:41 AM, the Administrator stated that he had not realized the posted nurse staffing information was from the previous day and had not been updated. During an interview on 4/29/2022 at 8:36 AM, the Director of Nursing reported nursing shifts were 7:00 AM to 7:00 PM and 7:00 PM to 7:00 AM. Review of the facility policy titled Posting Direct Care Daily Staffing Numbers, last reviewed on 1/22/2022, reads, Policy: Our facility will post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents . 1. Within two (2) hours of the beginning of each shift, the number of Licensed Nurses (RNs, LPNs, and LVNs) and the number of unlicensed nursing personnel (CNAs) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format.

Based on observation, interview, and record review, the facility failed to ensure kitchen equipment were maintained in a sanitary manner. Findings Include: During a tour of the main kitchen on 4/26/2022 beginning at approximately 9:26 AM with the Kitchen Manager, the uncovered deep fryer had oil that was dark brown with debris floating in it and an extensive build-up of dark murky oil. Along the sides of the fryer, there was extensive build-up of a white substance that had dripped down the side of the deep fryer. (photographic evidence obtained). During an interview on 4/26/2022 at approximately 9:30:AM, the Kitchen Manger confirmed the oil is dark brown with floating debris inside and has a build-up of a white substance. Review of the facility policy titled Deep Fryer Cleaning reads, Deep fryer will be cleaned on a regular basis as recommended by the manufacturer. Procedures: 1. Clean element whenever oil filtered or changed. 2. Wipe down the exterior at the ended of day. 3. Clean the fry baskets at the end of the day. 4. Boil out every- 3-6 months. 5. Inspect the fryer annually.

Based on observation, interview, and record review, the facility failed to ensure a clean, comfortable and homelike environment. Findings: On 10/18/2021 at 9:42 AM, an observation of Resident #14 showed the resident was seated in a wheelchair, alert and oriented by her bedside. Resident #14's pillowcase was stained with brown substance (photographic evidence obtained). During an interview on 10/18/2021 at approximately 9:42 AM, Resident #14 stated she was visually impaired, and she did not know when the last time her pillowcase was changed. During an interview on 10/18/2021 at approximately 11:06 AM, Staff A, Certified Nursing Assistant (CNA), stated resident linens were changed on shower days or as needed. Staff A stated she did not know about Resident #14's pillowcase or when the last time it was changed. On 10/19/2021 at approximately 9:40 AM, an observation of Resident #14 showed her pillowcase was stained with a brown substance. During an interview on 10/20/2021 at approximately 8:30 AM, the Director of Nursing stated Resident #14 was blind, and she was not aware of Resident #14's pillowcase was stained with brown substance. Review of the facility shower schedule revealed Resident #14 was last received shower on 10/16/2021.

Based on record review and interview, the facility failed to ensure a Level II Preadmission Screening and Resident Review (PASRR) evaluation was completed not later than 40 days of admission after a resident was determined to be staying in the facility for more than 30 days for 1 of 3 residents reviewed for PASRR screening, Resident #32, in a total sample of 21 residents. Findings: Review of Resident #32's records revealed the resident was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #32 had been a resident of the facility for 119 days on 10/19/2021. Review of Resident #32's Level I Preadmission Screening and Resident Review (PASRR) completed on 6/22/2021 reads, Section II: PASRR Screen Provisional Admission or Hospital Discharge Exemption: . Provisional Admission . The individual is being admitted under the 30-day hospital discharge exemption. If the individual's stay is anticipated to exceed 30 days, the NF [Nursing Facility] must notify the Level I screener on the 25th day of stay and the Level II evaluation must be completed no later than the 40th day of admission. During an interview on 10/19/2021 at 1:40 PM, the Director of Nursing (DON) stated the Level II Preadmission Screening and Resident Review for Resident #32 had not yet been completed.

Based on interviews, record reviews, and policy and procedure review, the facility failed to ensure the services provided met professional standards for following physician orders [REDACTED].#1 and #2, and delaying the initiation of cardiopulmonary resuscitation for five minutes when a resident with a full code status was found unresponsive and absent of vital signs, the resident did not survive, Resident #10. This has the potential to affect 47 of 47 residents at risk for medication errors, and 26 of 47 residents with a full code status at risk. Cross reference to F675, F678, F684, F726, F760, and F835 The findings included: 1) Review of the Florida Nurse Practice Act and the Scope of Nursing, Chapter 6 read: IX. Scope of Practice: 3. Responsibility of Administration - Health care facilities have a responsibility to provide competent care to patients, which includes competent nursing care. The administration has an obligation to assess each nurse's skills and abilities to provide care to a specific patient population. This is often accomplished through orientation programs, job, evaluations, training programs, and continuing education courses. The administration also has a responsibility to plan and budget, which includes allocating resources so that adequate and appropriate nursing care is available. Finally, the administration of a health care facility has a responsibility to take appropriate action to prevent or remedy incompetent care. In the event disciplinary action is warranted, the administration has a duty to follow facility discipline policies. 4. Responsibility of the Nurse - A nurse has a duty to provide competent care to patients. This includes clarifying work assignments with management, as well as determining and assessing her own skills, knowledge and abilities. Providing competent nursing care also includes using informed judgement and decision making. Informed decision making requires a nurse to use her own knowledge and skills, as well as recognizing when the nurse needs additional assistance. 2) Review of the Florida Board of Nursing Certified Nursing Assistant (CNA) read: All CNAs must complete a minimum of 24 hours of in-service training each biennium. In-service training hours shall include, but are not limited to, the following areas: CPR skills. 3) Review of Resident #1's facility record revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Initial dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 15 = no cognitive deficit. Review of the hospital AHCA (Agency for Health Care Administration) Form ,[DATE] dated [DATE] under the section titled, U. Mental/Cognitive Status At Transfer Alert, oriented, follows Instructions, was checked. Review of the Agency for Health Care Administration (AHCA) Nursing Homes Federal Reporting dated [DATE] revealed: Description of the Incident: The resident made an allegation of a staff member while changing her that she was punching her in her arm. Resident cried as Social Service was speaking to her. The Facility's Immediate Response revealed: 4. Statements was done by staff. 5. Interview was done by Social Service. Review of the written statement dated [DATE] by Staff P, CNA (Certified Nursing Assistant) read: At about 6:30 p.m. Sat. [DATE] was passing trays for supper. (Resident #1's name) was yelling she was wet and trying to crawl out of bed calling me all kinds of names that no one was changing her one of my co-worker came into her room to help me and she told him to get out, finally I started to change her bed and she was rowdy that I, when and got another co-worker (Staff V, CNA's name) to come and help me in the process of changing her bed she became mad at me for trying to change her and she begin to hit me and I, tried to catch her hands and arms and she was mad with (Staff V, CNA's name) for not helping her, and we trying to change her wet bed. I, call the nurse to tell her what had happen. Review of the written statement dated [DATE] by Staff V, CNA read: I was helping (Staff P, CNA's name) in room. The Resident became combative and refused care talking about she dieing. Review of the nursing progress notes dated [DATE] at 3:30 PM read: (Resident #1's name) is agitated making false accusations against staff. On [DATE] at 3:44 PM Reach out to hospice regards to behavior, staff is afraid to work with her due to false accusations she is making. During an interview on [DATE] at 8:55 AM with the Administrator a request was made for the complete investigation into the abuse allegation made by Resident #1. The Administrator stated that the corrective actions taken on behalf of Resident 1's abuse allegation, and pointed to a Posted Note and stated, there will be two staff in the room while accommodating her needs. The investigation was completed. Nurses are trained on how to redirect and care for patients. I am not a nurse my expectation is for them to know what they are doing. When asked if other residents residing on the same unit with Resident #1 were interviewed, to determine if they had suffered abuse, as part of the investigation, the Administrator replied she did not feel this was necessary since there was no abuse. When asked about this being part of the corrective action she stated, I was not aware that these were items that needed to be implemented as a corrective action when no alleged abuse had occurred. Review of the POS [REDACTED]. 2 Staff @ all times. All allegations will be reported. Document behaviors. Staff walk away if resident is upset. Ensure resident is safe. During an interview on [DATE] at 3:20 PM Staff P, stated, (Resident #1 name) was screaming she was soiled, I was passing trays at that time. I stopped and got help to clean her up. The resident started screaming 'you are killing me and cussing' and did not want the male CNA to touch her and all he was doing was helping me hold her and I was cleaning her. I went and got (Staff V, CNA's name) that made her mad she started saying that I was punching her. I was trying not to get punched and clean her up quickly, I felt I was the one who got abused. During an interview on [DATE] at 3:45 PM via telephone Staff V, CNA stated, I was called by (Staff P, CNA's name) in to help with this resident. I was supporting the (Resident #1's name) and the resident was looking at me and asking why am I allowing this to happen. I tried to reassure her as much as possible. The resident was swinging and cussing at (Staff P, CNA's name) and fussing at me. During an interview on [DATE] at 12:45 PM the Social Services Director stated, I completed the AHCA 5 day report. I had no training on how to conduct this investigation. I took down the witness statements and asked (Resident #1's name) the questions. Since the DON (Director of Nursing) was gone it was given to me to do. (Resident #1's name) had no recollection about the allegation of abuse. I go in and talk to her and she does not remember anything. Yesterday she was fussing at the staff. I would speak to her and she would say nothing. Review of Resident #1's lab dated [DATE] revealed Ammonia 100 High. (too much ammonia in the body can cause psychological problems like confusion, tiredness, and possibly coma or death) Review of the physician's orders [REDACTED]. Diagnosis: [REDACTED]. Dated [DATE] at 12:00 AM read: [MEDICATION NAME] 30 ml every 6 hours as needed. Review of the Medication Administration Record [REDACTED]. For the period of [DATE] at 9:00 PM to [DATE] the MAR indicated [REDACTED]. [MEDICATION NAME] 10 GM/15 ML Solution give 30 ML (20GM) by mouth every 6 hours as needed - [MEDICAL CONDITION] of liver. The documentation showed [MEDICATION NAME] was not administered as needed and was documented as discontinued on [DATE] at 9:00 AM. Review of the Discontinued Order - As Needed (Handwritten) form read: [MEDICATION NAME] 10 GM/15 ML (15 grams to 15 milliliters) Solution by mouth. Original Fill Date: [DATE]. Give 30 milligram by mouth as needed every 6 hours as needed. Discontinued Date: [DATE] at 1:14 PM. [MEDICATION NAME] 10 gm/15 ML Solution. Original Fill Date: [DATE]. Give 30 ML (20GM) by mouth every 6 hours as needed. Discontinued Date: [DATE] at 11:03 PM. [MEDICATION NAME] 10 GM/15 ML Solution. Original Fill Date: [DATE]. Give 30 Milliliter by mouth as needed every 6 hours. Discontinued Date: [DATE] at 11:03 PM. The Discontinued Orders were completed by licensed nursing staff and did not have a physician's signature line or signature for the discontinuation of the medication. During an interview on [DATE] at approximately 1:12 PM Resident #1's daughter stated, My mother would have periods of confusion and craziness and when that happened, I knew it was the ammonia level and she wasn't getting her [MEDICATION NAME]. During an interview on [DATE] at approximately 2:00 PM with the Administrator a request was made for documentation of the administration of [MEDICATION NAME] as ordered by the physician for the period of [DATE] at 9:00 PM to [DATE] at 9:00 AM (the resident was discharged to the hospital for an unrelated concern at approximately 7:00 PM on [DATE]) or for the physician's orders [REDACTED]. The Administrator stated she would have nursing provide the documentation. During an interview on [DATE] at approximately 10:00 AM with the Administrator a request was made for documentation of the administration of [MEDICATION NAME] as ordered by the physician for the period of [DATE] at 9:00 PM to [DATE] at 9:00 AM (the resident was discharged to the hospital for an unrelated concern at approximately 7:00 PM on [DATE]) or for the physician's orders [REDACTED]. The Administrator stated she let nursing know the documentation was needed. During an interview on [DATE] at approximately 4:00 PM with the Administrator a request was made for documentation of the administration of [MEDICATION NAME] as ordered by the physician for the period of [DATE] at 9:00 PM to [DATE] at 9:00 AM (the resident was discharged to the hospital for an unrelated concern at approximately 7:00 PM on [DATE]) or for the physician's orders [REDACTED]. The Administrator did not respond. No additional documentation was provided. 4) Review of Resident #2's facility record revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the hospice Treatment or Medication Form dated [DATE] [MEDICATION NAME] 1 mg oral every 4 hours PRN (as needed). Dated [DATE] read: [MEDICATION NAME] concentrate 20:1 10 mg = 0.5 ml SL (sublingual) every 4 hours ATC (around the clock). [MEDICATION NAME] 1 mg SL/PO (by mouth) every 4 hours ATC. (MONTH) hold for sedation. Please continue [MEDICATION NAME] sulfate and [MEDICATION NAME] every 4 hours PRN (as needed). Dated: [DATE] Lensin/Mycosamine 0.125 mg SL every 4 hours PRN - secretions. D/C (discontinue) nonessential meds d/t (due to) decline. Review of the Controlled Drug Declining Inventory Sheet for [MEDICATION NAME] ([MEDICATION NAME])1 mg tablet revealed the medication was signed out for administration on [DATE] at 10:00 AM, at 2:00 PM, at 08:00 PM, and at 12:00 AM. On [DATE] at 4:00 AM, at 8:00 AM, at 10:00 AM, at 12:00 PM, at 2:00 PM, at 5:30 PM, at 8:00 PM, and at 10:00 PM. On [DATE] at 12:00 midnight. [MEDICATION NAME] 100 mg/5 ml concentrate was signed out for administration [DATE] at 10:00 AM, at 02:00 PM, at 08:00 PM, [DATE] at 12:00 AM, [DATE] at 04:00 AM, 8:00 AM, at 10:00 AM, at 12:00 PM, at 2:00 PM, at 5:30 PM, at 8:00 PM, and at 10:00 PM. On [DATE] at 12:00 midnight and at 4:15 AM. Review of the care plan revised on [DATE] read: Focus: The resident is on pain medication therapy r/t end stage diagnosis. Goal: The resident will be free of any discomfort or adverse side effects from pain medication. Interventions: Administer [MEDICATION NAME] medications as ordered by physician. Monitor/document side effects and effectiveness Q (every) shift. Ask physician to review medication if side effects persist. Monitor/document/report PRN adverse reactions to [MEDICATION NAME] therapy: altered mental status, respiratory distress/decreased respirations, sedation. Focus: Use of [MEDICAL CONDITION] antianxiety drug places resident at risk for drug-related: Cognitive impairment. Initiated [DATE]. Goal: Resident will receive the least dosage of the prescribed [MEDICAL CONDITION] drug (s) to ensure maximum functional ability both mentally and physically. Interventions: [MEDICATION NAME] as ordered. Observe for side effects and hold medication for increased lethargy. Review of the nursing progress notes dated [DATE] at 2:37 PM New orders from hospice nurse [MEDICATION NAME] 1 mg PO @ HS (by mouth at hour of sleep). Dated: [DATE] at 6:21 AM Resident is not wanting to take his medications ([MEDICATION NAME]) Very lethargic and not wanting to open his mouth. Dated: [DATE] at 9:58 AM Resident tried to get out of bed. Stated he forgot he could not walk. Resident fell on his right side on the floor. Resident did not hit his head. Red marks on right hip and right shoulder. DON (Director of Nursing) and MD (Medical Doctor) notified. Resident was reminded to use call light any time he needs to get up. Dated: [DATE] at 11:11 AM Resident laying in bed sleeping. Easily arousable. No signs of pain or distress. Resident stated he was just tired and wanted to back to sleep. Date: [DATE] at 12:29 AM This nurse writing called hospice due to Resident making changes in mental status. Resident is restless, asking for someone to help him, climbing out of bed, Not eating or drinking sufficient amount. He is c/o (complaint of) abdominal pain. Hospice nurse on called made a visit received new order to increase [MEDICATION NAME], Q 4 hrs. PRN (hours as needed). Resident is being monitored closely to prevent resident injuries. Dated: [DATE] at 1:38 PM The resident has had a change is condition. When first observed the resident's jaw was twisted to the right and [MEDICAL CONDITION] is suspected. I obtained vital signs and notified hospice as well as his family. Family has been in to see the resident but hospice has not been in at this time 1:41 PM. (There was no documentation of the physician having been notified of the change in condition). Dated: [DATE] at 10:07 AM read: Resident is nonresponsive. Family notified and in facility. Hospice nurse in facility. Resident is currently on 4 L (liters) of O2 (oxygen) via nasal cannula r/t apnea (cessation of breathing). Dated: [DATE] at 12:23 PM. Resident eyes are no longer reactive to light. RR (respirations) approximately 8 per minutes, on 4 L O2 via nasal cannula. On [DATE] at 2:24 PM Being medicated on schedule every 2 hours as instructed by Hospice. Respirations 7 per minute. Currently unarousable again. On [DATE] at 3:52 PM Resident is wheezing and moaning. Still asleep. Not arousable. Breathing is slow and labored. On [DATE] at 3:3 PM Resident is currently lying in bed quietly sleeping with eyes half open. Responds to painful stimuli. Skin warm and dry to touch except for feet is cool. Respirations with long periods of inhale and exhale. No urine output so far this shift. Requires total assistance with ADL's, turning and repositioning. PO (by mouth) meal intake is zero d/t (due to) decrease alertness. On [DATE] at 9:04 AM Resident only responsive to painful stimuli. Hospice nurse in to see resident and review orders. Upon assessment determined to send resident to ER (emergency room ). Review of the hospice nursing progress notes dated [DATE] at 8:30 AM read, Reason for Focused Visit: Dying process/decline. Medication assessed for: Medicine reconciliation done. Effectiveness. Not taking meds as prescribed. Clinician Narrative Note: When I arrived there patient was unresponsive. Reviewed medications and patient has been getting the [MEDICATION NAME] 1 mg every 2 hours and [MEDICATION NAME] 10 mg every 2 hours instead of every 4 hours as ordered. Spoke with DON (Director of Nursing) and ADON (Assistant Director of Nursing) and they would like the patient to be sent to the ER for medication overdose. Spoke with sister at the bedside and she would like the patient to be sent out as well. Heat rate: 56. Respirations: 8. Blood Pressure ,[DATE]. O2 Sat (saturation) 92% on 2 LPM (liters per minute). Dated: [DATE] at 11:35 AM read, Clinician Narrative Note: Spoke to ER MD and the RN (Registered Nurse) along with sister at the bedside. Patient was given [MEDICATION NAME] to reverse the effects from the [MEDICATION NAME]. Dated: [DATE], unable to read time, Clinician Narrative Note: Patient had decline somewhat over the weekend .possibly transitioning. Pt (Patient) was in hospital ER with sister at Pt's bedside. Cp (Chaplin) spent much time comforting and encouraging pt's sister and later praying with both. Because sister did not want pt to go back to facility from which pt came, sister was looking for other options. Review of the EMS (Emergency Medical Services) note dated [DATE] revealed Chief Complaint: Overdose [MEDICATION NAME]. Meds Admin (Medications Administered) [MEDICATION NAME] 0.4 IV (intravenously). Review of the hospital records dated [DATE] revealed Chief Complaint: Drug overdose. History and Physical: Presents to ED via EMS d/t accidental overdose. Pt. sister states Pt has end stage liver failure and is on hospice at Crestwood Nursing home. Pt. was supposed to give (sic) 10 mg every 4 hours but they were giving 10 mg every 2 hours per Pt. sister. EMS gave Pt. [MEDICATION NAME] and drastically improved. Pt. denies any other Sx (symptoms) at this time. Free Text: Pt. sister does not like care given to Pt. at Crestwood Nursing home and would like someone else. Re-Evaluation/Progress #1: After [MEDICATION NAME] - Re-Eval Status: Improved. Eval Following Treatment: Pt. feels better, Condition improved. Condition: Stable. Review of the hospital Emergency Patient Record dated [DATE] revealed: Priority: 2/Emergent. Ingestion - Presenting signs/symptoms: Decreased Resp (respirations), Decreased L[NAME] (level of consciousness). Emergency Notes: [DATE] Assumed care of Pt. from previous RN. Pt. is alert when name is spoken to. Pt. has sister and hospice rep (representative) at bedside. Pt. is showing no signs of distress. Per Pt. advocate, Pt's family is requesting new hospice representation. Pt. is to be DC (discharged ) to new facility when it is determined. At 12:04 PM Pt. is resting comfortably with family at his side. No signs of distress noted. During an interview on [DATE] at 2:02 PM Staff A, Unit Manager/LPN (Licensed Practical Nurse) she stated, I am responsible for the unit, both of them since the other Unit Manager quit. I was involved in (Resident #2's name) transfer to the hospital. The hospice nurse came to me and told me the Resident had been given [MEDICATION NAME] and [MEDICATION NAME] every two hours the day before and was obtunded (lethargy in which the patient has a lessened interest in the environment, slowed responses to stimulation, and tends to sleep more than normal with drowsiness in between sleep states) with a very low respiratory rate. We told the DON who said to transfer the resident if that's what the sister wanted. The Administrator was called by the DON and told that the resident had a medication error and needed to go to the ED. So, I called 911 and got him to the hospital. That's all the involvement I had, except that I told The Administrator that the resident wasn't coming back because the sister didn't want him to. I called the hospital for an update and the hospice nurse let us know too. I didn't make out an incident report. When a resident gets medication, we should be monitoring them for any side effects and holding them and calling the doctor or the hospice nurse for any further orders if there are side effects. It is my expectation that I be informed of any changes in the residents' condition so that the resident can be assessed, and the problem can be addressed with the doctor. I expect the nurses to assess the residents for signs of over sedation. If a resident is sedated, hold medications until they check with hospice or the doctor and document all of that in the chart. During an interview on [DATE] at 4:55 PM the Hospice Nurse for Resident #2 stated, I did his initial consult on [DATE], and saw him again on [DATE], and when I saw him on Monday [DATE] there was a big difference, he was unresponsive when I saw him. It was reported to me that he had multiple falls over the weekend and agitation. The Resident's sister told me that he had been given medication every two hours per our orders and I knew that we did not have any orders for medications every two hours. When I checked our orders, we still had [MEDICATION NAME] 0.5 ml every 4 hours and a PRN (as needed) order for every 4 hours. But we did not give orders to medicate every 2 hours. After talking to the Director of Nursing and assessing the patient we were all in agreement that the patient should be sent to the ED and the Resident's sister agreed. I followed up on him once he went to the ED. He received [MEDICATION NAME] and was much more alert when I saw him, he was agitated but responsive. Our goal in pain control in end of life is to provide and promote comfort, we want our patients to be pain free, without anxiety. We want our patients to have enough medication to remain comfortable, not overmedicate them to a point where they require reversal agents. I was shocked because the man I saw on Monday was nowhere near the man I saw on Thursday. That was gross overmedication. The patient's sister did not want him to go back to Crestwood, and because we don't have another facility, we discharged him to another hospice, so the family had a sense of peace and comfort with his care. This Nurse should be reported because this was negligent. During a telephone interview on [DATE] at 10:45 AM the Hospice Doctor stated, I am the Physician for hospice and am aware of (Resident #2's name). He began hospice sometime in July. When he was first on service, he was taking [MEDICATION NAME] I believe and the switch to [MEDICATION NAME] began just a few days before he went to the emergency room . We routinely order [MEDICATION NAME] and [MEDICATION NAME] for comfort and anxiety. Our goal is anxiety reduction, symptom control and pain freedom at end of life. We medicate according to the patient's symptomology and frequently have routine orders and orders for breakthrough pain or anxiety. If I or any other of the hospice Physicians thinks medication more frequently than every four hours is necessary, we would order more frequent routine administration of narcotic [MEDICATION NAME]. Although, in my field I seldom have to worry about [MEDICATION NAME] administration and the concomitant use of benzodiazepines such as [MEDICATION NAME]. There would be a significant CNS (central nervous system) depression and respiratory depression effects particularly acute in a patient with liver and kidney disease. I would not have recommended every two hours around the clock administration of these drugs to (Resident #2's name) especially because of his diagnosis. We did not give or instruct the nurses at Crestwood to administer [MEDICATION NAME] and [MEDICATION NAME] every two hours. In this case he was overmedicated, and I would expect any nurse to call to speak with either the nurses or the doctor on call to determine if the medication should continue at the prescribed times or be adjusted and held. My understanding is (Resident #2's name) was obtunded (lethargy in which the patient has a lessened interest in the environment, slowed responses to stimulation, and tends to sleep more than normal with drowsiness in between sleep states) with a respiratory rate of ,[DATE] with long apneic (cessation of respiration) periods, this was discussed with family and the nursing home and the decision to send the patient out to the hospital for treatment was made by the family, staff and our staff followed the family wishes. Our nurse followed up in the emergency room and the patient had a significant change in alertness with [MEDICATION NAME] administration which overall tells us that he was overmedicated and that was not recognized by the staff at Crestwood. Overdosage and the need to use reversal agents has a profound effect on the patients that I treat, not only physical but psychological as well for both patients and their families. During an interview on [DATE] at 9:37 AM via telephone the DON stated, I did not evaluate (Resident #2's name). The first I heard about it was when the ADON/Educator told me he had been medicated every two hours with [MEDICATION NAME] and he was unarousable with a respiratory rate of 6 or 7 per minute. She stated he needed to be transferred out because we were killing him with medications, that he was obtunded and unable to respond to painful stimuli. The hospice nurse and sister wanted to transfer him to the hospital for evaluation and treatment. I never went to evaluate the resident he was already seen by the hospice nurse and the ADON, so I just started getting the transfer started. I trusted their judgement that he needed to be transferred. I did not do any investigation, there was no time to as I was suspended on [DATE]. I did not review the Narcotic Administration sheets. I did not look at any of the nurses' documentation or check any physician orders. I did not know that it was an adverse incident. I was told that he was administered medication every two hours of [MEDICATION NAME] and [MEDICATION NAME], but that he did not have orders to medicate that frequently. I did not instruct the nurses to make out an incident report. The Administrator knew the patient went to the hospital, got administered [MEDICATION NAME], and the sister did not want him to come back because of this. We were notified that day that he would not be returning. I really did not get to investigate any of this, I just started in (MONTH) and it takes time to determine that processes are broken. We have a lot of work to do to improve the care we deliver. We don't have a code blue sheet that we fill out if a resident codes. I wasn't aware that the policy stated we had one. I would think that if someone has a CPR card, they are proficient according to the American Red Cross. I didn't do anything to assess the staff competency in CPR or their comfort level in CPR. Anyone who is CPR certified can start CPR. I did not look at any of the Code Blues that we started and was not tracking them or looking at the documentation, that is the responsibility of the Unit manager to do that and bring any concerns to me and the Administrator during the morning meetings. I was not aware that a resident did not have CPR started for five minutes. We don't have an AED (Automated External Defibrillator) that I am aware of. I'm not the Risk Manager, that's the ADON's job. I realize that there are problems here and some staff are not liking the changes that I tried to start, I wanted to do a good job and make changes. Ultimately, as the DON I am responsible for those things and everything that the nursing staff does and the interactions between departments to make sure things are done correctly. During an interview on [DATE] at 3:30 PM the ADON stated, The last time I worked was on [DATE], the ,[DATE] AM shift, the morning that (Resident #2's name) medication mistake was found. I was involved because I was finishing up and his sister asked me about medications, and the last time a medication mistake was discovered. An attempt was made to interview the nurse, via telephone to her last known number, who administered [MEDICATION NAME] and [MEDICATION NAME] to Resident #2. The nurse is no longer employed by the facility. The nurse had resigned from her position. The message received was that the number had been changed or was no longer in service. 5) Review of Resident #10's facility record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. The resident had a Full Code Status. Review of the nursing progress note dated [DATE] at 10:45 PM read: While receiving report from off going nurse, nursing assistant called for assistance to patient's room. Upon entering the room patient was assessed with [REDACTED]. Pulse palpated without result. Code Blue called, crash cart was brought to room. At 10:50 PM compressions were started. 911 was called. 6 rounds of compressions and breaths were performed. EMS arrived assessed the patient, transported patient to hospital. Review of Resident #10's record revealed there was no documentation of a Code Blue form. Review of the hospital records for Resident #10 dated [DATE] at 11:28 PM revealed HPI (History of Present Illness) Chief Complaint: [MEDICAL CONDITION], found down. Arrest Circumstances: Unwitnessed arrest. Context: Resuscitation [MEDICATION NAME] IV X 2 (for two doses). Context of Onset: Found unresponsive in [MEDICAL CONDITION]. Severity: Onset Severe. Severity: Current Severe. Free Test HPI Notes: Found unresponsive at nursing home with no pulse, EMS called and found pulseless. Alertness: Unresponsive. Pupils: Dilated, Nonreactive. Resp/Chest: No spontaneous Respirations. Cardiovascular: Pulseless. Neurologic: Unresponsive. Re-Evaluation: After extended effort to resuscitate she never regained pulses. Bedside ultrasound showed no cardiac activity. Patient Discharge & Departure: Condition: Expired. Disposition Decision: 2358 (11:58 PM). Date: [DATE]. During an interview on [DATE] at 2:25 PM Staff B, LPN stated, I work over at our sister facility I'm only helping out here. We share the same policies and procedures. I would not administer [MEDICATION NAME] to a resident that was lethargic or unresponsive. If the doctor did not write a hold for sedation order I would hold the medication and call them so that they could adjust the dose or timing of the medications or send the resident out to be evaluated. I am CPR certified and its current. I don't know where the emergency cart is, I am just helping out here. If I didn't know the resident's code status, I would not start CPR until I checked the chart. There is no other way to know that information. It's on my report sheet, but I don't always have that on me. I don't know how long that would take; maybe five minutes or less. You can't start CPR on a resident who is a DNR, so I would not start CPR until I knew for sure. I haven't gotten any training on code blue policy, medication policy or anything else recently. During an interview on [DATE] at 8:40 AM Staff I, LPN stated, I just started about one month ago, I got a week of orientation. I'm a brand-new nurse and still feel a little overwhelmed at times. My orientation was passing medications with another nurse. They didn't give me any type of check off sheet or competency to have anyone fill out. I did not go over any policies on code blue or any other policy during orientation. If a resident had orders to medicate with [MEDICATION NAME] and [MEDICATION NAME] around the clock, I would not administer the medications if the resident was lethargic or difficult to wake up or had shallow respirations. That would be contraindicated. I would call the doctor or the hospice nurse t

Based on interviews, record reviews, policy and procedure review, the facility failed to ensure the fundamental principles of quality of care was provided to facility residents with professional standards of practice, their plan of care, and residents' choices for 3 of 15 sampled residents, Residents #1, #2, and #10. The facility failed to follow physicians orders for medication administration and standards of practice when a resident was identified through lab results with a high blood ammonia level, (too much ammonia in the body can cause psychological problems like confusion, tiredness, and possibly coma or death) for not administering [MEDICATION NAME], (used to reduce the amount of ammonia in the blood) for Resident #1. The facility failed to follow physicians orders and standards of practice with the continuation of the administration of [MEDICATION NAME] (an opioid narcotic used for moderate to severe pain), and [MEDICATION NAME] (used for anxiety which acts on the brain and central nerves system), when a resident was assessed to be unresponsive, with decreased respirations, eyes non-reactive to light; Resident #2, (a major drug interaction exists between [MEDICATION NAME] and [MEDICATION NAME] that can lead to serious side effects including respiratory distress, coma, and even death). Resident #2 was transferred to the hospital emergency room and diagnosed by the hospital with an accidental overdose of [MEDICATION NAME]. The facility failed to initiate cardiopulmonary resuscitation immediately, resulting in a five minute delay in the initiation of CPR for Resident #10, with a full code status, when found unresponsive and absent of vital signs, the resident did not survive. The facility failed to initiate a plan of correction and thorough investigation into an abuse allegation made by Resident #1 placing 47 of 47 residents at risk, the facility failed to investigate and initiate a plan of correct for the identified neglect of significant medication errors for Residents #1 and #2, placing 47 of 47 residents at risk for deficient practice, and the facility failed to investigate and initiate a plan of correction for the neglect of a five minute delay in the initiation of CPR for Resident #10, with a full code status, when found unresponsive and absent of vital signs, the resident did not survive, placing 26 residents with a full code status at risk in a total of 47 residents. Cross reference to F600, F607, F610, F 658, F678, F726 and F835. The findings included: 1) Review of the Florida Nurse Practice Act and the Scope of Nursing, Chapter 6 read: IX. Scope of Practice: 3. Responsibility of Administration - Health care facilities have a responsibility to provide competent care to patients, which includes competent nursing care. The administration has an obligation to assess each nurse's skills and abilities to provide care to a specific patient population. This is often accomplished through orientation programs, job, evaluations, training programs, and continuing education courses. The administration also has a responsibility to plan and budget, which includes allocating resources so that adequate and appropriate nursing care is available. Finally, the administration of a health care facility has a responsibility to take appropriate action to prevent or remedy incompetent care. In the event disciplinary action is warranted, the administration has a duty to follow facility discipline policies. 4. Responsibility of the Nurse - A nurse has a duty to provide competent care to patients. This includes clarifying work assignments with management, as well as determining and assessing her own skills, knowledge and abilities. Providing competent nursing care also includes using informed judgement and decision making. Informed decision making requires a nurse to use her own knowledge and skills, as well as recognizing when the nurse needs additional assistance. 2) Review of Resident #1's facility record revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Initial dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 15 = no cognitive deficit. Review of the hospital AHCA (Agency for Health Care Administration) Form ,[DATE] dated [DATE] under the section titled, U. Mental/Cognitive Status At Transfer Alert, oriented, follows Instructions, was checked. Review of the Agency for Health Care Administration (AHCA) Nursing Homes Federal Reporting dated [DATE] revealed: Description of the Incident: The resident made an allegation of a staff member while changing her that she was punching her in her arm. Resident cried as Social Service was speaking to her. The Facility's Immediate Response revealed: 4. Statements was done by staff. 5. Interview was done by Social Service. Review of the written statement dated [DATE] by Staff P, CNA (Certified Nursing Assistant) read: At about 6:30 p.m. Sat. [DATE] was passing trays for supper. (Resident #1's name) was yelling she was wet and trying to crawl out of bed calling me all kinds of names that no one was changing her one of my co-worker came into her room to help me and she told him to get out, finally I started to change her bed and she was rowdy that I, when and got another co-worker (Staff V, CNA's name) to come and help me in the process of changing her bed she became mad at me for trying to change her and she begin to hit me and I, tried to catch her hands and arms and she was mad with (Staff V, CNA's name) for not helping her, and we trying to change her wet bed. I, call the nurse to tell her what had happen. Review of the written statement dated [DATE] by Staff V, CNA read: I was helping (Staff P, CNA's name) in room. The Resident became combative and refused care talking about she dieing. Review of the nursing progress notes dated [DATE] at 3:30 PM read: (Resident #1's name) is agitated making false accusations against staff. On [DATE] at 3:44 PM Reach out to hospice regards to behavior, staff is afraid to work with her due to false accusations she is making. During an interview on [DATE] at 8:55 AM with the Administrator a request was made for the complete investigation into the abuse allegation made by Resident #1. The Administrator stated that the corrective actions taken on behalf of Resident 1's abuse allegation, and pointed to a Posted Note and stated, there will be two staff in the room while accommodating her needs. The investigation was completed. Nurses are trained on how to redirect and care for patients. I am not a nurse my expectation is for them to know what they are doing. When asked if other residents residing on the same unit with Resident #1 were interviewed, to determine if they had suffered abuse, as part of the investigation, the Administrator replied she did not feel this was necessary since there was no abuse. When asked about this being part of the corrective action she stated, I was not aware that these were items that needed to be implemented as a corrective action when no alleged abuse had occurred. Review of the POS [REDACTED]. 2 Staff @ all times. All allegations will be reported. Document behaviors. Staff walk away if resident is upset. Ensure resident is safe. During an interview on [DATE] at 3:20 PM Staff P, stated, (Resident #1 name) was screaming she was soiled, I was passing trays at that time. I stopped and got help to clean her up. The resident started screaming 'you are killing me and cussing' and did not want the male CNA to touch her and all he was doing was helping me hold her and I was cleaning her. I went and got (Staff V, CNA's name) that made her mad she started saying that I was punching her. I was trying not to get punched and clean her up quickly, I felt I was the one who got abused. During an interview on [DATE] at 3:45 PM via telephone Staff V, CNA stated, I was called by (Staff P, CNA's name) in to help with this resident. I was supporting the (Resident #1's name) and the resident was looking at me and asking why am I allowing this to happen. I tried to reassure her as much as possible. The resident was swinging and cussing at (Staff P, CNA's name) and fussing at me. During an interview on [DATE] at 12:45 PM the Social Services Director stated, I completed the AHCA 5 day report. I had no training on how to conduct this investigation. I took down the witness statements and asked (Resident #1's name) the questions. Since the DON (Director of Nursing) was gone it was given to me to do. (Resident #1's name) had no recollection about the allegation of abuse. I go in and talk to her and she does not remember anything. Yesterday she was fussing at the staff. I would speak to her and she would say nothing. Review of Resident #1's lab dated [DATE] revealed Ammonia 100 High. (too much ammonia in the body can cause psychological problems like confusion, tiredness, and possibly coma or death) Review of the physician's orders [REDACTED]. Diagnosis: [REDACTED]. Dated [DATE] at 12:00 AM read: [MEDICATION NAME] 30 ml every 6 hours as needed. Review of the Medication Administration Record [REDACTED]. For the period of [DATE] at 9:00 PM to [DATE] the MAR indicated [REDACTED]. [MEDICATION NAME] 10 GM/15 ML Solution give 30 ML (20GM) by mouth every 6 hours as needed - [MEDICAL CONDITION] of liver. The documentation showed [MEDICATION NAME] was not administered as needed and was documented as discontinued on [DATE] at 9:00 AM. Review of the Discontinued Order - As Needed (Handwritten) form read: [MEDICATION NAME] 10 GM/15 ML (15 grams to 15 milliliters) Solution by mouth. Original Fill Date: [DATE]. Give 30 milligram by mouth as needed every 6 hours as needed. Discontinued Date: [DATE] at 1:14 PM. [MEDICATION NAME] 10 gm/15 ML Solution. Original Fill Date: [DATE]. Give 30 ML (20GM) by mouth every 6 hours as needed. Discontinued Date: [DATE] at 11:03 PM. [MEDICATION NAME] 10 GM/15 ML Solution. Original Fill Date: [DATE]. Give 30 Milliliter by mouth as needed every 6 hours. Discontinued Date: [DATE] at 11:03 PM. The Discontinued Orders were completed by licensed nursing staff and did not have a physician's signature line or signature for the discontinuation of the medication. During an interview on [DATE] at approximately 1:12 PM Resident #1's daughter stated, My mother would have periods of confusion and craziness and when that happened, I knew it was the ammonia level and she wasn't getting her [MEDICATION NAME]. During an interview on [DATE] at approximately 2:00 PM with the Administrator a request was made for documentation of the administration of [MEDICATION NAME] as ordered by the physician for the period of [DATE] at 9:00 PM to [DATE] at 9:00 AM (the resident was discharged to the hospital for an unrelated concern at approximately 7:00 PM on [DATE]) or for the physician's orders [REDACTED]. The Administrator stated she would have nursing provide the documentation. During an interview on [DATE] at approximately 10:00 AM with the Administrator a request was made for documentation of the administration of [MEDICATION NAME] as ordered by the physician for the period of [DATE] at 9:00 PM to [DATE] at 9:00 AM (the resident was discharged to the hospital for an unrelated concern at approximately 7:00 PM on [DATE]) or for the physician's orders [REDACTED]. The Administrator stated she let nursing know the documentation was needed. During an interview on [DATE] at approximately 4:00 PM with the Administrator a request was made for documentation of the administration of [MEDICATION NAME] as ordered by the physician for the period of [DATE] at 9:00 PM to [DATE] at 9:00 AM (the resident was discharged to the hospital for an unrelated concern at approximately 7:00 PM on [DATE]) or for the physician's orders [REDACTED]. The Administrator did not respond. No additional documentation was provided. 3) Review of Resident #2's facility record revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the hospice Treatment or Medication Form dated [DATE] [MEDICATION NAME] 1 mg oral every 4 hours PRN (as needed). Dated [DATE] read: [MEDICATION NAME] concentrate 20:1 10 mg = 0.5 ml SL (sublingual) every 4 hours ATC (around the clock). [MEDICATION NAME] 1 mg SL/PO (by mouth) every 4 hours ATC. (MONTH) hold for sedation. Please continue [MEDICATION NAME] sulfate and [MEDICATION NAME] every 4 hours PRN (as needed). Dated: [DATE] Lensin/Mycosamine 0.125 mg SL every 4 hours PRN - secretions. D/C (discontinue) nonessential meds d/t (due to) decline. Review of the Controlled Drug Declining Inventory Sheet for [MEDICATION NAME] ([MEDICATION NAME])1 mg tablet revealed the medication was signed out for administration on [DATE] at 10:00 AM, at 2:00 PM, at 08:00 PM, and at 12:00 AM. On [DATE] at 4:00 AM, at 8:00 AM, at 10:00 AM, at 12:00 PM, at 2:00 PM, at 5:30 PM, at 8:00 PM, and at 10:00 PM. On [DATE] at 12:00 midnight. [MEDICATION NAME] 100 mg/5 ml concentrate was signed out for administration [DATE] at 10:00 AM, at 02:00 PM, at 08:00 PM, [DATE] at 12:00 AM, [DATE] at 04:00 AM, 8:00 AM, at 10:00 AM, at 12:00 PM, at 2:00 PM, at 5:30 PM, at 8:00 PM, and at 10:00 PM. On [DATE] at 12:00 midnight and at 4:15 AM. Review of the care plan revised on [DATE] read: Focus: The resident is on pain medication therapy r/t end stage diagnosis. Goal: The resident will be free of any discomfort or adverse side effects from pain medication. Interventions: Administer [MEDICATION NAME] medications as ordered by physician. Monitor/document side effects and effectiveness Q (every) shift. Ask physician to review medication if side effects persist. Monitor/document/report PRN adverse reactions to [MEDICATION NAME] therapy: altered mental status, respiratory distress/decreased respirations, sedation. Focus: Use of [MEDICAL CONDITION] antianxiety drug places resident at risk for drug-related: Cognitive impairment. Initiated [DATE]. Goal: Resident will receive the least dosage of the prescribed [MEDICAL CONDITION] drug (s) to ensure maximum functional ability both mentally and physically. Interventions: [MEDICATION NAME] as ordered. Observe for side effects and hold medication for increased lethargy. Review of the nursing progress notes dated [DATE] at 2:37 PM New orders from hospice nurse [MEDICATION NAME] 1 mg PO @ HS (by mouth at hour of sleep). Dated: [DATE] at 6:21 AM Resident is not wanting to take his medications ([MEDICATION NAME]) Very lethargic and not wanting to open his mouth. Dated: [DATE] at 9:58 AM Resident tried to get out of bed. Stated he forgot he could not walk. Resident fell on his right side on the floor. Resident did not hit his head. Red marks on right hip and right shoulder. DON (Director of Nursing) and MD (Medical Doctor) notified. Resident was reminded to use call light any time he needs to get up. Dated: [DATE] at 11:11 AM Resident laying in bed sleeping. Easily arousable. No signs of pain or distress. Resident stated he was just tired and wanted to back to sleep. Date: [DATE] at 12:29 AM This nurse writing called hospice due to Resident making changes in mental status. Resident is restless, asking for someone to help him, climbing out of bed, Not eating or drinking sufficient amount. He is c/o (complaint of) abdominal pain. Hospice nurse on called made a visit received new order to increase [MEDICATION NAME], Q 4 hrs. PRN (hours as needed). Resident is being monitored closely to prevent resident injuries. Dated: [DATE] at 1:38 PM The resident has had a change is condition. When first observed the resident's jaw was twisted to the right and [MEDICAL CONDITION] is suspected. I obtained vital signs and notified hospice as well as his family. Family has been in to see the resident but hospice has not been in at this time 1:41 PM. (There was no documentation of the physician having been notified of the change in condition). Dated: [DATE] at 10:07 AM read: Resident is nonresponsive. Family notified and in facility. Hospice nurse in facility. Resident is currently on 4 L (liters) of O2 (oxygen) via nasal cannula r/t apnea (cessation of breathing). Dated: [DATE] at 12:23 PM. Resident eyes are no longer reactive to light. RR (respirations) approximately 8 per minutes, on 4 L O2 via nasal cannula. On [DATE] at 2:24 PM Being medicated on schedule every 2 hours as instructed by Hospice. Respirations 7 per minute. Currently unarousable again. On [DATE] at 3:52 PM Resident is wheezing and moaning. Still asleep. Not arousable. Breathing is slow and labored. On [DATE] at 3:3 PM Resident is currently lying in bed quietly sleeping with eyes half open. Responds to painful stimuli. Skin warm and dry to touch except for feet is cool. Respirations with long periods of inhale and exhale. No urine output so far this shift. Requires total assistance with ADL's, turning and repositioning. PO (by mouth) meal intake is zero d/t (due to) decrease alertness. On [DATE] at 9:04 AM Resident only responsive to painful stimuli. Hospice nurse in to see resident and review orders. Upon assessment determined to send resident to ER (emergency room ). Review of the hospice nursing progress notes dated [DATE] at 8:30 AM read, Reason for Focused Visit: Dying process/decline. Medication assessed for: Medicine reconciliation done. Effectiveness. Not taking meds as prescribed. Clinician Narrative Note: When I arrived there patient was unresponsive. Reviewed medications and patient has been getting the [MEDICATION NAME] 1 mg every 2 hours and [MEDICATION NAME] 10 mg every 2 hours instead of every 4 hours as ordered. Spoke with DON (Director of Nursing) and ADON (Assistant Director of Nursing) and they would like the patient to be sent to the ER for medication overdose. Spoke with sister at the bedside and she would like the patient to be sent out as well. Heat rate: 56. Respirations: 8. Blood Pressure ,[DATE]. O2 Sat (saturation) 92% on 2 LPM (liters per minute). Dated: [DATE] at 11:35 AM read, Clinician Narrative Note: Spoke to ER MD and the RN (Registered Nurse) along with sister at the bedside. Patient was given [MEDICATION NAME] to reverse the effects from the [MEDICATION NAME]. Dated: [DATE], unable to read time, Clinician Narrative Note: Patient had decline somewhat over the weekend .possibly transitioning. Pt (Patient) was in hospital ER with sister at Pt's bedside. Cp (Chaplin) spent much time comforting and encouraging pt's sister and later praying with both. Because sister did not want pt to go back to facility from which pt came, sister was looking for other options. Review of the EMS (Emergency Medical Services) note dated [DATE] revealed Chief Complaint: Overdose [MEDICATION NAME]. Meds Admin (Medications Administered) [MEDICATION NAME] 0.4 IV (intravenously). Review of the hospital records dated [DATE] revealed Chief Complaint: Drug overdose. History and Physical: Presents to ED via EMS d/t accidental overdose. Pt. sister states Pt has end stage liver failure and is on hospice at Crestwood Nursing home. Pt. was supposed to give (sic) 10 mg every 4 hours but they were giving 10 mg every 2 hours per Pt. sister. EMS gave Pt. [MEDICATION NAME] and drastically improved. Pt. denies any other Sx (symptoms) at this time. Free Text: Pt. sister does not like care given to Pt. at Crestwood Nursing home and would like someone else. Re-Evaluation/Progress #1: After [MEDICATION NAME] - Re-Eval Status: Improved. Eval Following Treatment: Pt. feels better, Condition improved. Condition: Stable. Review of the hospital Emergency Patient Record dated [DATE] revealed: Priority: 2/Emergent. Ingestion - Presenting signs/symptoms: Decreased Resp (respirations), Decreased L[NAME] (level of consciousness). Emergency Notes: [DATE] Assumed care of Pt. from previous RN. Pt. is alert when name is spoken to. Pt. has sister and hospice rep (representative) at bedside. Pt. is showing no signs of distress. Per Pt. advocate, Pt's family is requesting new hospice representation. Pt. is to be DC (discharged ) to new facility when it is determined. At 12:04 PM Pt. is resting comfortably with family at his side. No signs of distress noted. During an interview on [DATE] at 2:02 PM Staff A, Unit Manager/LPN (Licensed Practical Nurse) she stated, I am responsible for the unit, both of them since the other Unit Manager quit. I was involved in (Resident #2's name) transfer to the hospital. The hospice nurse came to me and told me the Resident had been given [MEDICATION NAME] and [MEDICATION NAME] every two hours the day before and was obtunded (lethargy in which the patient has a lessened interest in the environment, slowed responses to stimulation, and tends to sleep more than normal with drowsiness in between sleep states) with a very low respiratory rate. We told the DON who said to transfer the resident if that's what the sister wanted. The Administrator was called by the DON and told that the resident had a medication error and needed to go to the ED. So, I called 911 and got him to the hospital. That's all the involvement I had, except that I told The Administrator that the resident wasn't coming back because the sister didn't want him to. I called the hospital for an update and the hospice nurse let us know too. I didn't make out an incident report. When a resident gets medication, we should be monitoring them for any side effects and holding them and calling the doctor or the hospice nurse for any further orders if there are side effects. It is my expectation that I be informed of any changes in the residents' condition so that the resident can be assessed, and the problem can be addressed with the doctor. I expect the nurses to assess the residents for signs of over sedation. If a resident is sedated, hold medications until they check with hospice or the doctor and document all of that in the chart. During an interview on [DATE] at 4:55 PM the Hospice Nurse for Resident #2 stated, I did his initial consult on [DATE], and saw him again on [DATE], and when I saw him on Monday [DATE] there was a big difference, he was unresponsive when I saw him. It was reported to me that he had multiple falls over the weekend and agitation. The Resident's sister told me that he had been given medication every two hours per our orders and I knew that we did not have any orders for medications every two hours. When I checked our orders, we still had [MEDICATION NAME] 0.5 ml every 4 hours and a PRN (as needed) order for every 4 hours. But we did not give orders to medicate every 2 hours. After talking to the Director of Nursing and assessing the patient we were all in agreement that the patient should be sent to the ED and the Resident's sister agreed. I followed up on him once he went to the ED. He received [MEDICATION NAME] and was much more alert when I saw him, he was agitated but responsive. Our goal in pain control in end of life is to provide and promote comfort, we want our patients to be pain free, without anxiety. We want our patients to have enough medication to remain comfortable, not overmedicate them to a point where they require reversal agents. I was shocked because the man I saw on Monday was nowhere near the man I saw on Thursday. That was gross overmedication. The patient's sister did not want him to go back to Crestwood, and because we don't have another facility, we discharged him to another hospice, so the family had a sense of peace and comfort with his care. This Nurse should be reported because this was negligent. During a telephone interview on [DATE] at 10:45 AM the Hospice Doctor stated, I am the Physician for hospice and am aware of (Resident #2's name). He began hospice sometime in July. When he was first on service, he was taking [MEDICATION NAME] I believe and the switch to [MEDICATION NAME] began just a few days before he went to the emergency room . We routinely order [MEDICATION NAME] and [MEDICATION NAME] for comfort and anxiety. Our goal is anxiety reduction, symptom control and pain freedom at end of life. We medicate according to the patient's symptomology and frequently have routine orders and orders for breakthrough pain or anxiety. If I or any other of the hospice Physicians thinks medication more frequently than every four hours is necessary, we would order more frequent routine administration of narcotic [MEDICATION NAME]. Although, in my field I seldom have to worry about [MEDICATION NAME] administration and the concomitant use of benzodiazepines such as [MEDICATION NAME]. There would be a significant CNS (central nervous system) depression and respiratory depression effects particularly acute in a patient with liver and kidney disease. I would not have recommended every two hours around the clock administration of these drugs to (Resident #2's name) especially because of his diagnosis. We did not give or instruct the nurses at Crestwood to administer [MEDICATION NAME] and [MEDICATION NAME] every two hours. In this case he was overmedicated, and I would expect any nurse to call to speak with either the nurses or the doctor on call to determine if the medication should continue at the prescribed times or be adjusted and held. My understanding is (Resident #2's name) was obtunded (lethargy in which the patient has a lessened interest in the environment, slowed responses to stimulation, and tends to sleep more than normal with drowsiness in between sleep states) with a respiratory rate of ,[DATE] with long apneic (cessation of respiration) periods, this was discussed with family and the nursing home and the decision to send the patient out to the hospital for treatment was made by the family, staff and our staff followed the family wishes. Our nurse followed up in the emergency room and the patient had a significant change in alertness with [MEDICATION NAME] administration which overall tells us that he was overmedicated and that was not recognized by the staff at Crestwood. Overdosage and the need to use reversal agents has a profound effect on the patients that I treat, not only physical but psychological as well for both patients and their families. During an interview on [DATE] at 9:37 AM via telephone the DON stated, I did not evaluate (Resident #2's name). The first I heard about it was when the ADON/Educator told me he had been medicated every two hours with [MEDICATION NAME] and he was unarousable with a respiratory rate of 6 or 7 per minute. She stated he needed to be transferred out because we were killing him with medications, that he was obtunded and unable to respond to painful stimuli. The hospice nurse and sister wanted to transfer him to the hospital for evaluation and treatment. I never went to evaluate the resident he was already seen by the hospice nurse and the ADON, so I just started getting the transfer started. I trusted their judgement that he needed to be transferred. I did not do any investigation, there was no time to as I was suspended on [DATE]. I did not review the Narcotic Administration sheets. I did not look at any of the nurses' documentation or check any physician orders. I did not know that it was an adverse incident. I was told that he was administered medication every two hours of [MEDICATION NAME] and [MEDICATION NAME], but that he did not have orders to medicate that frequently. I did not instruct the nurses to make out an incident report. The Administrator knew the patient went to the hospital, got administered [MEDICATION NAME], and the sister did not want him to come back because of this. We were notified that day that he would not be returning. I really did not get to investigate any of this, I just started in (MONTH) and it takes time to determine that processes are broken. We have a lot of work to do to improve the care we deliver. We don't have a code blue sheet that we fill out if a resident codes. I wasn't aware that the policy stated we had one. I would think that if someone has a CPR card, they are proficient according to the American Red Cross. I didn't do anything to assess the staff competency in CPR or their comfort level in CPR. Anyone who is CPR certified can start CPR. I did not look at any of the Code Blues that we started and was not tracking them or looking at the documentation, that is the responsibility of the Unit manager to do that and bring any concerns to me and the Administrator during the morning meetings. I was not aware that a resident did not have CPR started for five minutes. We don't have an AED (Automated External Defibrillator) that I am aware of. I'm not the Risk Manager, that's the ADON's job. I realize that there are problems here and some staff are not liking the changes that I tried to start, I wanted to do a good job and make changes. Ultimately, as the DON I am responsible for those things and everything that the nursing staff does and the interactions between departments to make sure things are done correctly. During an interview on [DATE] at 3:30 PM the ADON stated, The last time I worked was on [DATE], the ,[DATE] AM shift, the morning that (Resident #2's name) medication mistake was found. I was involved because I was finishing up and his sister asked me about medications, and the last time a medication mistake was discovered. An attempt was made to interview the nurse, via telephone to her last known number, who administered [MEDICATION NAME] and [MEDICATION NAME] to Resident #2. The nurse is no longer employed by the facility. The nurse had resigned from her position. The message received was that the number had been changed or was no longer in service. 4) Review of Resident #10's facility record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. The resident had a Full Code Status. Review of the nursing progress note dated [DATE] at 10:45 PM read: While receiving report from off going nurse, nursing assistant called for assistance to patient's room. Upon entering the room patient was assessed with [REDACTED]. Pulse palpated without result. Code Blue called, crash cart was brought to room. At 10:50 PM compressions were started. 911 was called. 6 rounds of compressions and breaths were performed. EMS arrived assessed the patient, transported patient to hospital. Review of Resident #10's record revealed there was no documentation of a Code Blue form. Review of the hospital records for Resident #10 dated [DATE] at 11:28 PM revealed HPI (History of Present Illness) Chief Complaint: [MEDICAL CONDITION], found down. Arrest Circumstances: Unwitnessed arrest. Context: Resuscitation [MEDICATION NAME] IV X 2 (for two doses). Context of Onset: Found unresponsive in [MEDICAL CONDITION]. Severity: Onset Severe. Severity: Current Severe. Free Test HPI Notes: Found unresponsive at nursing home with no pulse, EMS called and found pulseless. Alertness: Unresponsive. Pupils: Dilated, Nonreactive. Resp/Chest: No spontaneous Respirations. Cardiovascular: Pulseless. Neurologic: Unresponsive. Re-Evaluation: After extended effort to resuscitate she never regained pulses. Bedside ultrasound showed no cardiac activity. Patient Discharge & Departure: Condition: Expired. Disposition Decision: 2358 (11:58 PM). Date: [DATE]. During an interview on [DATE] at 2:25 PM Staff B, LPN stated, I work over at our sister facility I'm only helping out here. We share the same policies and procedures. I would not administer [MEDICATION NAME] to a resident that was lethargic or unresponsive. If the doctor did

Based on interviews, record reviews, and policy and procedure reviews the facility failed to ensure nursing staff had appropriate competencies and skills sets to provide nursing and related services to assure resident safety and to attain or maintain their highest practicable physical well-being for 3 of 15 sampled residents, Residents #1, #2, and #10. The facility failed to follow physicians orders for medication administration and standards of practice when a resident was identified through lab results with a high blood ammonia level, (too much ammonia in the body can cause psychological problems like confusion, tiredness, and possibly coma or death) for not administering [MEDICATION NAME], (used to reduce the amount of ammonia in the blood) for Resident #1. The facility failed to follow physicians orders and standards of practice with the continuation of the administration of [MEDICATION NAME] (an opioid narcotic used for moderate to severe pain), and [MEDICATION NAME] (used for anxiety which acts on the brain and central nerves system), when a resident was assessed to be unresponsive, with decreased respirations, eyes non-reactive to light; Resident #2, (a major drug interaction exists between [MEDICATION NAME] and [MEDICATION NAME] that can lead to serious side effects including respiratory distress, coma, and even death). Resident #2 was transferred to the hospital emergency room and diagnosed by the hospital with an accidental overdose of [MEDICATION NAME]. The facility failed to ensure cardiopulmonary resuscitation was initiated immediately when a resident was found unresponsive and absent of vital signs, resulting in a five minute delay, the resident had a full code status, the resident did not survive, Resident #10. The facility failed to initiate a plan of correction and thorough investigation into an abuse allegation made by Resident #1 placing 47 of 47 residents at risk, the facility failed to investigate and initiate a plan of correct for the identified neglect of significant medication errors for Residents #1 and #2, placing 47 of 47 residents at risk for the same deficient practice, and the facility failed to investigate and initiate a plan of correction for the neglect of a five minute delay in the initiation of CPR for Resident #10, with a full code status, when found unresponsive and absent of vital signs, the resident did not survive, placing 26 residents with a full code status at risk in a total of 47 residents. Cross reference to F600, F658, F675, F678, F760, and F835 The findings included: 1) Review of the Florida Nurse Practice Act and the Scope of Nursing, Chapter 6 read: IX. Scope of Practice: 3. Responsibility of Administration - Health care facilities have a responsibility to provide competent care to patients, which includes competent nursing care. The administration has an obligation to assess each nurse's skills and abilities to provide care to a specific patient population. This is often accomplished through orientation programs, job, evaluations, training programs, and continuing education courses. The administration also has a responsibility to plan and budget, which includes allocating resources so that adequate and appropriate nursing care is available. Finally, the administration of a health care facility has a responsibility to take appropriate action to prevent or remedy incompetent care. In the event disciplinary action is warranted, the administration has a duty to follow facility discipline policies. 4. Responsibility of the Nurse - A nurse has a duty to provide competent care to patients. This includes clarifying work assignments with management, as well as determining and assessing her own skills, knowledge and abilities. Providing competent nursing care also includes using informed judgement and decision making. Informed decision making requires a nurse to use her own knowledge and skills, as well as recognizing when the nurse needs additional assistance. 2) Review of Resident #1's facility record revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. 3) Review of the Minimum Data Set (MDS) Initial dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 15 = no cognitive deficit. Review of the hospital AHCA (Agency for Health Care Administration) Form ,[DATE] dated [DATE] under the section titled, U. Mental/Cognitive Status At Transfer Alert, oriented, follows Instructions, was checked. Review of the Agency for Health Care Administration (AHCA) Nursing Homes Federal Reporting dated [DATE] revealed: Description of the Incident: The resident made an allegation of a staff member while changing her that she was punching her in her arm. Resident cried as Social Service was speaking to her. The Facility's Immediate Response revealed: 4. Statements was done by staff. 5. Interview was done by Social Service. Review of the written statement dated [DATE] by Staff P, CNA (Certified Nursing Assistant) read: At about 6:30 p.m. Sat. [DATE] was passing trays for supper. (Resident #1's name) was yelling she was wet and trying to crawl out of bed calling me all kinds of names that no one was changing her one of my co-worker came into her room to help me and she told him to get out, finally I started to change her bed and she was rowdy that I, when and got another co-worker (Staff V, CNA's name) to come and help me in the process of changing her bed she became mad at me for trying to change her and she begin to hit me and I, tried to catch her hands and arms and she was mad with (Staff V, CNA's name) for not helping her, and we trying to change her wet bed. I, call the nurse to tell her what had happen. Review of the written statement dated [DATE] by Staff V, CNA read: I was helping (Staff P, CNA's name) in room. The Resident became combative and refused care talking about she dieing. Review of the nursing progress notes dated [DATE] at 3:30 PM read: (Resident #1's name) is agitated making false accusations against staff. On [DATE] at 3:44 PM Reach out to hospice regards to behavior, staff is afraid to work with her due to false accusations she is making. During an interview on [DATE] at 8:55 AM with the Administrator a request was made for the complete investigation into the abuse allegation made by Resident #1. The Administrator stated that the corrective actions taken on behalf of Resident 1's abuse allegation, and pointed to a Posted Note and stated, there will be two staff in the room while accommodating her needs. The investigation was completed. Nurses are trained on how to redirect and care for patients. I am not a nurse my expectation is for them to know what they are doing. When asked if other residents residing on the same unit with Resident #1 were interviewed, to determine if they had suffered abuse, as part of the investigation, the Administrator replied she did not feel this was necessary since there was no abuse. When asked about this being part of the corrective action she stated, I was not aware that these were items that needed to be implemented as a corrective action when no alleged abuse had occurred. Review of the POS [REDACTED]. 2 Staff @ all times. All allegations will be reported. Document behaviors. Staff walk away if resident is upset. Ensure resident is safe. During an interview on [DATE] at 3:20 PM Staff P, stated, (Resident #1 name) was screaming she was soiled, I was passing trays at that time. I stopped and got help to clean her up. The resident started screaming 'you are killing me and cussing' and did not want the male CNA to touch her and all he was doing was helping me hold her and I was cleaning her. I went and got (Staff V, CNA's name) that made her mad she started saying that I was punching her. I was trying not to get punched and clean her up quickly, I felt I was the one who got abused. During an interview on [DATE] at 3:45 PM via telephone Staff V, CNA stated, I was called by (Staff P, CNA's name) in to help with this resident. I was supporting the (Resident #1's name) and the resident was looking at me and asking why am I allowing this to happen. I tried to reassure her as much as possible. The resident was swinging and cussing at (Staff P, CNA's name) and fussing at me. During an interview on [DATE] at 12:45 PM the Social Services Director stated, I completed the AHCA 5 day report. I had no training on how to conduct this investigation. I took down the witness statements and asked (Resident #1's name) the questions. Since the DON (Director of Nursing) was gone it was given to me to do. (Resident #1's name) had no recollection about the allegation of abuse. I go in and talk to her and she does not remember anything. Yesterday she was fussing at the staff. I would speak to her and she would say nothing. Review of Resident #1's lab dated [DATE] revealed Ammonia 100 High. (too much ammonia in the body can cause psychological problems like confusion, tiredness, and possibly coma or death) Review of the physician's orders [REDACTED]. Diagnosis: [REDACTED]. Dated [DATE] at 12:00 AM read: [MEDICATION NAME] 30 ml every 6 hours as needed. Review of the Medication Administration Record [REDACTED]. For the period of [DATE] at 9:00 PM to [DATE] the MAR indicated [REDACTED]. [MEDICATION NAME] 10 GM/15 ML Solution give 30 ML (20GM) by mouth every 6 hours as needed - [MEDICAL CONDITION] of liver. The documentation showed [MEDICATION NAME] was not administered as needed and was documented as discontinued on [DATE] at 9:00 AM. Review of the Discontinued Order - As Needed (Handwritten) form read: [MEDICATION NAME] 10 GM/15 ML (15 grams to 15 milliliters) Solution by mouth. Original Fill Date: [DATE]. Give 30 milligram by mouth as needed every 6 hours as needed. Discontinued Date: [DATE] at 1:14 PM. [MEDICATION NAME] 10 gm/15 ML Solution. Original Fill Date: [DATE]. Give 30 ML (20GM) by mouth every 6 hours as needed. Discontinued Date: [DATE] at 11:03 PM. [MEDICATION NAME] 10 GM/15 ML Solution. Original Fill Date: [DATE]. Give 30 Milliliter by mouth as needed every 6 hours. Discontinued Date: [DATE] at 11:03 PM. The Discontinued Orders were completed by licensed nursing staff and did not have a physician's signature line or signature for the discontinuation of the medication. During an interview on [DATE] at approximately 1:12 PM Resident #1's daughter stated, My mother would have periods of confusion and craziness and when that happened, I knew it was the ammonia level and she wasn't getting her [MEDICATION NAME]. During an interview on [DATE] at approximately 2:00 PM with the Administrator a request was made for documentation of the administration of [MEDICATION NAME] as ordered by the physician for the period of [DATE] at 9:00 PM to [DATE] at 9:00 AM (the resident was discharged to the hospital for an unrelated concern at approximately 7:00 PM on [DATE]) or for the physician's orders [REDACTED]. The Administrator stated she would have nursing provide the documentation. During an interview on [DATE] at approximately 10:00 AM with the Administrator a request was made for documentation of the administration of [MEDICATION NAME] as ordered by the physician for the period of [DATE] at 9:00 PM to [DATE] at 9:00 AM (the resident was discharged to the hospital for an unrelated concern at approximately 7:00 PM on [DATE]) or for the physician's orders [REDACTED]. The Administrator stated she let nursing know the documentation was needed. During an interview on [DATE] at approximately 4:00 PM with the Administrator a request was made for documentation of the administration of [MEDICATION NAME] as ordered by the physician for the period of [DATE] at 9:00 PM to [DATE] at 9:00 AM (the resident was discharged to the hospital for an unrelated concern at approximately 7:00 PM on [DATE]) or for the physician's orders [REDACTED]. The Administrator did not respond. No additional documentation was provided. 4) Review of Resident #2's facility record revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the hospice Treatment or Medication Form dated [DATE] [MEDICATION NAME] 1 mg oral every 4 hours PRN (as needed). Dated [DATE] read: [MEDICATION NAME] concentrate 20:1 10 mg = 0.5 ml SL (sublingual) every 4 hours ATC (around the clock). [MEDICATION NAME] 1 mg SL/PO (by mouth) every 4 hours ATC. (MONTH) hold for sedation. Please continue [MEDICATION NAME] sulfate and [MEDICATION NAME] every 4 hours PRN (as needed). Dated: [DATE] Lensin/Mycosamine 0.125 mg SL every 4 hours PRN - secretions. D/C (discontinue) nonessential meds d/t (due to) decline. Review of the Controlled Drug Declining Inventory Sheet for [MEDICATION NAME] ([MEDICATION NAME])1 mg tablet revealed the medication was signed out for administration on [DATE] at 10:00 AM, at 2:00 PM, at 08:00 PM, and at 12:00 AM. On [DATE] at 4:00 AM, at 8:00 AM, at 10:00 AM, at 12:00 PM, at 2:00 PM, at 5:30 PM, at 8:00 PM, and at 10:00 PM. On [DATE] at 12:00 midnight. [MEDICATION NAME] 100 mg/5 ml concentrate was signed out for administration [DATE] at 10:00 AM, at 02:00 PM, at 08:00 PM, [DATE] at 12:00 AM, [DATE] at 04:00 AM, 8:00 AM, at 10:00 AM, at 12:00 PM, at 2:00 PM, at 5:30 PM, at 8:00 PM, and at 10:00 PM. On [DATE] at 12:00 midnight and at 4:15 AM. Review of the care plan revised on [DATE] read: Focus: The resident is on pain medication therapy r/t end stage diagnosis. Goal: The resident will be free of any discomfort or adverse side effects from pain medication. Interventions: Administer [MEDICATION NAME] medications as ordered by physician. Monitor/document side effects and effectiveness Q (every) shift. Ask physician to review medication if side effects persist. Monitor/document/report PRN adverse reactions to [MEDICATION NAME] therapy: altered mental status, respiratory distress/decreased respirations, sedation. Focus: Use of [MEDICAL CONDITION] antianxiety drug places resident at risk for drug-related: Cognitive impairment. Initiated [DATE]. Goal: Resident will receive the least dosage of the prescribed [MEDICAL CONDITION] drug (s) to ensure maximum functional ability both mentally and physically. Interventions: [MEDICATION NAME] as ordered. Observe for side effects and hold medication for increased lethargy. Review of the nursing progress notes dated [DATE] at 2:37 PM New orders from hospice nurse [MEDICATION NAME] 1 mg PO @ HS (by mouth at hour of sleep). Dated: [DATE] at 6:21 AM Resident is not wanting to take his medications ([MEDICATION NAME]) Very lethargic and not wanting to open his mouth. Dated: [DATE] at 9:58 AM Resident tried to get out of bed. Stated he forgot he could not walk. Resident fell on his right side on the floor. Resident did not hit his head. Red marks on right hip and right shoulder. DON (Director of Nursing) and MD (Medical Doctor) notified. Resident was reminded to use call light any time he needs to get up. Dated: [DATE] at 11:11 AM Resident laying in bed sleeping. Easily arousable. No signs of pain or distress. Resident stated he was just tired and wanted to back to sleep. Date: [DATE] at 12:29 AM This nurse writing called hospice due to Resident making changes in mental status. Resident is restless, asking for someone to help him, climbing out of bed, Not eating or drinking sufficient amount. He is c/o (complaint of) abdominal pain. Hospice nurse on called made a visit received new order to increase [MEDICATION NAME], Q 4 hrs. PRN (hours as needed). Resident is being monitored closely to prevent resident injuries. Dated: [DATE] at 1:38 PM The resident has had a change is condition. When first observed the resident's jaw was twisted to the right and [MEDICAL CONDITION] is suspected. I obtained vital signs and notified hospice as well as his family. Family has been in to see the resident but hospice has not been in at this time 1:41 PM. (There was no documentation of the physician having been notified of the change in condition). Dated: [DATE] at 10:07 AM read: Resident is nonresponsive. Family notified and in facility. Hospice nurse in facility. Resident is currently on 4 L (liters) of O2 (oxygen) via nasal cannula r/t apnea (cessation of breathing). Dated: [DATE] at 12:23 PM. Resident eyes are no longer reactive to light. RR (respirations) approximately 8 per minutes, on 4 L O2 via nasal cannula. On [DATE] at 2:24 PM Being medicated on schedule every 2 hours as instructed by Hospice. Respirations 7 per minute. Currently unarousable again. On [DATE] at 3:52 PM Resident is wheezing and moaning. Still asleep. Not arousable. Breathing is slow and labored. On [DATE] at 3:3 PM Resident is currently lying in bed quietly sleeping with eyes half open. Responds to painful stimuli. Skin warm and dry to touch except for feet is cool. Respirations with long periods of inhale and exhale. No urine output so far this shift. Requires total assistance with ADL's, turning and repositioning. PO (by mouth) meal intake is zero d/t (due to) decrease alertness. On [DATE] at 9:04 AM Resident only responsive to painful stimuli. Hospice nurse in to see resident and review orders. Upon assessment determined to send resident to ER (emergency room ). Review of the hospice nursing progress notes dated [DATE] at 8:30 AM read, Reason for Focused Visit: Dying process/decline. Medication assessed for: Medicine reconciliation done. Effectiveness. Not taking meds as prescribed. Clinician Narrative Note: When I arrived there patient was unresponsive. Reviewed medications and patient has been getting the [MEDICATION NAME] 1 mg every 2 hours and [MEDICATION NAME] 10 mg every 2 hours instead of every 4 hours as ordered. Spoke with DON (Director of Nursing) and ADON (Assistant Director of Nursing) and they would like the patient to be sent to the ER for medication overdose. Spoke with sister at the bedside and she would like the patient to be sent out as well. Heat rate: 56. Respirations: 8. Blood Pressure ,[DATE]. O2 Sat (saturation) 92% on 2 LPM (liters per minute). Dated: [DATE] at 11:35 AM read, Clinician Narrative Note: Spoke to ER MD and the RN (Registered Nurse) along with sister at the bedside. Patient was given [MEDICATION NAME] to reverse the effects from the [MEDICATION NAME]. Dated: [DATE], unable to read time, Clinician Narrative Note: Patient had decline somewhat over the weekend .possibly transitioning. Pt (Patient) was in hospital ER with sister at Pt's bedside. Cp (Chaplin) spent much time comforting and encouraging pt's sister and later praying with both. Because sister did not want pt to go back to facility from which pt came, sister was looking for other options. Review of the EMS (Emergency Medical Services) note dated [DATE] revealed Chief Complaint: Overdose [MEDICATION NAME]. Meds Admin (Medications Administered) [MEDICATION NAME] 0.4 IV (intravenously). Review of the hospital records dated [DATE] revealed Chief Complaint: Drug overdose. History and Physical: Presents to ED via EMS d/t accidental overdose. Pt. sister states Pt has end stage liver failure and is on hospice at Crestwood Nursing home. Pt. was supposed to give (sic) 10 mg every 4 hours but they were giving 10 mg every 2 hours per Pt. sister. EMS gave Pt. [MEDICATION NAME] and drastically improved. Pt. denies any other Sx (symptoms) at this time. Free Text: Pt. sister does not like care given to Pt. at Crestwood Nursing home and would like someone else. Re-Evaluation/Progress #1: After [MEDICATION NAME] - Re-Eval Status: Improved. Eval Following Treatment: Pt. feels better, Condition improved. Condition: Stable. Review of the hospital Emergency Patient Record dated [DATE] revealed: Priority: 2/Emergent. Ingestion - Presenting signs/symptoms: Decreased Resp (respirations), Decreased L[NAME] (level of consciousness). Emergency Notes: [DATE] Assumed care of Pt. from previous RN. Pt. is alert when name is spoken to. Pt. has sister and hospice rep (representative) at bedside. Pt. is showing no signs of distress. Per Pt. advocate, Pt's family is requesting new hospice representation. Pt. is to be DC (discharged ) to new facility when it is determined. At 12:04 PM Pt. is resting comfortably with family at his side. No signs of distress noted. During an interview on [DATE] at 2:02 PM Staff A, Unit Manager/LPN (Licensed Practical Nurse) she stated, I am responsible for the unit, both of them since the other Unit Manager quit. I was involved in (Resident #2's name) transfer to the hospital. The hospice nurse came to me and told me the Resident had been given [MEDICATION NAME] and [MEDICATION NAME] every two hours the day before and was obtunded (lethargy in which the patient has a lessened interest in the environment, slowed responses to stimulation, and tends to sleep more than normal with drowsiness in between sleep states) with a very low respiratory rate. We told the DON who said to transfer the resident if that's what the sister wanted. The Administrator was called by the DON and told that the resident had a medication error and needed to go to the ED. So, I called 911 and got him to the hospital. That's all the involvement I had, except that I told The Administrator that the resident wasn't coming back because the sister didn't want him to. I called the hospital for an update and the hospice nurse let us know too. I didn't make out an incident report. When a resident gets medication, we should be monitoring them for any side effects and holding them and calling the doctor or the hospice nurse for any further orders if there are side effects. It is my expectation that I be informed of any changes in the residents' condition so that the resident can be assessed, and the problem can be addressed with the doctor. I expect the nurses to assess the residents for signs of over sedation. If a resident is sedated, hold medications until they check with hospice or the doctor and document all of that in the chart. During an interview on [DATE] at 4:55 PM the Hospice Nurse for Resident #2 stated, I did his initial consult on [DATE], and saw him again on [DATE], and when I saw him on Monday [DATE] there was a big difference, he was unresponsive when I saw him. It was reported to me that he had multiple falls over the weekend and agitation. The Resident's sister told me that he had been given medication every two hours per our orders and I knew that we did not have any orders for medications every two hours. When I checked our orders, we still had [MEDICATION NAME] 0.5 ml every 4 hours and a PRN (as needed) order for every 4 hours. But we did not give orders to medicate every 2 hours. After talking to the Director of Nursing and assessing the patient we were all in agreement that the patient should be sent to the ED and the Resident's sister agreed. I followed up on him once he went to the ED. He received [MEDICATION NAME] and was much more alert when I saw him, he was agitated but responsive. Our goal in pain control in end of life is to provide and promote comfort, we want our patients to be pain free, without anxiety. We want our patients to have enough medication to remain comfortable, not overmedicate them to a point where they require reversal agents. I was shocked because the man I saw on Monday was nowhere near the man I saw on Thursday. That was gross overmedication. The patient's sister did not want him to go back to Crestwood, and because we don't have another facility, we discharged him to another hospice, so the family had a sense of peace and comfort with his care. This Nurse should be reported because this was negligent. During a telephone interview on [DATE] at 10:45 AM the Hospice Doctor stated, I am the Physician for hospice and am aware of (Resident #2's name). He began hospice sometime in July. When he was first on service, he was taking [MEDICATION NAME] I believe and the switch to [MEDICATION NAME] began just a few days before he went to the emergency room . We routinely order [MEDICATION NAME] and [MEDICATION NAME] for comfort and anxiety. Our goal is anxiety reduction, symptom control and pain freedom at end of life. We medicate according to the patient's symptomology and frequently have routine orders and orders for breakthrough pain or anxiety. If I or any other of the hospice Physicians thinks medication more frequently than every four hours is necessary, we would order more frequent routine administration of narcotic [MEDICATION NAME]. Although, in my field I seldom have to worry about [MEDICATION NAME] administration and the concomitant use of benzodiazepines such as [MEDICATION NAME]. There would be a significant CNS (central nervous system) depression and respiratory depression effects particularly acute in a patient with liver and kidney disease. I would not have recommended every two hours around the clock administration of these drugs to (Resident #2's name) especially because of his diagnosis. We did not give or instruct the nurses at Crestwood to administer [MEDICATION NAME] and [MEDICATION NAME] every two hours. In this case he was overmedicated, and I would expect any nurse to call to speak with either the nurses or the doctor on call to determine if the medication should continue at the prescribed times or be adjusted and held. My understanding is (Resident #2's name) was obtunded (lethargy in which the patient has a lessened interest in the environment, slowed responses to stimulation, and tends to sleep more than normal with drowsiness in between sleep states) with a respiratory rate of ,[DATE] with long apneic (cessation of respiration) periods, this was discussed with family and the nursing home and the decision to send the patient out to the hospital for treatment was made by the family, staff and our staff followed the family wishes. Our nurse followed up in the emergency room and the patient had a significant change in alertness with [MEDICATION NAME] administration which overall tells us that he was overmedicated and that was not recognized by the staff at Crestwood. Overdosage and the need to use reversal agents has a profound effect on the patients that I treat, not only physical but psychological as well for both patients and their families. During an interview on [DATE] at 9:37 AM via telephone the DON stated, I did not evaluate (Resident #2's name). The first I heard about it was when the ADON/Educator told me he had been medicated every two hours with [MEDICATION NAME] and he was unarousable with a respiratory rate of 6 or 7 per minute. She stated he needed to be transferred out because we were killing him with medications, that he was obtunded and unable to respond to painful stimuli. The hospice nurse and sister wanted to transfer him to the hospital for evaluation and treatment. I never went to evaluate the resident he was already seen by the hospice nurse and the ADON, so I just started getting the transfer started. I trusted their judgement that he needed to be transferred. I did not do any investigation, there was no time to as I was suspended on [DATE]. I did not review the Narcotic Administration sheets. I did not look at any of the nurses' documentation or check any physician orders. I did not know that it was an adverse incident. I was told that he was administered medication every two hours of [MEDICATION NAME] and [MEDICATION NAME], but that he did not have orders to medicate that frequently. I did not instruct the nurses to make out an incident report. The Administrator knew the patient went to the hospital, got administered [MEDICATION NAME], and the sister did not want him to come back because of this. We were notified that day that he would not be returning. I really did not get to investigate any of this, I just started in (MONTH) and it takes time to determine that processes are broken. We have a lot of work to do to improve the care we deliver. We don't have a code blue sheet that we fill out if a resident codes. I wasn't aware that the policy stated we had one. I would think that if someone has a CPR card, they are proficient according to the American Red Cross. I didn't do anything to assess the staff competency in CPR or their comfort level in CPR. Anyone who is CPR certified can start CPR. I did not look at any of the Code Blues that we started and was not tracking them or looking at the documentation, that is the responsibility of the Unit manager to do that and bring any concerns to me and the Administrator during the morning meetings. I was not aware that a resident did not have CPR started for five minutes. We don't have an AED (Automated External Defibrillator) that I am aware of. I'm not the Risk Manager, that's the ADON's job. I realize that there are problems here and some staff are not liking the changes that I tried to start, I wanted to do a good job and make changes. Ultimately, as the DON I am responsible for those things and everything that the nursing staff does and the interactions between departments to make sure things are done correctly. During an interview on [DATE] at 3:30 PM the ADON stated, The last time I worked was on [DATE], the ,[DATE] AM shift, the morning that (Resident #2's name) medication mistake was found. I was involved because I was finishing up and his sister asked me about medications, and the last time a medication mistake was discovered. An attempt was made to interview the nurse, via telephone to her last known number, who administered [MEDICATION NAME] and [MEDICATION NAME] to Resident #2. The nurse is no longer employed by the facility. The nurse had resigned from her position. The message received was that the number had been changed or was no longer in service. 5) Review of Resident #10's facility record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. The resident had a Full Code Status. Review of the nursing progress note dated [DATE] at 10:45 PM read: While receiving report from off going nurse, nursing assistant called for assistance to patient's room. Upon entering the room patient was assessed with [REDACTED]. Pulse palpated without result. Code Blue called, crash cart was brought to room. At 10:50 PM compressions were started. 911 was called. 6 rounds of compressions and breaths were performed. EMS arrived assessed the patient, transported patient to hospital. Review of Resident #10's record revealed there was no documentation of a Code Blue form. Review of the hospital records for Resident #10 dated [DATE] at 11:28 PM revealed HPI (History of Present Illness) Chief Complaint: [MEDICAL CONDITION], found down. Arrest Circumstances: Unwitnessed arrest. Context: Resuscitation [MEDICATION NAME] IV X 2 (for two doses). Context of Onset: Found unresponsive in [MEDICAL CONDITION]. Severity: Onset Severe. Severity: Current Severe. Free Test HPI Notes: Found unresponsive at nursing home with no pulse, EMS called and found pulseless. Alertness: Unresponsive. Pupils: Dilated, Nonreactive. Resp/Chest: No spontaneous Respirations. Cardiovascular: Pulseless. Neurologic: Unresponsive. Re-Evaluation: After extended effort to resuscitate she never regained pulses. Bedside ultrasound showed no cardiac activity. Patient Discharge & Departure: Condition: Expired. Disposition Decision: 2358 (11:58 PM). Date: [DATE]. During an interview on [DATE] at 2:25 PM Staff B, LPN stated, I work over at our sister facility I'm only helping out here. We share the same policies and procedures. I would not administer [MEDICATION NAME] to a resident that

Based on interviews, record reviews, and policy and procedure reviews the facility failed to ensure the facility was administered in a manner that enables the use of its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to ensure nursing staff had appropriate competencies and skills sets to provide nursing and related services to assure resident safety and to attain or maintain their highest practicable physical well-being for 3 of 15 sampled residents, Residents #1, #2, and #10. The facility failed to thoroughly investigate an allegation of abuse of a staff member punching a resident in the arm, Resident #1. The facility failed to implement policy and procedures for medication administration by not following physicians orders and standards of practice when a resident was identified through lab results with a high blood ammonia level, (too much ammonia in the body can cause psychological problems like confusion, tiredness, and possibly coma or death) for not administering [MEDICATION NAME], (used to reduce the amount of ammonia in the blood) for Resident #1. The facility failed to follow physicians orders, implement policy and procedures, and follow standards of practice with the continuation of the administration of [MEDICATION NAME] (an opioid narcotic used for moderate to severe pain), and [MEDICATION NAME] (used for anxiety which acts on the brain and central nerves system), when a resident was assessed to be unresponsive, with decreased respirations, eyes non-reactive to light; Resident #2, (a major drug interaction exists between [MEDICATION NAME] and [MEDICATION NAME] that can lead to serious side effects including respiratory distress, coma, and even death). Resident #2 was transferred to the hospital emergency room and diagnosed by the hospital with an accidental overdose of [MEDICATION NAME]. The facility failed to implement cardiopulmonary resuscitation (CPR) for a resident with a full code status when found unresponsive and absent of vital signs. This resulted in a five minute delay, the resident did not survive, Resident #10. The facility failed to initiate a plan of correction and thorough investigation into an abuse allegation made by Resident #1 placing 47 of 47 residents at risk, the facility failed to investigate and initiate a plan of correct for the identified neglect of significant medication errors for Residents #1 and #2, placing 47 of 47 residents at risk for deficient practice, and the facility failed to investigate and initiate a plan of correction for the neglect for a five minute delay in the initiation of CPR for Resident #10, with a full code status, when found unresponsive and absent of vital signs, the resident did not survive, placing 26 residents with a full code status at risk in a total of 47 residents. Cross reference to F600, F607, F610, F658, F675, F678, F684, F726, F760, and F835 The findings included: 1) Review of the Florida Nurse Practice Act and the Scope of Nursing, Chapter 6 read: IX. Scope of Practice: 3. Responsibility of Administration - Health care facilities have a responsibility to provide competent care to patients, which includes competent nursing care. The administration has an obligation to assess each nurse's skills and abilities to provide care to a specific patient population. This is often accomplished through orientation programs, job, evaluations, training programs, and continuing education courses. The administration also has a responsibility to plan and budget, which includes allocating resources so that adequate and appropriate nursing care is available. Finally, the administration of a health care facility has a responsibility to take appropriate action to prevent or remedy incompetent care. In the event disciplinary action is warranted, the administration has a duty to follow facility discipline policies. 4. Responsibility of the Nurse - A nurse has a duty to provide competent care to patients. This includes clarifying work assignments with management, as well as determining and assessing her own skills, knowledge and abilities. Providing competent nursing care also includes using informed judgement and decision making. Informed decision making requires a nurse to use her own knowledge and skills, as well as recognizing when the nurse needs additional assistance. Review of the Florida Board of Nursing Certified Nursing Assistant (CNA) read: All CNAs must complete a minimum of 24 hours of in-service training each biennium. In-service training hours shall include, but are not limited to, the following areas: CPR skills. During an interview on [DATE] at 4:10 PM the facility Medical Director stated, The problem is the administration and all the changes that they have been going through. The follow up on issues has been lacking. The nurses have been very hesitant to call. Apparently the previous Medical Director did not answer pages, that may be part of the lack of calling regarding incidents. I have worked hard to have the nurses understand I will answer day or night, they are expected to call me with any concerns. I was aware that (Resident #2's name) had been administered medications that required him to be sent to the Emergency Department, The Administrator told me,she said it was because the sister wanted him to go, and did not tell me that it may have been a medication error. I try to allow the hospice nurses and physician to dictate what happens with the hospice residents. 2) Review of Resident #1's facility record revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Initial dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 15 = no cognitive deficit. Review of the hospital AHCA (Agency for Health Care Administration) Form ,[DATE] dated [DATE] under the section titled, U. Mental/Cognitive Status At Transfer Alert, oriented, follows Instructions, was checked. Review of the Agency for Health Care Administration (AHCA) Nursing Homes Federal Reporting dated [DATE] revealed: Description of the Incident: The resident made an allegation of a staff member while changing her that she was punching her in her arm. Resident cried as Social Service was speaking to her. The Facility's Immediate Response revealed: 4. Statements was done by staff. 5. Interview was done by Social Service. Review of the written statement dated [DATE] by Staff P, CNA (Certified Nursing Assistant) read: At about 6:30 p.m. Sat. [DATE] was passing trays for supper. (Resident #1's name) was yelling she was wet and trying to crawl out of bed calling me all kinds of names that no one was changing her one of my co-worker came into her room to help me and she told him to get out, finally I started to change her bed and she was rowdy that I, when and got another co-worker (Staff V, CNA's name) to come and help me in the process of changing her bed she became mad at me for trying to change her and she begin to hit me and I, tried to catch her hands and arms and she was mad with (Staff V, CNA's name) for not helping her, and we trying to change her wet bed. I, call the nurse to tell her what had happen. Review of the written statement dated [DATE] by Staff V, CNA read: I was helping (Staff P, CNA's name) in room. The Resident became combative and refused care talking about she dieing. Review of the nursing progress notes dated [DATE] at 3:30 PM read: (Resident #1's name) is agitated making false accusations against staff. On [DATE] at 3:44 PM Reach out to hospice regards to behavior, staff is afraid to work with her due to false accusations she is making. During an interview on [DATE] at 8:55 AM with the Administrator a request was made for the complete investigation into the abuse allegation made by Resident #1. The Administrator stated that the corrective actions taken on behalf of Resident 1's abuse allegation, and pointed to a Posted Note and stated, there will be two staff in the room while accommodating her needs. The investigation was completed. Nurses are trained on how to redirect and care for patients. I am not a nurse my expectation is for them to know what they are doing. When asked if other residents residing on the same unit with Resident #1 were interviewed, to determine if they had suffered abuse, as part of the investigation, the Administrator replied she did not feel this was necessary since there was no abuse. When asked about this being part of the corrective action she stated, I was not aware that these were items that needed to be implemented as a corrective action when no alleged abuse had occurred. Review of the POS [REDACTED]. 2 Staff @ all times. All allegations will be reported. Document behaviors. Staff walk away if resident is upset. Ensure resident is safe. During an interview on [DATE] at 3:20 PM Staff P, stated, (Resident #1 name) was screaming she was soiled, I was passing trays at that time. I stopped and got help to clean her up. The resident started screaming 'you are killing me and cussing' and did not want the male CNA to touch her and all he was doing was helping me hold her and I was cleaning her. I went and got (Staff V, CNA's name) that made her mad she started saying that I was punching her. I was trying not to get punched and clean her up quickly, I felt I was the one who got abused. During an interview on [DATE] at 3:45 PM via telephone Staff V, CNA stated, I was called by (Staff P, CNA's name) in to help with this resident. I was supporting the (Resident #1's name) and the resident was looking at me and asking why am I allowing this to happen. I tried to reassure her as much as possible. The resident was swinging and cussing at (Staff P, CNA's name) and fussing at me. During an interview on [DATE] at 12:45 PM the Social Services Director stated, I completed the AHCA 5 day report. I had no training on how to conduct this investigation. I took down the witness statements and asked (Resident #1's name) the questions. Since the DON (Director of Nursing) was gone it was given to me to do. (Resident #1's name) had no recollection about the allegation of abuse. I go in and talk to her and she does not remember anything. Yesterday she was fussing at the staff. I would speak to her and she would say nothing. Review of Resident #1's lab dated [DATE] revealed Ammonia 100 High. (too much ammonia in the body can cause psychological problems like confusion, tiredness, and possibly coma or death) Review of the physician's orders [REDACTED]. Diagnosis: [REDACTED]. Dated [DATE] at 12:00 AM read: [MEDICATION NAME] 30 ml every 6 hours as needed. Review of the Medication Administration Record [REDACTED]. For the period of [DATE] at 9:00 PM to [DATE] the MAR indicated [REDACTED]. [MEDICATION NAME] 10 GM/15 ML Solution give 30 ML (20GM) by mouth every 6 hours as needed - [MEDICAL CONDITION] of liver. The documentation showed [MEDICATION NAME] was not administered as needed and was documented as discontinued on [DATE] at 9:00 AM. Review of the Discontinued Order - As Needed (Handwritten) form read: [MEDICATION NAME] 10 GM/15 ML (15 grams to 15 milliliters) Solution by mouth. Original Fill Date: [DATE]. Give 30 milligram by mouth as needed every 6 hours as needed. Discontinued Date: [DATE] at 1:14 PM. [MEDICATION NAME] 10 gm/15 ML Solution. Original Fill Date: [DATE]. Give 30 ML (20GM) by mouth every 6 hours as needed. Discontinued Date: [DATE] at 11:03 PM. [MEDICATION NAME] 10 GM/15 ML Solution. Original Fill Date: [DATE]. Give 30 Milliliter by mouth as needed every 6 hours. Discontinued Date: [DATE] at 11:03 PM. The Discontinued Orders were completed by licensed nursing staff and did not have a physician's signature line or signature for the discontinuation of the medication. During an interview on [DATE] at approximately 1:12 PM Resident #1's daughter stated, My mother would have periods of confusion and craziness and when that happened, I knew it was the ammonia level and she wasn't getting her [MEDICATION NAME]. During an interview on [DATE] at approximately 2:00 PM with the Administrator a request was made for documentation of the administration of [MEDICATION NAME] as ordered by the physician for the period of [DATE] at 9:00 PM to [DATE] at 9:00 AM (the resident was discharged to the hospital for an unrelated concern at approximately 7:00 PM on [DATE]) or for the physician's orders [REDACTED]. The Administrator stated she would have nursing provide the documentation. During an interview on [DATE] at approximately 10:00 AM with the Administrator a request was made for documentation of the administration of [MEDICATION NAME] as ordered by the physician for the period of [DATE] at 9:00 PM to [DATE] at 9:00 AM (the resident was discharged to the hospital for an unrelated concern at approximately 7:00 PM on [DATE]) or for the physician's orders [REDACTED]. The Administrator stated she let nursing know the documentation was needed. During an interview on [DATE] at approximately 4:00 PM with the Administrator a request was made for documentation of the administration of [MEDICATION NAME] as ordered by the physician for the period of [DATE] at 9:00 PM to [DATE] at 9:00 AM (the resident was discharged to the hospital for an unrelated concern at approximately 7:00 PM on [DATE]) or for the physician's orders [REDACTED]. The Administrator did not respond. No additional documentation was provided. 3) Review of Resident #2's facility record revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the hospice Treatment or Medication Form dated [DATE] [MEDICATION NAME] 1 mg oral every 4 hours PRN (as needed). Dated [DATE] read: [MEDICATION NAME] concentrate 20:1 10 mg = 0.5 ml SL (sublingual) every 4 hours ATC (around the clock). [MEDICATION NAME] 1 mg SL/PO (by mouth) every 4 hours ATC. (MONTH) hold for sedation. Please continue [MEDICATION NAME] sulfate and [MEDICATION NAME] every 4 hours PRN (as needed). Dated: [DATE] Lensin/Mycosamine 0.125 mg SL every 4 hours PRN - secretions. D/C (discontinue) nonessential meds d/t (due to) decline. Review of the Controlled Drug Declining Inventory Sheet for [MEDICATION NAME] ([MEDICATION NAME])1 mg tablet revealed the medication was signed out for administration on [DATE] at 10:00 AM, at 2:00 PM, at 08:00 PM, and at 12:00 AM. On [DATE] at 4:00 AM, at 8:00 AM, at 10:00 AM, at 12:00 PM, at 2:00 PM, at 5:30 PM, at 8:00 PM, and at 10:00 PM. On [DATE] at 12:00 midnight. [MEDICATION NAME] 100 mg/5 ml concentrate was signed out for administration [DATE] at 10:00 AM, at 02:00 PM, at 08:00 PM, [DATE] at 12:00 AM, [DATE] at 04:00 AM, 8:00 AM, at 10:00 AM, at 12:00 PM, at 2:00 PM, at 5:30 PM, at 8:00 PM, and at 10:00 PM. On [DATE] at 12:00 midnight and at 4:15 AM. Review of the care plan revised on [DATE] read: Focus: The resident is on pain medication therapy r/t end stage diagnosis. Goal: The resident will be free of any discomfort or adverse side effects from pain medication. Interventions: Administer [MEDICATION NAME] medications as ordered by physician. Monitor/document side effects and effectiveness Q (every) shift. Ask physician to review medication if side effects persist. Monitor/document/report PRN adverse reactions to [MEDICATION NAME] therapy: altered mental status, respiratory distress/decreased respirations, sedation. Focus: Use of [MEDICAL CONDITION] antianxiety drug places resident at risk for drug-related: Cognitive impairment. Initiated [DATE]. Goal: Resident will receive the least dosage of the prescribed [MEDICAL CONDITION] drug (s) to ensure maximum functional ability both mentally and physically. Interventions: [MEDICATION NAME] as ordered. Observe for side effects and hold medication for increased lethargy. Review of the nursing progress notes dated [DATE] at 2:37 PM New orders from hospice nurse [MEDICATION NAME] 1 mg PO @ HS (by mouth at hour of sleep). Dated: [DATE] at 6:21 AM Resident is not wanting to take his medications ([MEDICATION NAME]) Very lethargic and not wanting to open his mouth. Dated: [DATE] at 9:58 AM Resident tried to get out of bed. Stated he forgot he could not walk. Resident fell on his right side on the floor. Resident did not hit his head. Red marks on right hip and right shoulder. DON (Director of Nursing) and MD (Medical Doctor) notified. Resident was reminded to use call light any time he needs to get up. Dated: [DATE] at 11:11 AM Resident laying in bed sleeping. Easily arousable. No signs of pain or distress. Resident stated he was just tired and wanted to back to sleep. Date: [DATE] at 12:29 AM This nurse writing called hospice due to Resident making changes in mental status. Resident is restless, asking for someone to help him, climbing out of bed, Not eating or drinking sufficient amount. He is c/o (complaint of) abdominal pain. Hospice nurse on called made a visit received new order to increase [MEDICATION NAME], Q 4 hrs. PRN (hours as needed). Resident is being monitored closely to prevent resident injuries. Dated: [DATE] at 1:38 PM The resident has had a change is condition. When first observed the resident's jaw was twisted to the right and [MEDICAL CONDITION] is suspected. I obtained vital signs and notified hospice as well as his family. Family has been in to see the resident but hospice has not been in at this time 1:41 PM. (There was no documentation of the physician having been notified of the change in condition). Dated: [DATE] at 10:07 AM read: Resident is nonresponsive. Family notified and in facility. Hospice nurse in facility. Resident is currently on 4 L (liters) of O2 (oxygen) via nasal cannula r/t apnea (cessation of breathing). Dated: [DATE] at 12:23 PM. Resident eyes are no longer reactive to light. RR (respirations) approximately 8 per minutes, on 4 L O2 via nasal cannula. On [DATE] at 2:24 PM Being medicated on schedule every 2 hours as instructed by Hospice. Respirations 7 per minute. Currently unarousable again. On [DATE] at 3:52 PM Resident is wheezing and moaning. Still asleep. Not arousable. Breathing is slow and labored. On [DATE] at 3:3 PM Resident is currently lying in bed quietly sleeping with eyes half open. Responds to painful stimuli. Skin warm and dry to touch except for feet is cool. Respirations with long periods of inhale and exhale. No urine output so far this shift. Requires total assistance with ADL's, turning and repositioning. PO (by mouth) meal intake is zero d/t (due to) decrease alertness. On [DATE] at 9:04 AM Resident only responsive to painful stimuli. Hospice nurse in to see resident and review orders. Upon assessment determined to send resident to ER (emergency room ). Review of the hospice nursing progress notes dated [DATE] at 8:30 AM read, Reason for Focused Visit: Dying process/decline. Medication assessed for: Medicine reconciliation done. Effectiveness. Not taking meds as prescribed. Clinician Narrative Note: When I arrived there patient was unresponsive. Reviewed medications and patient has been getting the [MEDICATION NAME] 1 mg every 2 hours and [MEDICATION NAME] 10 mg every 2 hours instead of every 4 hours as ordered. Spoke with DON (Director of Nursing) and ADON (Assistant Director of Nursing) and they would like the patient to be sent to the ER for medication overdose. Spoke with sister at the bedside and she would like the patient to be sent out as well. Heat rate: 56. Respirations: 8. Blood Pressure ,[DATE]. O2 Sat (saturation) 92% on 2 LPM (liters per minute). Dated: [DATE] at 11:35 AM read, Clinician Narrative Note: Spoke to ER MD and the RN (Registered Nurse) along with sister at the bedside. Patient was given [MEDICATION NAME] to reverse the effects from the [MEDICATION NAME]. Dated: [DATE], unable to read time, Clinician Narrative Note: Patient had decline somewhat over the weekend .possibly transitioning. Pt (Patient) was in hospital ER with sister at Pt's bedside. Cp (Chaplin) spent much time comforting and encouraging pt's sister and later praying with both. Because sister did not want pt to go back to facility from which pt came, sister was looking for other options. Review of the EMS (Emergency Medical Services) note dated [DATE] revealed Chief Complaint: Overdose [MEDICATION NAME]. Meds Admin (Medications Administered) [MEDICATION NAME] 0.4 IV (intravenously). Review of the hospital records dated [DATE] revealed Chief Complaint: Drug overdose. History and Physical: Presents to ED via EMS d/t accidental overdose. Pt. sister states Pt has end stage liver failure and is on hospice at Crestwood Nursing home. Pt. was supposed to give (sic) 10 mg every 4 hours but they were giving 10 mg every 2 hours per Pt. sister. EMS gave Pt. [MEDICATION NAME] and drastically improved. Pt. denies any other Sx (symptoms) at this time. Free Text: Pt. sister does not like care given to Pt. at Crestwood Nursing home and would like someone else. Re-Evaluation/Progress #1: After [MEDICATION NAME] - Re-Eval Status: Improved. Eval Following Treatment: Pt. feels better, Condition improved. Condition: Stable. Review of the hospital Emergency Patient Record dated [DATE] revealed: Priority: 2/Emergent. Ingestion - Presenting signs/symptoms: Decreased Resp (respirations), Decreased L[NAME] (level of consciousness). Emergency Notes: [DATE] Assumed care of Pt. from previous RN. Pt. is alert when name is spoken to. Pt. has sister and hospice rep (representative) at bedside. Pt. is showing no signs of distress. Per Pt. advocate, Pt's family is requesting new hospice representation. Pt. is to be DC (discharged ) to new facility when it is determined. At 12:04 PM Pt. is resting comfortably with family at his side. No signs of distress noted. During an interview on [DATE] at 2:02 PM Staff A, Unit Manager/LPN (Licensed Practical Nurse) she stated, I am responsible for the unit, both of them since the other Unit Manager quit. I was involved in (Resident #2's name) transfer to the hospital. The hospice nurse came to me and told me the Resident had been given [MEDICATION NAME] and [MEDICATION NAME] every two hours the day before and was obtunded (lethargy in which the patient has a lessened interest in the environment, slowed responses to stimulation, and tends to sleep more than normal with drowsiness in between sleep states) with a very low respiratory rate. We told the DON who said to transfer the resident if that's what the sister wanted. The Administrator was called by the DON and told that the resident had a medication error and needed to go to the ED. So, I called 911 and got him to the hospital. That's all the involvement I had, except that I told The Administrator that the resident wasn't coming back because the sister didn't want him to. I called the hospital for an update and the hospice nurse let us know too. I didn't make out an incident report. When a resident gets medication, we should be monitoring them for any side effects and holding them and calling the doctor or the hospice nurse for any further orders if there are side effects. It is my expectation that I be informed of any changes in the residents' condition so that the resident can be assessed, and the problem can be addressed with the doctor. I expect the nurses to assess the residents for signs of over sedation. If a resident is sedated, hold medications until they check with hospice or the doctor and document all of that in the chart. During an interview on [DATE] at 4:55 PM the Hospice Nurse for Resident #2 stated, I did his initial consult on [DATE], and saw him again on [DATE], and when I saw him on Monday [DATE] there was a big difference, he was unresponsive when I saw him. It was reported to me that he had multiple falls over the weekend and agitation. The Resident's sister told me that he had been given medication every two hours per our orders and I knew that we did not have any orders for medications every two hours. When I checked our orders, we still had [MEDICATION NAME] 0.5 ml every 4 hours and a PRN (as needed) order for every 4 hours. But we did not give orders to medicate every 2 hours. After talking to the Director of Nursing and assessing the patient we were all in agreement that the patient should be sent to the ED and the Resident's sister agreed. I followed up on him once he went to the ED. He received [MEDICATION NAME] and was much more alert when I saw him, he was agitated but responsive. Our goal in pain control in end of life is to provide and promote comfort, we want our patients to be pain free, without anxiety. We want our patients to have enough medication to remain comfortable, not overmedicate them to a point where they require reversal agents. I was shocked because the man I saw on Monday was nowhere near the man I saw on Thursday. That was gross overmedication. The patient's sister did not want him to go back to Crestwood, and because we don't have another facility, we discharged him to another hospice, so the family had a sense of peace and comfort with his care. This Nurse should be reported because this was negligent. During a telephone interview on [DATE] at 10:45 AM the Hospice Doctor stated, I am the Physician for hospice and am aware of (Resident #2's name). He began hospice sometime in July. When he was first on service, he was taking [MEDICATION NAME] I believe and the switch to [MEDICATION NAME] began just a few days before he went to the emergency room . We routinely order [MEDICATION NAME] and [MEDICATION NAME] for comfort and anxiety. Our goal is anxiety reduction, symptom control and pain freedom at end of life. We medicate according to the patient's symptomology and frequently have routine orders and orders for breakthrough pain or anxiety. If I or any other of the hospice Physicians thinks medication more frequently than every four hours is necessary, we would order more frequent routine administration of narcotic [MEDICATION NAME]. Although, in my field I seldom have to worry about [MEDICATION NAME] administration and the concomitant use of benzodiazepines such as [MEDICATION NAME]. There would be a significant CNS (central nervous system) depression and respiratory depression effects particularly acute in a patient with liver and kidney disease. I would not have recommended every two hours around the clock administration of these drugs to (Resident #2's name) especially because of his diagnosis. We did not give or instruct the nurses at Crestwood to administer [MEDICATION NAME] and [MEDICATION NAME] every two hours. In this case he was overmedicated, and I would expect any nurse to call to speak with either the nurses or the doctor on call to determine if the medication should continue at the prescribed times or be adjusted and held. My understanding is (Resident #2's name) was obtunded (lethargy in which the patient has a lessened interest in the environment, slowed responses to stimulation, and tends to sleep more than normal with drowsiness in between sleep states) with a respiratory rate of ,[DATE] with long apneic (cessation of respiration) periods, this was discussed with family and the nursing home and the decision to send the patient out to the hospital for treatment was made by the family, staff and our staff followed the family wishes. Our nurse followed up in the emergency room and the patient had a significant change in alertness with [MEDICATION NAME] administration which overall tells us that he was overmedicated and that was not recognized by the staff at Crestwood. Overdosage and the need to use reversal agents has a profound effect on the patients that I treat, not only physical but psychological as well for both patients and their families. During an interview on [DATE] at 9:37 AM via telephone the DON stated, I did not evaluate (Resident #2's name). The first I heard about it was when the ADON/Educator told me he had been medicated every two hours with [MEDICATION NAME] and he was unarousable with a respiratory rate of 6 or 7 per minute. She stated he needed to be transferred out because we were killing him with medications, that he was obtunded and unable to respond to painful stimuli. The hospice nurse and sister wanted to transfer him to the hospital for evaluation and treatment. I never went to evaluate the resident he was already seen by the hospice nurse and the ADON, so I just started getting the transfer started. I trusted their judgement that he needed to be transferred. I did not do any investigation, there was no time to as I was suspended on [DATE]. I did not review the Narcotic Administration sheets. I did not look at any of the nurses' documentation or check any physician orders. I did not know that it was an adverse incident. I was told that he was administered medication every two hours of [MEDICATION NAME] and [MEDICATION NAME], but that he did not have orders to medicate that frequently. I did not instruct the nurses to make out an incident report. The Administrator knew the patient went to the hospital, got administered [MEDICATION NAME], and the sister did not want him to come back because of this. We were notified that day that he would not be returning. I really did not get to investigate any of this, I just started in (MONTH) and it takes time to determine that processes are broken. We have a lot of work to do to improve the care we deliver. We don't have a code blue sheet that we fill out if a resident codes. I wasn't aware that the policy stated we had one. I would think that if someone has a CPR card, they are proficient according to the American Red Cross. I didn't do anything to assess the staff competency in CPR or their comfort level in CPR. Anyone who is CPR certified can start CPR. I did not look at any of the Code Blues that we started and was not tracking them or looking at the documentation, that is the responsibility of the Unit manager to do that and bring any concerns to me and the Administrator during the morning meetings. I was not aware that a resident did not have CPR started for five minutes. We don't have an AED (Automated External Defibrillator) that I am aware of. I'm not the Risk Manager, that's the ADON's job. I realize that there are problems here and some staff are not liking the changes that I tried to start, I wanted to do a good job and make changes. Ultimately, as the DON I am responsible for those things and everything that the nursing staff does and the interactions between departments to make sure things are done correctly. During an interview on [DATE] at 3:30 PM the ADON stated, The last time I worked was on [DATE], the ,[DATE] AM shift, the morning that (Resident #2's name) medication mistake was found. I was involved because I was finishing up and his sister asked me about medications, and the last time a medication mistake was discovered. An attempt was made to interview the nurse, via telephone to her last known number, who administered [MEDICATION NAME] and [MEDICATION NAME] to Resident #2. The nurse is no longer employed by the facility. The nurse had resigned from her position. The message received was that the number had been changed or was no longer in service. 4) Review of Resident #10's facility record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. The resident had a Full Code Status. Review of the nursing progress note dated [DATE] at 10:45 PM read: While receiving report from off going nur

Based on interviews, record reviews, policy and procedure review, the facility failed to ensure 3 of 15 sampled residents were free from abuse and/or neglect, Residents #1, #2, and #10. The facility failed to follow physicians ordered medications when a resident was identified through lab results with a high blood ammonia level, (too much ammonia in the body can cause psychological problems like confusion, tiredness, and possibly coma or death) for the administration of [MEDICATION NAME], (used to reduce the amount of ammonia in the blood) for Resident #1. The facility failed to follow physicians orders and standards of practice with the continuation of the administration of [MEDICATION NAME] (an opioid narcotic used for moderate to severe pain), and [MEDICATION NAME] (used for anxiety which acts on the brain and central nerves system), when a resident was assessed to be unresponsive, with decreased respirations, eyes non-reactive to light; Resident #2, (a major drug interaction exists between [MEDICATION NAME] and [MEDICATION NAME] that can lead to serious side effects including respiratory distress, coma, and even death). Resident #2 was transferred to the hospital emergency room and diagnosed by the hospital with an accidental overdose of [MEDICATION NAME]. The facility failed to ensure cardiopulmonary resuscitation was initiated immediately when a resident was found unresponsive and absent of vital signs, resulting in a five minute delay, the resident had a full code status, the resident did not survive, Resident #10. The facility failed to initiate a plan of correction and thorough investigation into an abuse allegation made by a resident of a staff member punching her in the arm, Resident #1, placing 47 of 47 residents at risk, the facility failed to investigate and initiate a plan of correct for the identified neglect of significant medication errors for Residents #1 and #2, placing 47 of 47 residents at risk for deficient practice, and the facility failed to investigate and initiate a plan of correction for the neglect of a five minute delay in the initiation of CPR for Resident #10, with a full code status, when found unresponsive and absent of vital signs, the resident did not survive, places 26 residents with a full code status at risk in a total of 47 residents. Cross reference to F607, F610, F684, and F835. The findings included: 1) Review of Resident #1's facility record revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Initial dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 15 = no cognitive deficit. Review of the hospital AHCA (Agency for Health Care Administration) Form ,[DATE] dated [DATE] under the section titled, U. Mental/Cognitive Status At Transfer Alert, oriented, follows Instructions, was checked. Review of the Agency for Health Care Administration (AHCA) Nursing Homes Federal Reporting dated [DATE] revealed: Description of the Incident: The resident made an allegation of a staff member while changing her that she was punching her in her arm. Resident cried as Social Service was speaking to her. The Facility's Immediate Response revealed: 4. Statements was done by staff. 5. Interview was done by Social Service. Review of the written statement dated [DATE] by Staff P, CNA (Certified Nursing Assistant) read: At about 6:30 p.m. Sat. [DATE] was passing trays for supper. (Resident #1's name) was yelling she was wet and trying to crawl out of bed calling me all kinds of names that no one was changing her one of my co-worker came into her room to help me and she told him to get out, finally I started to change her bed and she was rowdy that I, when and got another co-worker (Staff V, CNA's name) to come and help me in the process of changing her bed she became mad at me for trying to change her and she begin to hit me and I, tried to catch her hands and arms and she was mad with (Staff V, CNA's name) for not helping her, and we trying to change her wet bed. I, call the nurse to tell her what had happen. Review of the written statement dated [DATE] by Staff V, CNA read: I was helping (Staff P, CNA's name) in room. The Resident became combative and refused care talking about she dieing. Review of the nursing progress notes dated [DATE] at 3:30 PM read: (Resident #1's name) is agitated making false accusations against staff. On [DATE] at 3:44 PM Reach out to hospice regards to behavior, staff is afraid to work with her due to false accusations she is making. During an interview on [DATE] at 8:55 AM with the Administrator a request was made for the complete investigation into the abuse allegation made by Resident #1. The Administrator stated that the corrective actions taken on behalf of Resident 1's abuse allegation, and pointed to a Posted Note and stated, There will be two staff in the room while accommodating her needs. The investigation was completed. Nurses are trained on how to redirect and care for patients. I am not a nurse my expectation is for them to know what they are doing. When asked if other residents residing on the same unit with Resident #1 were interviewed, to determine if they had suffered abuse, as part of the investigation, the Administrator replied she did not feel this was necessary since there was no abuse. When asked about this being part of the corrective action she stated, I was not aware that these were items that needed to be implemented as a corrective action when no alleged abuse had occurred. Review of the POS [REDACTED]. 2 Staff @ all times. All allegations will be reported. Document behaviors. Staff walk away if resident is upset. Ensure resident is safe. During an interview on [DATE] at 3:20 PM Staff P, stated, (Resident #1 name) was screaming she was soiled, I was passing trays at that time. I stopped and got help to clean her up. The resident started screaming 'you are killing me and cussing' and did not want the male CNA to touch her and all he was doing was helping me hold her and I was cleaning her. I went and got (Staff V, CNA's name) that made her mad she started saying that I was punching her. I was trying not to get punched and clean her up quickly, I felt I was the one who got abused. During an interview on [DATE] at 3:45 PM via telephone Staff V, CNA stated, I was called by (Staff P, CNA's name) in to help with this resident. I was supporting the (Resident #1's name) and the resident was looking at me and asking why am I allowing this to happen. I tried to reassure her as much as possible. The resident was swinging and cussing at (Staff P, CNA's name) and fussing at me. During an interview on [DATE] at 12:45 PM the Social Services Director stated, I completed the AHCA 5 day report. I had no training on how to conduct this investigation. I took down the witness statements and asked (Resident #1's name) the questions. Since the DON (Director of Nursing) was gone it was given to me to do. (Resident #1's name) had no recollection about the allegation of abuse. I go in and talk to her and she does not remember anything. Yesterday she was fussing at the staff. I would speak to her and she would say nothing. Review of Resident #1's lab dated [DATE] revealed Ammonia 100 High. (too much ammonia in the body can cause psychological problems like confusion, tiredness, and possibly coma or death) Review of the physician's orders [REDACTED]. Diagnosis: [REDACTED]. Dated [DATE] at 12:00 AM read: [MEDICATION NAME] 30 ml every 6 hours as needed. Review of the Medication Administration Record [REDACTED]. For the period of [DATE] at 9:00 PM to [DATE] the MAR indicated [REDACTED]. [MEDICATION NAME] 10 GM/15 ML Solution give 30 ML (20 GM) by mouth every 6 hours as needed - [MEDICAL CONDITION] of liver. The documentation showed [MEDICATION NAME] was not administered as needed and was documented as discontinued on [DATE] at 9:00 AM. Review of the Discontinued Order - As Needed (Handwritten) form read: [MEDICATION NAME] 10 GM/15 ML (15 grams to 15 milliliters) Solution by mouth. Original Fill Date: [DATE]. Give 30 milligrams (mg) by mouth as needed every 6 hours as needed. Discontinued Date: [DATE] at 1:14 PM. [MEDICATION NAME] 10 gm/15 ML Solution. Original Fill Date: [DATE]. Give 30 ML (20 GM) by mouth every 6 hours as needed. Discontinued Date: [DATE] at 11:03 PM. [MEDICATION NAME] 10 GM/15 ML Solution. Original Fill Date: [DATE]. Give 30 Milliliter by mouth as needed every 6 hours. Discontinued Date: [DATE] at 11:03 PM. The Discontinued Orders were completed by licensed nursing staff and did not have a physician's signature line or signature for the discontinuation of the medication. During an interview on [DATE] at approximately 1:12 PM Resident #1's daughter stated, My mother would have periods of confusion and craziness and when that happened, I knew it was the ammonia level and she wasn't getting her [MEDICATION NAME]. During an interview on [DATE] at approximately 2:00 PM with the Administrator a request was made for documentation of the administration of [MEDICATION NAME] as ordered by the physician for the period of [DATE] at 9:00 PM to [DATE] at 9:00 AM (the resident was discharged to the hospital for an unrelated concern at approximately 7:00 PM on [DATE]) or for the physician's orders [REDACTED]. The Administrator stated she would have nursing provide the documentation. During an interview on [DATE] at approximately 10:00 AM with the Administrator a request was made for documentation of the administration of [MEDICATION NAME] as ordered by the physician for the period of [DATE] at 9:00 PM to [DATE] at 9:00 AM (the resident was discharged to the hospital for an unrelated concern at approximately 7:00 PM on [DATE]) or for the physician's orders [REDACTED]. The Administrator stated she let nursing know the documentation was needed. During an interview on [DATE] at approximately 4:00 PM with the Administrator a request was made for documentation of the administration of [MEDICATION NAME] as ordered by the physician for the period of [DATE] at 9:00 PM to [DATE] at 9:00 AM (the resident was discharged to the hospital for an unrelated concern at approximately 7:00 PM on [DATE]) or for the physician's orders [REDACTED]. The Administrator did not respond. No additional documentation was provided. 2) Review of Resident #2's facility record revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the hospice Treatment or Medication Form dated [DATE] [MEDICATION NAME] 1 mg oral every 4 hours PRN (as needed). Dated [DATE] read: [MEDICATION NAME] concentrate 20:1 10 mg = 0.5 ml SL (sublingual) every 4 hours ATC (around the clock). [MEDICATION NAME] 1 mg SL/PO (by mouth) every 4 hours ATC. (MONTH) hold for sedation. Please continue [MEDICATION NAME] sulfate and [MEDICATION NAME] every 4 hours PRN (as needed). Dated: [DATE] Lensin/Mycosamine 0.125 mg SL every 4 hours PRN - secretions. D/C (discontinue) nonessential meds d/t (due to) decline. Review of the Controlled Drug Declining Inventory Sheet for [MEDICATION NAME] ([MEDICATION NAME])1 mg tablet revealed the medication was signed out for administration on [DATE] at 10:00 AM, at 2:00 PM, at 08:00 PM, and at 12:00 AM. On [DATE] at 4:00 AM, at 8:00 AM, at 10:00 AM, at 12:00 PM, at 2:00 PM, at 5:30 PM, at 8:00 PM, and at 10:00 PM. On [DATE] at 12:00 midnight. [MEDICATION NAME] 100 mg/5 ml concentrate was signed out for administration [DATE] at 10:00 AM, at 02:00 PM, at 08:00 PM, [DATE] at 12:00 AM, [DATE] at 04:00 AM, 8:00 AM, at 10:00 AM, at 12:00 PM, at 2:00 PM, at 5:30 PM, at 8:00 PM, and at 10:00 PM. On [DATE] at 12:00 midnight and at 4:15 AM. Review of the care plan revised on [DATE] read: Focus: The resident is on pain medication therapy r/t end stage diagnosis. Goal: The resident will be free of any discomfort or adverse side effects from pain medication. Interventions: Administer [MEDICATION NAME] medications as ordered by physician. Monitor/document side effects and effectiveness Q (every) shift. Ask physician to review medication if side effects persist. Monitor/document/report PRN adverse reactions to [MEDICATION NAME] therapy: altered mental status, respiratory distress/decreased respirations, sedation. Focus: Use of [MEDICAL CONDITION] antianxiety drug places resident at risk for drug-related: Cognitive impairment. Initiated [DATE]. Goal: Resident will receive the least dosage of the prescribed [MEDICAL CONDITION] drug (s) to ensure maximum functional ability both mentally and physically. Interventions: [MEDICATION NAME] as ordered. Observe for side effects and hold medication for increased lethargy. Review of the nursing progress notes dated [DATE] at 2:37 PM New orders from hospice nurse [MEDICATION NAME] 1 mg PO @ HS (by mouth at hour of sleep). Dated: [DATE] at 6:21 AM Resident is not wanting to take his medications ([MEDICATION NAME]) Very lethargic and not wanting to open his mouth. Dated: [DATE] at 9:58 AM Resident tried to get out of bed. Stated he forgot he could not walk. Resident fell on his right side on the floor. Resident did not hit his head. Red marks on right hip and right shoulder. DON (Director of Nursing) and MD (Medical Doctor) notified. Resident was reminded to use call light any time he needs to get up. Dated: [DATE] at 11:11 AM Resident laying in bed sleeping. Easily arousable. No signs of pain or distress. Resident stated he was just tired and wanted to back to sleep. Date: [DATE] at 12:29 AM This nurse writing called hospice due to Resident making changes in mental status. Resident is restless, asking for someone to help him, climbing out of bed, Not eating or drinking sufficient amount. He is c/o (complaint of) abdominal pain. Hospice nurse on call made a visit received new order to increase [MEDICATION NAME], Q 4 hrs. PRN (hours as needed). Resident is being monitored closely to prevent resident injuries. Dated: [DATE] at 1:38 PM The resident has had a change in condition. When first observed the resident's jaw was twisted to the right and [MEDICAL CONDITION] is suspected. I obtained vital signs and notified hospice as well as his family. Family has been in to see the resident but hospice has not been in at this time 1:41 PM. (There was no documentation of the physician having been notified of the change in condition). Dated: [DATE] at 10:07 AM read: Resident is nonresponsive. Family notified and in facility. Hospice nurse in facility. Resident is currently on 4 L (liters) of O2 (oxygen) via nasal cannula r/t apnea (cessation of breathing). Dated: [DATE] at 12:23 PM. Resident eyes are no longer reactive to light. RR (respirations) approximately 8 per minutes, on 4 L O2 via nasal cannula. On [DATE] at 2:24 PM Being medicated on schedule every 2 hours as instructed by Hospice. Respirations 7 per minute. Currently unarousable again. On [DATE] at 3:52 PM Resident is wheezing and moaning. Still asleep. Not arousable. Breathing is slow and labored. On [DATE] at 3:30 PM Resident is currently lying in bed quietly sleeping with eyes half open. Responds to painful stimuli. Skin warm and dry to touch except for feet is cool. Respirations with long periods of inhale and exhale. No urine output so far this shift. Requires total assistance with ADL's, turning and repositioning. PO (by mouth) meal intake is zero d/t (due to) decrease alertness. On [DATE] at 9:04 AM Resident only responsive to painful stimuli. Hospice nurse in to see resident and review orders. Upon assessment determined to send resident to ER (emergency room ). Review of the hospice nursing progress notes dated [DATE] at 8:30 AM read, Reason for Focused Visit: Dying process/decline. Medication assessed for: Medicine reconciliation done. Effectiveness. Not taking meds as prescribed. Clinician Narrative Note: When I arrived there patient was unresponsive. Reviewed medications and patient has been getting the [MEDICATION NAME] 1 mg every 2 hours and [MEDICATION NAME] 10 mg every 2 hours instead of every 4 hours as ordered. Spoke with DON (Director of Nursing) and ADON (Assistant Director of Nursing) and they would like the patient to be sent to the ER for medication overdose. Spoke with sister at the bedside and she would like the patient to be sent out as well. Heart rate: 56. Respirations: 8. Blood Pressure ,[DATE]. O2 Sat (saturation) 92% on 2 LPM (liters per minute). Dated: [DATE] at 11:35 AM read, Clinician Narrative Note: Spoke to ER MD and the RN (Registered Nurse) along with sister at the bedside. Patient was given [MEDICATION NAME] to reverse the effects from the [MEDICATION NAME]. Dated: [DATE], unable to read time, Clinician Narrative Note: Patient had decline somewhat over the weekend .possibly transitioning. Pt (Patient) was in hospital ER with sister at Pt's bedside. Cp (Chaplin) spent much time comforting and encouraging pt's sister and later praying with both. Because sister did not want pt to go back to facility from which pt came, sister was looking for other options. Review of the EMS (Emergency Medical Services) note dated [DATE] revealed Chief Complaint: Overdose [MEDICATION NAME]. Meds Admin (Medications Administered) [MEDICATION NAME] 0.4 IV (intravenously). Review of the hospital records dated [DATE] revealed Chief Complaint: Drug overdose. History and Physical: Presents to ED via EMS d/t accidental overdose. Pt. sister states Pt has end stage liver failure and is on hospice at Crestwood Nursing home. Pt. was supposed to give (sic) 10 mg every 4 hours but they were giving 10 mg every 2 hours per Pt. sister. EMS gave Pt. [MEDICATION NAME] and drastically improved. Pt. denies any other Sx (symptoms) at this time. Free Text: Pt. sister does not like care given to Pt. at Crestwood Nursing home and would like someone else. Re-Evaluation/Progress #1: After [MEDICATION NAME] - Re-Eval Status: Improved. Eval Following Treatment: Pt. feels better, Condition improved. Condition: Stable. Review of the hospital Emergency Patient Record dated [DATE] revealed: Priority: 2/Emergent. Ingestion - Presenting signs/symptoms: Decreased Resp (respirations), Decreased L[NAME] (level of consciousness). Emergency Notes: [DATE] Assumed care of Pt. from previous RN. Pt. is alert when name is spoken to. Pt. has sister and hospice rep (representative) at bedside. Pt. is showing no signs of distress. Per Pt. advocate, Pt's family is requesting new hospice representation. Pt. is to be DC (discharged ) to new facility when it is determined. At 12:04 PM Pt. is resting comfortably with family at his side. No signs of distress noted. During an interview on [DATE] at 2:02 PM Staff A, Unit Manager/LPN (Licensed Practical Nurse) she stated, I am responsible for the unit, both of them since the other Unit Manager quit. I was involved in (Resident #2's name) transfer to the hospital. The hospice nurse came to me and told me the Resident had been given [MEDICATION NAME] and [MEDICATION NAME] every two hours the day before and was obtunded (lethargy in which the patient has a lessened interest in the environment, slowed responses to stimulation, and tends to sleep more than normal with drowsiness in between sleep states) with a very low respiratory rate. We told the DON who said to transfer the resident if that's what the sister wanted. The Administrator was called by the DON and told that the resident had a medication error and needed to go to the ED. So, I called 911 and got him to the hospital. That's all the involvement I had, except that I told The Administrator that the resident wasn't coming back because the sister didn't want him to. I called the hospital for an update and the hospice nurse let us know too. I didn't make out an incident report. When a resident gets medication, we should be monitoring them for any side effects and holding them and calling the doctor or the hospice nurse for any further orders if there are side effects. It is my expectation that I be informed of any changes in the residents' condition so that the resident can be assessed, and the problem can be addressed with the doctor. I expect the nurses to assess the residents for signs of over sedation. If a resident is sedated, hold medications until they check with hospice or the doctor and document all of that in the chart. During an interview on [DATE] at 4:55 PM the Hospice Nurse for Resident #2 stated, I did his initial consult on [DATE], and saw him again on [DATE], and when I saw him on Monday [DATE] there was a big difference, he was unresponsive when I saw him. It was reported to me that he had multiple falls over the weekend and agitation. The Resident's sister told me that he had been given medication every two hours per our orders and I knew that we did not have any orders for medications every two hours. When I checked our orders, we still had [MEDICATION NAME] 0.5 ml every 4 hours and a PRN (as needed) order for every 4 hours. But we did not give orders to medicate every 2 hours. After talking to the Director of Nursing and assessing the patient we were all in agreement that the patient should be sent to the ED and the Resident's sister agreed. I followed up on him once he went to the ED. He received [MEDICATION NAME] and was much more alert when I saw him, he was agitated but responsive. Our goal in pain control in end of life is to provide and promote comfort, we want our patients to be pain free, without anxiety. We want our patients to have enough medication to remain comfortable, not overmedicate them to a point where they require reversal agents. I was shocked because the man I saw on Monday was nowhere near the man I saw on Thursday. That was gross overmedication. The patient's sister did not want him to go back to Crestwood, and because we don't have another facility, we discharged him to another hospice, so the family had a sense of peace and comfort with his care. This Nurse should be reported because this was negligent. During a telephone interview on [DATE] at 10:45 AM the Hospice Doctor stated, I am the Physician for hospice and am aware of (Resident #2's name). He began hospice sometime in July. When he was first on service, he was taking [MEDICATION NAME] I believe and the switch to [MEDICATION NAME] began just a few days before he went to the emergency room . We routinely order [MEDICATION NAME] and [MEDICATION NAME] for comfort and anxiety. Our goal is anxiety reduction, symptom control and pain freedom at end of life. We medicate according to the patient's symptomology and frequently have routine orders and orders for breakthrough pain or anxiety. If I or any other of the hospice Physicians thinks medication more frequently than every four hours is necessary, we would order more frequent routine administration of narcotic [MEDICATION NAME]. Although, in my field I seldom have to worry about [MEDICATION NAME] administration and the concomitant use of benzodiazepines such as [MEDICATION NAME]. There would be a significant CNS (central nervous system) depression and respiratory depression effects particularly acute in a patient with liver and kidney disease. I would not have recommended every two hours around the clock administration of these drugs to (Resident #2's name) especially because of his diagnosis. We did not give or instruct the nurses at Crestwood to administer [MEDICATION NAME] and [MEDICATION NAME] every two hours. In this case he was overmedicated, and I would expect any nurse to call to speak with either the nurses or the doctor on call to determine if the medication should continue at the prescribed times or be adjusted and held. My understanding is (Resident #2's name) was obtunded (lethargy in which the patient has a lessened interest in the environment, slowed responses to stimulation, and tends to sleep more than normal with drowsiness in between sleep states) with a respiratory rate of ,[DATE] with long apneic (cessation of respiration) periods, this was discussed with family and the nursing home and the decision to send the patient out to the hospital for treatment was made by the family, staff and our staff followed the family wishes. Our nurse followed up in the emergency room and the patient had a significant change in alertness with [MEDICATION NAME] administration which overall tells us that he was overmedicated and that was not recognized by the staff at Crestwood. Overdosage and the need to use reversal agents has a profound effect on the patients that I treat, not only physical but psychological as well for both patients and their families. During an interview on [DATE] at 9:37 AM via telephone the DON stated, I did not evaluate (Resident #2's name). The first I heard about it was when the ADON/Educator told me he had been medicated every two hours with [MEDICATION NAME] and he was unarousable with a respiratory rate of 6 or 7 per minute. She stated he needed to be transferred out because we were killing him with medications, that he was obtunded and unable to respond to painful stimuli. The hospice nurse and sister wanted to transfer him to the hospital for evaluation and treatment. I never went to evaluate the resident he was already seen by the hospice nurse and the ADON, so I just started getting the transfer started. I trusted their judgement that he needed to be transferred. I did not do any investigation, there was no time to as I was suspended on [DATE]. I did not review the Narcotic Administration sheets. I did not look at any of the nurses' documentation or check any physician orders. I did not know that it was an adverse incident. I was told that he was administered medication every two hours of [MEDICATION NAME] and [MEDICATION NAME], but that he did not have orders to medicate that frequently. I did not instruct the nurses to make out an incident report. The Administrator knew the patient went to the hospital, got administered [MEDICATION NAME], and the sister did not want him to come back because of this. We were notified that day that he would not be returning. I really did not get to investigate any of this, I just started in (MONTH) and it takes time to determine that processes are broken. We have a lot of work to do to improve the care we deliver. We don't have a code blue sheet that we fill out if a resident codes. I wasn't aware that the policy stated we had one. I would think that if someone has a CPR card, they are proficient according to the American Red Cross. I didn't do anything to assess the staff competency in CPR or their comfort level in CPR. Anyone who is CPR certified can start CPR. I did not look at any of the Code Blues that we started and was not tracking them or looking at the documentation, that is the responsibility of the Unit manager to do that and bring any concerns to me and the Administrator during the morning meetings. I was not aware that a resident did not have CPR started for five minutes. We don't have an AED (Automated External Defibrillator) that I am aware of. I'm not the Risk Manager, that's the ADON's job. I realize that there are problems here and some staff are not liking the changes that I tried to start, I wanted to do a good job and make changes. Ultimately, as the DON I am responsible for those things and everything that the nursing staff does and the interactions between departments to make sure things are done correctly. During an interview on [DATE] at 3:30 PM the ADON stated, The last time I worked was on [DATE], the ,[DATE] AM shift, the morning that (Resident #2's name) medication mistake was found. I was involved because I was finishing up and his sister asked me about medications, and the last time a medication mistake was discovered. An attempt was made to interview the nurse, via telephone to her last known number, who administered [MEDICATION NAME] and [MEDICATION NAME] to Resident #2. The nurse is no longer employed by the facility. The nurse had resigned from her position. The message received was that the number had been changed or was no longer in service. 3) Review of Resident #10's facility record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. The resident had a Full Code Status. Review of the nursing progress note dated [DATE] at 10:45 PM read: While receiving report from off going nurse, nursing assistant called for assistance to patient's room. Upon entering the room patient was assessed with [REDACTED]. Pulse palpated without result. Code Blue called, crash cart was brought to room. At 10:50 PM compressions were started. 911 was called. 6 rounds of compressions and breaths were performed. EMS arrived assessed the patient, transported patient to hospital. Review of Resident #10's record revealed there was no documentation of a Code Blue form. Review of the hospital records for Resident #10 dated [DATE] at 11:28 PM revealed HPI (History of Present Illness) Chief Complaint: [MEDICAL CONDITION], found down. Arrest Circumstances: Unwitnessed arrest. Context: Resuscitation [MEDICATION NAME] IV X 2 (for two doses). Context of Onset: Found unresponsive in [MEDICAL CONDITION]. Severity: Onset Severe. Severity: Current Severe. Free Test HPI Notes: Found unresponsive at nursing home with no pulse, EMS called and found pulseless. Alertness: Unresponsive. Pupils: Dilated, Nonreactive. Resp/Chest: No spontaneous Respirations. Cardiovascular: Pulseless. Neurologic: Unresponsive. Re-Evaluation: After extended effort to resuscitate she never regained pulses. Bedside ultrasound showed no cardiac activity. Patient Discharge & Departure: Condition: Expired. Disposition Decision: 2358 (11:58 PM). Date: [DATE]. During an interview on [DATE] at 2:25 PM Staff B, LPN stated, I work over at our sister facility I'm only helping out here. We share the same policies and procedures. I would not administer [MEDICATION NAME] to a resident that was lethargic or unresponsive. If the doctor did not write a hold for sedation order I would hold the medication and call them so that they could adjust the dose or timing of the medications or send the resident out to be evaluated. I am CPR certified and its current. I don't know where the emergency cart is, I am just helping out here. If I didn't know the resident's code status, I would not start CPR until I checked the chart. There is no other way to know that information. It's on my report sheet, but I don't always have that on me. I don't know how long that would take; maybe five minutes or less. You can't start CPR on a resident who is a DNR, so I would not start CPR until I knew for sure. I haven't gotten any training on code blue policy, medication policy or anything else recently. During an interview on [DATE] at 8:40 AM Staff I, LPN stated, I just started about one month ago, I got a week of orientation. I'm a brand-new nurse and still feel a little overwhelmed at times. My orientation was passing medications with another nurse. They didn't give me any type of check off sheet or competency to have anyone fill out. I did not go over any policies on code blue or any other policy during orientation. If a resident had orders to medicate with [MEDICATION NAME] and [MEDICATION NAME] around the clock, I would not administer the medications if the resident was lethargic or difficult to wake up or had shallow respirations. That would be contraindicated. I would call the doctor or the hospice nurse to let them know. Pain control in a resident who in end of life care is keeping t

Based on interviews, record reviews, and policy and procedure review, the facility failed to ensure abuse and neglect policy and procedures were implemented for 3 of 15 sampled residents, Residents #1, #2, and #10 by failing to follow the physician's orders [REDACTED].#1, failed to follow facility policy and procedures and standards of practice by continuing to administer [MEDICATION NAME] (an opioid narcotic used for moderate to severe pain), and [MEDICATION NAME] (used for anxiety which acts on the brain and central nerves system), when a resident was assessed to be unresponsive, with decreased respirations, eyes non-reactive to light; Resident #2, (a major drug interaction exists between [MEDICATION NAME] and [MEDICATION NAME] that can lead to serious side effects including respiratory distress, coma, and even death). Resident #2 was transferred to the hospital emergency room and diagnosed by the hospital with an accidental overdose of [MEDICATION NAME]. The facility failed to ensure cardiopulmonary resuscitation was initiated immediately when a resident was found unresponsive and absent of vital signs, resulting in a five minute delay, the resident had a full code status, the resident did not survive, Resident #10. The facility failure to implement their abuse and neglect policy and procedure to initiate a plan of correction and thorough investigation into an abuse allegation made by Resident #1 places 47 of 47 residents at risk, the facility failure to implement their abuse and neglect policy and procedures to investigate and initiate a plan of correct for neglect of significant medication errors for Residents #1 and #2, places 47 of 47 residents at risk for deficient practice, and the facility failure to implement their abuse policy and procedure to investigate and initiate a plan of correction for the neglect of a five minute delay in the initiation of CPR for Resident #10, with a full code status, when found unresponsive and absent of vital signs, the resident did not survive, places 26 residents with a full code status at risk in a total of 47 residents. Cross reference to F600, F610, F684, and F835. The findings included: 1) Review of Resident #1's facility record revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Add New Record dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 15 = no cognitive deficit. Review of the hospital AHCA (Agency for Health Care Administration) Form ,[DATE] dated [DATE] under the section titled, U. Mental/Cognitive Status At Transfer Alert, oriented, follows Instructions, was checked. Review of the Agency for Health Care Administration (AHCA) Nursing Homes Federal Reporting dated [DATE] revealed: Description of the Incident: The resident made an allegation of a staff member while changing her that she was punching her in her arm. Resident cried as Social Service was speaking to her. The Facility's Immediate Response revealed: 4. Statements was done by staff. 5. Interview was done by Social Service. Review of the written statement dated [DATE] by Staff P, CNA (Certified Nursing Assistant) read: At about 6:30 p.m. Sat. [DATE] was passing trays for supper. (Resident #1's name) was yelling she was wet and trying to crawl out of bed calling me all kinds of names that no one was changing her one of my co-worker came into her room to help me and she told him to get out, finally I started to change her bed and she was rowdy that I, when and got another co-worker (Staff V, CNA's name) to come and help me in the process of changing her bed she became mad at me for trying to change her and she begin to hit me and I, tried to catch her hands and arms and she was mad with (Staff V, CNA's name) for not helping her, and we trying to change her wet bed. I, call the nurse to tell her what had happen. Review of the written statement dated [DATE] by Staff V, CNA read: I was helping (Staff P, CNA's name) in room. The Resident became combative and refused care talking about she dieing. Review of the nursing progress notes dated [DATE] at 3:30 PM read: (Resident #1's name) is agitated making false accusations against staff. On [DATE] at 3:44 PM Reach out to hospice regards to behavior, staff is afraid to work with her due to false accusations she is making. During an interview on [DATE] at 8:55 AM with the Administrator a request was made for the complete investigation into the abuse allegation made by Resident #1. The Administrator stated that the corrective actions taken on behalf of Resident 1's abuse allegation, and pointed to a Posted Note and stated, There will be two staff in the room while accommodating her needs. The investigation was completed. Nurses are trained on how to redirect and care for patients. I am not a nurse my expectation is for them to know what they are doing. When asked if other residents residing on the same unit with Resident #1 were interviewed, to determine if they had suffered abuse, as part of the investigation, the Administrator replied she did not feel this was necessary since there was no abuse. When asked about this being part of the corrective action she stated, I was not aware that these were items that needed to be implemented as a corrective action when no alleged abuse had occurred. Review of the POS [REDACTED]. 2 Staff @ all times. All allegations will be reported. Document behaviors. Staff walk away if resident is upset. Ensure resident is safe. During an interview on [DATE] at 3:20 PM Staff P, stated, (Resident #1 name) was screaming she was soiled, I was passing trays at that time. I stopped and got help to clean her up. The resident started screaming 'you are killing me and cussing' and did not want the male CNA to touch her and all he was doing was helping me hold her and I was cleaning her. I went and got (Staff V, CNA's name) that made her mad she started saying that I was punching her. I was trying not to get punched and clean her up quickly, I felt I was the one who got abused. During an interview on [DATE] at 3:45 PM via telephone Staff V, CNA stated, I was called by (Staff P, CNA's name) in to help with this resident. I was supporting the (Resident #1's name) and the resident was looking at me and asking why am I allowing this to happen. I tried to reassure her as much as possible. The resident was swinging and cussing at (Staff P, CNA's name) and fussing at me. During an interview on [DATE] at 12:45 PM the Social Services Director stated, I completed the AHCA 5 day report. I had no training on how to conduct this investigation. I took down the witness statements and asked (Resident #1's name) the questions. Since the DON (Director of Nursing) was gone it was given to me to do. (Resident #1's name) had no recollection about the allegation of abuse. I go in and talk to her and she does not remember anything. Yesterday she was fussing at the staff. I would speak to her and she would say nothing. Review of Resident #1's lab dated [DATE] revealed Ammonia 100 High. (too much ammonia in the body can cause psychological problems like confusion, tiredness, and possibly coma or death) Review of the physician's orders [REDACTED]. Diagnosis: [REDACTED]. Dated [DATE] at 12:00 AM read: [MEDICATION NAME] 30 ml every 6 hours as needed. Review of the Medication Administration Record [REDACTED]. For the period of [DATE] at 9:00 PM to [DATE] the MAR indicated [REDACTED]. [MEDICATION NAME] 10 GM/15 ML Solution give 30 ML (20GM) by mouth every 6 hours as needed - [MEDICAL CONDITION] of liver. The documentation showed [MEDICATION NAME] was not administered as needed and was documented as discontinued on [DATE] at 9:00 AM. Review of the Discontinued Order - As Needed (Handwritten) form read: [MEDICATION NAME] 10 GM/15 ML (15 grams to 15 milliliters) Solution by mouth. Original Fill Date: [DATE]. Give 30 milligram by mouth as needed every 6 hours as needed. Discontinued Date: [DATE] at 1:14 PM. [MEDICATION NAME] 10 gm/15 ML Solution. Original Fill Date: [DATE]. Give 30 ML (20GM) by mouth every 6 hours as needed. Discontinued Date: [DATE] at 11:03 PM. [MEDICATION NAME] 10 GM/15 ML Solution. Original Fill Date: [DATE]. Give 30 Milliliter by mouth as needed every 6 hours. Discontinued Date: [DATE] at 11:03 PM. The Discontinued Orders were completed by licensed nursing staff and did not have a physician's signature line or signature for the discontinuation of the medication. During an interview on [DATE] at approximately 1:12 PM Resident #1's daughter stated, My mother would have periods of confusion and craziness and when that happened, I knew it was the ammonia level and she wasn't getting her [MEDICATION NAME]. During an interview on [DATE] at approximately 2:00 PM with the Administrator a request was made for documentation of the administration of [MEDICATION NAME] as ordered by the physician for the period of [DATE] at 9:00 PM to [DATE] at 9:00 AM (the resident was discharged to the hospital for an unrelated concern at approximately 7:00 PM on [DATE]) or for the physician's orders [REDACTED]. The Administrator stated she would have nursing provide the documentation. During an interview on [DATE] at approximately 10:00 AM with the Administrator a request was made for documentation of the administration of [MEDICATION NAME] as ordered by the physician for the period of [DATE] at 9:00 PM to [DATE] at 9:00 AM (the resident was discharged to the hospital for an unrelated concern at approximately 7:00 PM on [DATE]) or for the physician's orders [REDACTED]. The Administrator stated she let nursing know the documentation was needed. During an interview on [DATE] at approximately 4:00 PM with the Administrator a request was made for documentation of the administration of [MEDICATION NAME] as ordered by the physician for the period of [DATE] at 9:00 PM to [DATE] at 9:00 AM (the resident was discharged to the hospital for an unrelated concern at approximately 7:00 PM on [DATE]) or for the physician's orders [REDACTED]. The Administrator did not respond. No additional documentation was provided. 2) Review of Resident #2's facility record revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the hospice Treatment or Medication Form dated [DATE] [MEDICATION NAME] 1 mg oral every 4 hours PRN (as needed). Dated [DATE] read: [MEDICATION NAME] concentrate 20:1 10 mg = 0.5 ml SL (sublingual) every 4 hours ATC (around the clock). [MEDICATION NAME] 1 mg SL/PO (by mouth) every 4 hours ATC. (MONTH) hold for sedation. Please continue [MEDICATION NAME] sulfate and [MEDICATION NAME] every 4 hours PRN (as needed). Dated: [DATE] Lensin/Mycosamine 0.125 mg SL every 4 hours PRN - secretions. D/C (discontinue) nonessential meds d/t (due to) decline. Review of the Controlled Drug Declining Inventory Sheet for [MEDICATION NAME] ([MEDICATION NAME])1 mg tablet revealed the medication was signed out for administration on [DATE] at 10:00 AM, at 2:00 PM, at 08:00 PM, and at 12:00 AM. On [DATE] at 4:00 AM, at 8:00 AM, at 10:00 AM, at 12:00 PM, at 2:00 PM, at 5:30 PM, at 8:00 PM, and at 10:00 PM. On [DATE] at 12:00 midnight. [MEDICATION NAME] 100 mg/5 ml concentrate was signed out for administration [DATE] at 10:00 AM, at 02:00 PM, at 08:00 PM, [DATE] at 12:00 AM, [DATE] at 04:00 AM, 8:00 AM, at 10:00 AM, at 12:00 PM, at 2:00 PM, at 5:30 PM, at 8:00 PM, and at 10:00 PM. On [DATE] at 12:00 midnight and at 4:15 AM. Review of the care plan revised on [DATE] read: Focus: The resident is on pain medication therapy r/t end stage diagnosis. Goal: The resident will be free of any discomfort or adverse side effects from pain medication. Interventions: Administer [MEDICATION NAME] medications as ordered by physician. Monitor/document side effects and effectiveness Q (every) shift. Ask physician to review medication if side effects persist. Monitor/document/report PRN adverse reactions to [MEDICATION NAME] therapy: altered mental status, respiratory distress/decreased respirations, sedation. Focus: Use of [MEDICAL CONDITION] antianxiety drug places resident at risk for drug-related: Cognitive impairment. Initiated [DATE]. Goal: Resident will receive the least dosage of the prescribed [MEDICAL CONDITION] drug (s) to ensure maximum functional ability both mentally and physically. Interventions: [MEDICATION NAME] as ordered. Observe for side effects and hold medication for increased lethargy. Review of the nursing progress notes dated [DATE] at 2:37 PM New orders from hospice nurse [MEDICATION NAME] 1 mg PO @ HS (by mouth at hour of sleep). Dated: [DATE] at 6:21 AM Resident is not wanting to take his medications ([MEDICATION NAME]) Very lethargic and not wanting to open his mouth. Dated: [DATE] at 9:58 AM Resident tried to get out of bed. Stated he forgot he could not walk. Resident fell on his right side on the floor. Resident did not hit his head. Red marks on right hip and right shoulder. DON (Director of Nursing) and MD (Medical Doctor) notified. Resident was reminded to use call light any time he needs to get up. Dated: [DATE] at 11:11 AM Resident laying in bed sleeping. Easily arousable. No signs of pain or distress. Resident stated he was just tired and wanted to back to sleep. Date: [DATE] at 12:29 AM This nurse writing called hospice due to Resident making changes in mental status. Resident is restless, asking for someone to help him, climbing out of bed, Not eating or drinking sufficient amount. He is c/o (complaint of) abdominal pain. Hospice nurse on called made a visit received new order to increase [MEDICATION NAME], Q 4 hrs. PRN (hours as needed). Resident is being monitored closely to prevent resident injuries. Dated: [DATE] at 1:38 PM The resident has had a change is condition. When first observed the resident's jaw was twisted to the right and [MEDICAL CONDITION] is suspected. I obtained vital signs and notified hospice as well as his family. Family has been in to see the resident but hospice has not been in at this time 1:41 PM. (There was no documentation of the physician having been notified of the change in condition). Dated: [DATE] at 10:07 AM read: Resident is nonresponsive. Family notified and in facility. Hospice nurse in facility. Resident is currently on 4 L (liters) of O2 (oxygen) via nasal cannula r/t apnea (cessation of breathing). Dated: [DATE] at 12:23 PM. Resident eyes are no longer reactive to light. RR (respirations) approximately 8 per minutes, on 4 L O2 via nasal cannula. On [DATE] at 2:24 PM Being medicated on schedule every 2 hours as instructed by Hospice. Respirations 7 per minute. Currently unarousable again. On [DATE] at 3:52 PM Resident is wheezing and moaning. Still asleep. Not arousable. Breathing is slow and labored. On [DATE] at 3:30 PM Resident is currently lying in bed quietly sleeping with eyes half open. Responds to painful stimuli. Skin warm and dry to touch except for feet is cool. Respirations with long periods of inhale and exhale. No urine output so far this shift. Requires total assistance with ADL's, turning and repositioning. PO (by mouth) meal intake is zero d/t (due to) decrease alertness. On [DATE] at 9:04 AM Resident only responsive to painful stimuli. Hospice nurse in to see resident and review orders. Upon assessment determined to send resident to ER (emergency room ). Review of the hospice nursing progress notes dated [DATE] at 8:30 AM read, Reason for Focused Visit: Dying process/decline. Medication assessed for: Medicine reconciliation done. Effectiveness. Not taking meds as prescribed. Clinician Narrative Note: When I arrived there patient was unresponsive. Reviewed medications and patient has been getting the [MEDICATION NAME] 1 mg every 2 hours and [MEDICATION NAME] 10 mg every 2 hours instead of every 4 hours as ordered. Spoke with DON (Director of Nursing) and ADON (Assistant Director of Nursing) and they would like the patient to be sent to the ER for medication overdose. Spoke with sister at the bedside and she would like the patient to be sent out as well. Heat rate: 56. Respirations: 8. Blood Pressure ,[DATE]. O2 Sat (saturation) 92% on 2 LPM (liters per minute). Dated: [DATE] at 11:35 AM read, Clinician Narrative Note: Spoke to ER MD and the RN (Registered Nurse) along with sister at the bedside. Patient was given [MEDICATION NAME] to reverse the effects from the [MEDICATION NAME]. Dated: [DATE], unable to read time, Clinician Narrative Note: Patient had decline somewhat over the weekend .possibly transitioning. Pt (Patient) was in hospital ER with sister at Pt's bedside. Cp (Chaplin) spent much time comforting and encouraging pt's sister and later praying with both. Because sister did not want pt to go back to facility from which pt came, sister was looking for other options. Review of the EMS (Emergency Medical Services) note dated [DATE] revealed Chief Complaint: Overdose [MEDICATION NAME]. Meds Admin (Medications Administered) [MEDICATION NAME] 0.4 IV (intravenously). Review of the hospital records dated [DATE] revealed Chief Complaint: Drug overdose. History and Physical: Presents to ED via EMS d/t accidental overdose. Pt. sister states Pt has end stage liver failure and is on hospice at Crestwood Nursing home. Pt. was supposed to give (sic) 10 mg every 4 hours but they were giving 10 mg every 2 hours per Pt. sister. EMS gave Pt. [MEDICATION NAME] and drastically improved. Pt. denies any other Sx (symptoms) at this time. Free Text: Pt. sister does not like care given to Pt. at Crestwood Nursing home and would like someone else. Re-Evaluation/Progress #1: After [MEDICATION NAME] - Re-Eval Status: Improved. Eval Following Treatment: Pt. feels better, Condition improved. Condition: Stable. Review of the hospital Emergency Patient Record dated [DATE] revealed: Priority: 2/Emergent. Ingestion - Presenting signs/symptoms: Decreased Resp (respirations), Decreased L[NAME] (level of consciousness). Emergency Notes: [DATE] Assumed care of Pt. from previous RN. Pt. is alert when name is spoken to. Pt. has sister and hospice rep (representative) at bedside. Pt. is showing no signs of distress. Per Pt. advocate, Pt's family is requesting new hospice representation. Pt. is to be DC (discharged ) to new facility when it is determined. At 12:04 PM Pt. is resting comfortably with family at his side. No signs of distress noted. During an interview on [DATE] at 2:02 PM Staff A, Unit Manager/LPN (Licensed Practical Nurse) she stated, I am responsible for the unit, both of them since the other Unit Manager quit. I was involved in (Resident #2's name) transfer to the hospital. The hospice nurse came to me and told me the Resident had been given [MEDICATION NAME] and [MEDICATION NAME] every two hours the day before and was obtunded (lethargy in which the patient has a lessened interest in the environment, slowed responses to stimulation, and tends to sleep more than normal with drowsiness in between sleep states) with a very low respiratory rate. We told the DON who said to transfer the resident if that's what the sister wanted. The Administrator was called by the DON and told that the resident had a medication error and needed to go to the ED. So, I called 911 and got him to the hospital. That's all the involvement I had, except that I told The Administrator that the resident wasn't coming back because the sister didn't want him to. I called the hospital for an update and the hospice nurse let us know too. I didn't make out an incident report. When a resident gets medication, we should be monitoring them for any side effects and holding them and calling the doctor or the hospice nurse for any further orders if there are side effects. It is my expectation that I be informed of any changes in the residents' condition so that the resident can be assessed, and the problem can be addressed with the doctor. I expect the nurses to assess the residents for signs of over sedation. If a resident is sedated, hold medications until they check with hospice or the doctor and document all of that in the chart. During an interview on [DATE] at 4:55 PM the Hospice Nurse for Resident #2 stated, I did his initial consult on [DATE], and saw him again on [DATE], and when I saw him on Monday [DATE] there was a big difference, he was unresponsive when I saw him. It was reported to me that he had multiple falls over the weekend and agitation. The Resident's sister told me that he had been given medication every two hours per our orders and I knew that we did not have any orders for medications every two hours. When I checked our orders, we still had [MEDICATION NAME] 0.5 ml every 4 hours and a PRN (as needed) order for every 4 hours. But we did not give orders to medicate every 2 hours. After talking to the Director of Nursing and assessing the patient we were all in agreement that the patient should be sent to the ED and the Resident's sister agreed. I followed up on him once he went to the ED. He received [MEDICATION NAME] and was much more alert when I saw him, he was agitated but responsive. Our goal in pain control in end of life is to provide and promote comfort, we want our patients to be pain free, without anxiety. We want our patients to have enough medication to remain comfortable, not overmedicate them to a point where they require reversal agents. I was shocked because the man I saw on Monday was nowhere near the man I saw on Thursday. That was gross overmedication. The patient's sister did not want him to go back to Crestwood, and because we don't have another facility, we discharged him to another hospice, so the family had a sense of peace and comfort with his care. This Nurse should be reported because this was negligent. During a telephone interview on [DATE] at 10:45 AM the Hospice Doctor stated, I am the Physician for hospice and am aware of (Resident #2's name). He began hospice sometime in July. When he was first on service, he was taking [MEDICATION NAME] I believe and the switch to [MEDICATION NAME] began just a few days before he went to the emergency room . We routinely order [MEDICATION NAME] and [MEDICATION NAME] for comfort and anxiety. Our goal is anxiety reduction, symptom control and pain freedom at end of life. We medicate according to the patient's symptomology and frequently have routine orders and orders for breakthrough pain or anxiety. If I or any other of the hospice Physicians thinks medication more frequently than every four hours is necessary, we would order more frequent routine administration of narcotic [MEDICATION NAME]. Although, in my field I seldom have to worry about [MEDICATION NAME] administration and the concomitant use of benzodiazepines such as [MEDICATION NAME]. There would be a significant CNS (central nervous system) depression and respiratory depression effects particularly acute in a patient with liver and kidney disease. I would not have recommended every two hours around the clock administration of these drugs to Resident #2 especially because of his diagnosis. We did not give or instruct the nurses at Crestwood to administer [MEDICATION NAME] and [MEDICATION NAME] every two hours. In this case he was overmedicated, and I would expect any nurse to call to speak with either the nurses or the doctor on call to determine if the medication should continue at the prescribed times or be adjusted and held. My understanding is Resident #2 was obtunded (lethargy in which the patient has a lessened interest in the environment, slowed responses to stimulation, and tends to sleep more than normal with drowsiness in between sleep states) with a respiratory rate of ,[DATE] with long apneic (cessation of respiration) periods, this was discussed with family and the nursing home and the decision to send the patient out to the hospital for treatment was made by the family, staff and our staff followed the family wishes. Our nurse followed up in the emergency room and the patient had a significant change in alertness with [MEDICATION NAME] administration which overall tells us that he was overmedicated and that was not recognized by the staff at Crestwood. Overdosage and the need to use reversal agents has a profound effect on the patients that I treat, not only physical but psychological as well for both patients and their families. During an interview on [DATE] at 9:37 AM via telephone the DON stated, I did not evaluate (Resident #2's name). The first I heard about it was when the ADON/Educator told me he had been medicated every two hours with [MEDICATION NAME] and he was unarousable with a respiratory rate of 6 or 7 per minute. She stated he needed to be transferred out because we were killing him with medications, that he was obtunded and unable to respond to painful stimuli. The hospice nurse and sister wanted to transfer him to the hospital for evaluation and treatment. I never went to evaluate the resident he was already seen by the hospice nurse and the ADON, so I just started getting the transfer started. I trusted their judgement that he needed to be transferred. I did not do any investigation, there was no time to as I was suspended on [DATE]. I did not review the Narcotic Administration sheets. I did not look at any of the nurses' documentation or check any physician orders. I did not know that it was an adverse incident. I was told that he was administered medication every two hours of [MEDICATION NAME] and [MEDICATION NAME], but that he did not have orders to medicate that frequently. I did not instruct the nurses to make out an incident report. The Administrator knew the patient went to the hospital, got administered [MEDICATION NAME], and the sister did not want him to come back because of this. We were notified that day that he would not be returning. I really did not get to investigate any of this, I just started in (MONTH) and it takes time to determine that processes are broken. We have a lot of work to do to improve the care we deliver. We don't have a code blue sheet that we fill out if a resident codes. I wasn't aware that the policy stated we had one. I would think that if someone has a CPR card, they are proficient according to the American Red Cross. I didn't do anything to assess the staff competency in CPR or their comfort level in CPR. Anyone who is CPR certified can start CPR. I did not look at any of the Code Blues that we started and was not tracking them or looking at the documentation, that is the responsibility of the Unit manager to do that and bring any concerns to me and the Administrator during the morning meetings. I was not aware that a resident did not have CPR started for five minutes. We don't have an AED (Automated External Defibrillator) that I am aware of. I'm not the Risk Manager, that's the ADON's job. I realize that there are problems here and some staff are not liking the changes that I tried to start, I wanted to do a good job and make changes. Ultimately, as the DON I am responsible for those things and everything that the nursing staff does and the interactions between departments to make sure things are done correctly. During an interview on [DATE] at 3:30 PM the ADON stated, The last time I worked was on [DATE], the ,[DATE] AM shift, the morning that (Resident #2's name) medication mistake was found. I was involved because I was finishing up and his sister asked me about medications, and the last time a medication mistake was discovered. An attempt was made to interview the nurse, via telephone to her last known number, who administered [MEDICATION NAME] and [MEDICATION NAME] to Resident #2. The nurse is no longer employed by the facility. The nurse had resigned from her position. The message received was that the number had been changed or was no longer in service. 3) Review of Resident #10's facility record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. The resident had a Full Code Status. Review of the nursing progress note dated [DATE] at 10:45 PM read: While receiving report from off going nurse, nursing assistant called for assistance to patient's room. Upon entering the room patient was assessed with [REDACTED]. Pulse palpated without result. Code Blue called, crash cart was brought to room. At 10:50 PM compressions were started. 911 was called. 6 rounds of compressions and breaths were performed. EMS arrived assessed the patient, transported patient to hospital. Review of Resident #10's record revealed there was no documentation of a Code Blue form. Review of the hospital records for Resident #10 dated [DATE] at 11:28 PM revealed HPI (History of Present Illness) Chief Complaint: [MEDICAL CONDITION], found down. Arrest Circumstances: Unwitnessed arrest. Context: Resuscitation [MEDICATION NAME] IV X 2 (for two doses). Context of Onset: Found unresponsive in [MEDICAL CONDITION]. Severity: Onset Severe. Severity: Current Severe. Free Test HPI Notes: Found unresponsive at nursing home with no pulse, EMS called and found pulseless. Alertness: Unresponsive. Pupils: Dilated, Nonreactive. Resp/Chest: No spontaneous Respirations. Cardiovascular: Pulseless. Neurologic: Unresponsive. Re-Evaluation: After extended effort to resuscitate she never regained pulses. Bedside ultrasound showed no cardiac activity. Patient Discharge & Departure: Condition: Expired. Disposition Decision: 2358 (11:58 PM). Date: [DATE]. During an interview on [DATE] at 2:25 PM Staff B, LPN stated, I work over at our sister facility I'm only helping out here. We share the same policies and procedures. I would not administer [MEDICATION NAME] to a resident that was lethargic or unresponsive. If the doctor did not write a hold for sedation order I would hold the medication and call them so that they could adjust the dose or timing of the medications or send the resident out to be evaluated. I am CPR certified and its current. I don't know where the emergency cart is, I am just helping out here. If I didn't know the resident's code status, I would not start CPR until I checked the chart. There is no other way to know that information. It's on my report sheet, but I don't always have that on me. I don't know how long that would take; maybe five minutes or less. You can't start CPR on a resident who is a DNR, so I would not start CPR until I knew for sure. I haven't gotten any training on code blue policy, medication policy or anything else recently. During an interview on [DATE] at 8:40 AM Staff I, LPN stated, I just started about one month ago, I got a week of orientation. I'm a brand-new nurse and still feel a little overwhelmed at times. My orientation was passing medications with another nurse. They didn't give me any type of check off sheet or competency to have anyone fill out. I did not go over any policies on code blue or any other policy during orientation. If a resident had orders to medicate with [MEDICATION NAME] and [MEDICATION NAME] around the clock, I would not administer the medications if the resident was lethargic or difficult to wake up or had shallow respirations. That would be contraindicated. I would call the doctor or the hospice nurse to let them kno

Based on interviews, record reviews, and policy and procedure review, the facility failed to ensure an allegation of abuse for 1 of 15 sampled residents was thoroughly investigated, and failed to initiate an investigation of identified medication errors, Resident #1 and #2, and failed to initiate an investigation into the delay of five minutes before starting CPR (cardiopulmonary resuscitation) when a resident, with a full code status, was found unresponsive and absent of vital signs, the resident did not survive, Resident #10. The facility failure to thoroughly investigation an abuse allegation of a resident being punched in the arm by staff made by Resident #1 places 47 of 47 residents at risk, the facility's failure to an initiate an investigation for the identified medication errors for Residents #1 and #2, places 47 of 47 residents at risk for deficient practice, and the facility failure to initiate an investigation for the neglect of a five minute delay in the initiation of CPR for Resident #10, with a full code status, when found unresponsive and absent of vital signs, the resident did not survive, places 26 residents with a full code status at risk in a total of 47 residents. Cross reference to F600, F607, F684, and F835. The findings included: 1) Review of Resident #1's facility record revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Initial dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 15 = no cognitive deficit. Review of the hospital AHCA (Agency for Health Care Administration) Form ,[DATE] dated [DATE] under the section titled, U. Mental/Cognitive Status At Transfer Alert, oriented, follows Instructions, was checked. Review of the Agency for Health Care Administration (AHCA) Nursing Homes Federal Reporting dated [DATE] revealed: Description of the Incident: The resident made an allegation of a staff member while changing her that she was punching her in her arm. Resident cried as Social Service was speaking to her. The Facility's Immediate Response revealed: 4. Statements was done by staff. 5. Interview was done by Social Service. Review of the written statement dated [DATE] by Staff P, CNA (Certified Nursing Assistant) read: At about 6:30 p.m. Sat. [DATE] was passing trays for supper. (Resident #1's name) was yelling she was wet and trying to crawl out of bed calling me all kinds of names that no one was changing her one of my co-worker came into her room to help me and she told him to get out, finally I started to change her bed and she was rowdy that I, when and got another co-worker (Staff V, CNA's name) to come and help me in the process of changing her bed she became mad at me for trying to change her and she begin to hit me and I, tried to catch her hands and arms and she was mad with (Staff V, CNA's name) for not helping her, and we trying to change her wet bed. I, call the nurse to tell her what had happen. Review of the written statement dated [DATE] by Staff V, CNA read: I was helping (Staff P, CNA's name) in room. The Resident became combative and refused care talking about she dieing. Review of the nursing progress notes dated [DATE] at 3:30 PM read: (Resident #1's name) is agitated making false accusations against staff. On [DATE] at 3:44 PM Reach out to hospice regards to behavior, staff is afraid to work with her due to false accusations she is making. During an interview on [DATE] at 8:55 AM with the Administrator a request was made for the complete investigation into the abuse allegation made by Resident #1. The Administrator stated that the corrective actions taken on behalf of Resident 1's abuse allegation, and pointed to a Posted Note and stated, there will be two staff in the room while accommodating her needs. The investigation was completed. Nurses are trained on how to redirect and care for patients. I am not a nurse my expectation is for them to know what they are doing. When asked if other residents residing on the same unit with Resident #1 were interviewed, to determine if they had suffered abuse, as part of the investigation, the Administrator replied she did not feel this was necessary since there was no abuse. When asked about this being part of the corrective action she stated, I was not aware that these were items that needed to be implemented as a corrective action when no alleged abuse had occurred. Review of the POS [REDACTED]. 2 Staff @ all times. All allegations will be reported. Document behaviors. Staff walk away if resident is upset. Ensure resident is safe. During an interview on [DATE] at 3:20 PM Staff P, stated, (Resident #1 name) was screaming she was soiled, I was passing trays at that time. I stopped and got help to clean her up. The resident started screaming 'you are killing me and cussing' and did not want the male CNA to touch her and all he was doing was helping me hold her and I was cleaning her. I went and got (Staff V, CNA's name) that made her mad she started saying that I was punching her. I was trying not to get punched and clean her up quickly, I felt I was the one who got abused. During an interview on [DATE] at 3:45 PM via telephone Staff V, CNA stated, I was called by (Staff P, CNA's name( in to help with this resident. I was supporting the (Resident #1's name) and the resident was looking at me and asking why am I allowing this to happen. I tried to reassure her as much as possible. The resident was swinging and cussing at (Staff P, CNA's name) and fussing at me. During an interview on [DATE] at 12:45 PM the Social Services Director stated, I completed the AHCA 5 day report. I had no training on how to conduct this investigation. I took down the witness statements and asked (Resident #1's name) the questions. Since the DON (Director of Nursing) was gone it was given to me to do. (Resident #1's name) had no recollection about the allegation of abuse. I go in and talk to her and she does not remember anything. Yesterday she was fussing at the staff. I would speak to her and she would say nothing. Review of Resident #1's lab dated [DATE] revealed Ammonia 100 High. (too much ammonia in the body can cause psychological problems like confusion, tiredness, and possibly coma or death) Review of the physician's orders [REDACTED]. Diagnosis: [REDACTED]. Dated [DATE] at 12:00 AM read: [MEDICATION NAME] 30 ml every 6 hours as needed. Review of the Medication Administration Record [REDACTED]. For the period of [DATE] at 9:00 PM to [DATE] the MAR indicated [REDACTED]. [MEDICATION NAME] 10 GM/15 ML Solution give 30 ML (20GM) by mouth every 6 hours as needed - [MEDICAL CONDITION] of liver. The documentation showed [MEDICATION NAME] was not administered as needed and was documented as discontinued on [DATE] at 9:00 AM. Review of the Discontinued Order - As Needed (Handwritten) form read: [MEDICATION NAME] 10 GM/15 ML (15 grams to 15 milliliters) Solution by mouth. Original Fill Date: [DATE]. Give 30 milligram by mouth as needed every 6 hours as needed. Discontinued Date: [DATE] at 1:14 PM. [MEDICATION NAME] 10 gm/15 ML Solution. Original Fill Date: [DATE]. Give 30 ML (20GM) by mouth every 6 hours as needed. Discontinued Date: [DATE] at 11:03 PM. [MEDICATION NAME] 10 GM/15 ML Solution. Original Fill Date: [DATE]. Give 30 Milliliter by mouth as needed every 6 hours. Discontinued Date: [DATE] at 11:03 PM. The Discontinued Orders were completed by licensed nursing staff and did not have a physician's signature line or signature for the discontinuation of the medication. During an interview on [DATE] at approximately 1:12 PM Resident #1's daughter stated, My mother would have periods of confusion and craziness and when that happened, I knew it was the ammonia level and she wasn't getting her [MEDICATION NAME]. During an interview on [DATE] at approximately 2:00 PM with the Administrator a request was made for documentation of the administration of [MEDICATION NAME] as ordered by the physician for the period of [DATE] at 9:00 PM to [DATE] at 9:00 AM (the resident was discharged to the hospital for an unrelated concern at approximately 7:00 PM on [DATE]) or for the physician's orders [REDACTED]. The Administrator stated she would have nursing provide the documentation. During an interview on [DATE] at approximately 10:00 AM with the Administrator a request was made for documentation of the administration of [MEDICATION NAME] as ordered by the physician for the period of [DATE] at 9:00 PM to [DATE] at 9:00 AM (the resident was discharged to the hospital for an unrelated concern at approximately 7:00 PM on [DATE]) or for the physician's orders [REDACTED]. The Administrator stated she let nursing know the documentation was needed. During an interview on [DATE] at approximately 4:00 PM with the Administrator a request was made for documentation of the administration of [MEDICATION NAME] as ordered by the physician for the period of [DATE] at 9:00 PM to [DATE] at 9:00 AM (the resident was discharged to the hospital for an unrelated concern at approximately 7:00 PM on [DATE]) or for the physician's orders [REDACTED]. The Administrator did not respond. No additional documentation was provided. 2) Review of Resident #2's facility record revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the hospice Treatment or Medication Form dated [DATE] [MEDICATION NAME] 1 mg oral every 4 hours PRN (as needed). Dated [DATE] read: [MEDICATION NAME] concentrate 20:1 10 mg = 0.5 ml SL (sublingual) every 4 hours ATC (around the clock). [MEDICATION NAME] 1 mg SL/PO (by mouth) every 4 hours ATC. (MONTH) hold for sedation. Please continue [MEDICATION NAME] sulfate and [MEDICATION NAME] every 4 hours PRN (as needed). Dated: [DATE] Lensin/Mycosamine 0.125 mg SL every 4 hours PRN - secretions. D/C (discontinue) nonessential meds d/t (due to) decline. Review of the Controlled Drug Declining Inventory Sheet for [MEDICATION NAME] ([MEDICATION NAME])1 mg tablet revealed the medication was signed out for administration on [DATE] at 10:00 AM, at 2:00 PM, at 08:00 PM, and at 12:00 AM. On [DATE] at 4:00 AM, at 8:00 AM, at 10:00 AM, at 12:00 PM, at 2:00 PM, at 5:30 PM, at 8:00 PM, and at 10:00 PM. On [DATE] at 12:00 midnight. [MEDICATION NAME] 100 mg/5 ml concentrate was signed out for administration [DATE] at 10:00 AM, at 02:00 PM, at 08:00 PM, [DATE] at 12:00 AM, [DATE] at 04:00 AM, 8:00 AM, at 10:00 AM, at 12:00 PM, at 2:00 PM, at 5:30 PM, at 8:00 PM, and at 10:00 PM. On [DATE] at 12:00 midnight and at 4:15 AM. Review of the care plan revised on [DATE] read: Focus: The resident is on pain medication therapy r/t end stage diagnosis. Goal: The resident will be free of any discomfort or adverse side effects from pain medication. Interventions: Administer [MEDICATION NAME] medications as ordered by physician. Monitor/document side effects and effectiveness Q (every) shift. Ask physician to review medication if side effects persist. Monitor/document/report PRN adverse reactions to [MEDICATION NAME] therapy: altered mental status, respiratory distress/decreased respirations, sedation. Focus: Use of [MEDICAL CONDITION] antianxiety drug places resident at risk for drug-related: Cognitive impairment. Initiated [DATE]. Goal: Resident will receive the least dosage of the prescribed [MEDICAL CONDITION] drug (s) to ensure maximum functional ability both mentally and physically. Interventions: [MEDICATION NAME] as ordered. Observe for side effects and hold medication for increased lethargy. Review of the nursing progress notes dated [DATE] at 2:37 PM New orders from hospice nurse [MEDICATION NAME] 1 mg PO @ HS (by mouth at hour of sleep). Dated: [DATE] at 6:21 AM Resident is not wanting to take his medications ([MEDICATION NAME]) Very lethargic and not wanting to open his mouth. Dated: [DATE] at 9:58 AM Resident tried to get out of bed. Stated he forgot he could not walk. Resident fell on his right side on the floor. Resident did not hit his head. Red marks on right hip and right shoulder. DON (Director of Nursing) and MD (Medical Doctor) notified. Resident was reminded to use call light any time he needs to get up. Dated: [DATE] at 11:11 AM Resident laying in bed sleeping. Easily arousable. No signs of pain or distress. Resident stated he was just tired and wanted to back to sleep. Date: [DATE] at 12:29 AM This nurse writing called hospice due to Resident making changes in mental status. Resident is restless, asking for someone to help him, climbing out of bed, Not eating or drinking sufficient amount. He is c/o (complaint of) abdominal pain. Hospice nurse on called made a visit received new order to increase [MEDICATION NAME], Q 4 hrs. PRN (hours as needed). Resident is being monitored closely to prevent resident injuries. Dated: [DATE] at 1:38 PM The resident has had a change is condition. When first observed the resident's jaw was twisted to the right and [MEDICAL CONDITION] is suspected. I obtained vital signs and notified hospice as well as his family. Family has been in to see the resident but hospice has not been in at this time 1:41 PM. (There was no documentation of the physician having been notified of the change in condition). Dated: [DATE] at 10:07 AM read: Resident is nonresponsive. Family notified and in facility. Hospice nurse in facility. Resident is currently on 4 L (liters) of O2 (oxygen) via nasal cannula r/t apnea (cessation of breathing). Dated: [DATE] at 12:23 PM. Resident eyes are no longer reactive to light. RR (respirations) approximately 8 per minutes, on 4 L O2 via nasal cannula. On [DATE] at 2:24 PM Being medicated on schedule every 2 hours as instructed by Hospice. Respirations 7 per minute. Currently unarousable again. On [DATE] at 3:52 PM Resident is wheezing and moaning. Still asleep. Not arousable. Breathing is slow and labored. On [DATE] at 3:3 PM Resident is currently lying in bed quietly sleeping with eyes half open. Responds to painful stimuli. Skin warm and dry to touch except for feet is cool. Respirations with long periods of inhale and exhale. No urine output so far this shift. Requires total assistance with ADL's, turning and repositioning. PO (by mouth) meal intake is zero d/t (due to) decrease alertness. On [DATE] at 9:04 AM Resident only responsive to painful stimuli. Hospice nurse in to see resident and review orders. Upon assessment determined to send resident to ER (emergency room ). Review of the hospice nursing progress notes dated [DATE] at 8:30 AM read, Reason for Focused Visit: Dying process/decline. Medication assessed for: Medicine reconciliation done. Effectiveness. Not taking meds as prescribed. Clinician Narrative Note: When I arrived there patient was unresponsive. Reviewed medications and patient has been getting the [MEDICATION NAME] 1 mg every 2 hours and [MEDICATION NAME] 10 mg every 2 hours instead of every 4 hours as ordered. Spoke with DON (Director of Nursing) and ADON (Assistant Director of Nursing) and they would like the patient to be sent to the ER for medication overdose. Spoke with sister at the bedside and she would like the patient to be sent out as well. Heat rate: 56. Respirations: 8. Blood Pressure ,[DATE]. O2 Sat (saturation) 92% on 2 LPM (liters per minute). Dated: [DATE] at 11:35 AM read, Clinician Narrative Note: Spoke to ER MD and the RN (Registered Nurse) along with sister at the bedside. Patient was given [MEDICATION NAME] to reverse the effects from the [MEDICATION NAME]. Dated: [DATE], unable to read time, Clinician Narrative Note: Patient had decline somewhat over the weekend .possibly transitioning. Pt (Patient) was in hospital ER with sister at Pt's bedside. Cp (Chaplin) spent much time comforting and encouraging pt's sister and later praying with both. Because sister did not want pt to go back to facility from which pt came, sister was looking for other options. Review of the EMS (Emergency Medical Services) note dated [DATE] revealed Chief Complaint: Overdose [MEDICATION NAME]. Meds Admin (Medications Administered) [MEDICATION NAME] 0.4 IV (intravenously). Review of the hospital records dated [DATE] revealed Chief Complaint: Drug overdose. History and Physical: Presents to ED via EMS d/t accidental overdose. Pt. sister states Pt has end stage liver failure and is on hospice at Crestwood Nursing home. Pt. was supposed to give (sic) 10 mg every 4 hours but they were giving 10 mg every 2 hours per Pt. sister. EMS gave Pt. [MEDICATION NAME] and drastically improved. Pt. denies any other Sx (symptoms) at this time. Free Text: Pt. sister does not like care given to Pt. at Crestwood Nursing home and would like someone else. Re-Evaluation/Progress #1: After [MEDICATION NAME] - Re-Eval Status: Improved. Eval Following Treatment: Pt. feels better, Condition improved. Condition: Stable. Review of the hospital Emergency Patient Record dated [DATE] revealed: Priority: 2/Emergent. Ingestion - Presenting signs/symptoms: Decreased Resp (respirations), Decreased L[NAME] (level of consciousness). Emergency Notes: [DATE] Assumed care of Pt. from previous RN. Pt. is alert when name is spoken to. Pt. has sister and hospice rep (representative) at bedside. Pt. is showing no signs of distress. Per Pt. advocate, Pt's family is requesting new hospice representation. Pt. is to be DC (discharged ) to new facility when it is determined. At 12:04 PM Pt. is resting comfortably with family at his side. No signs of distress noted. During an interview on [DATE] at 2:02 PM Staff A, Unit Manger/LPN (Licensed Practical Nurse) she stated, I am responsible for the unit, both of them since the other Unit Manager quit. I was involved in (Resident #2's name) transfer to the hospital. The hospice nurse came to me and told me the Resident had been given [MEDICATION NAME] and [MEDICATION NAME] every two hours the day before and was obtunded (lethargy in which the patient has a lessened interest in the environment, slowed responses to stimulation, and tends to sleep more than normal with drowsiness in between sleep states) with a very low respiratory rate. We told the DON who said to transfer the resident if that's what the sister wanted. The Administrator was called by the DON and told that the resident had a medication error and needed to go to the ED. So, I called 911 and got him to the hospital. That's all the involvement I had, except that I told The Administrator that the resident wasn't coming back because the sister didn't want him to. I called the hospital for an update and the hospice nurse let us know too. I didn't make out an incident report. When a resident gets medication, we should be monitoring them for any side effects and holding them and calling the doctor or the hospice nurse for any further orders if there are side effects. It is my expectation that I be informed of any changes in the residents' condition so that the resident can be assessed, and the problem can be addressed with the doctor. I expect the nurses to assess the residents for signs of over sedation. If a resident is sedated, hold medications until they check with hospice or the doctor and document all of that in the chart. During an interview on [DATE] at 4:55 PM the Hospice Nurse for Resident #2 stated, I did his initial consult on [DATE], and saw him again on [DATE], and when I saw him on Monday [DATE] there was a big difference, he was unresponsive when I saw him. It was reported to me that he had multiple falls over the weekend and agitation. The Resident's sister told me that he had been given medication every two hours per our orders and I knew that we did not have any orders for medications every two hours. When I checked our orders, we still had [MEDICATION NAME] 0.5 ml every 4 hours and a PRN (as needed) order for every 4 hours. But we did not give orders to medicate every 2 hours. After talking to the Director of Nursing and assessing the patient we were all in agreement that the patient should be sent to the ED and the Resident's sister agreed. I followed up on him once he went to the ED. He received [MEDICATION NAME] and was much more alert when I saw him, he was agitated but responsive. Our goal in pain control in end of life is to provide and promote comfort, we want our patients to be pain free, without anxiety. We want our patients to have enough medication to remain comfortable, not overmedicate them to a point where they require reversal agents. I was shocked because the man I saw on Monday was nowhere near the man I saw on Thursday. That was gross overmedication. The patient's sister did not want him to go back to Crestwood, and because we don't have another facility, we discharged him to another hospice, so the family had a sense of peace and comfort with his care. This Nurse should be reported because this was negligent. During a telephone interview on [DATE] at 10:45 AM the Hospice Doctor stated, I am the Physician for hospice and am aware of (Resident #2's name). He began hospice sometime in July. When he was first on service, he was taking [MEDICATION NAME] I believe and the switch to [MEDICATION NAME] began just a few days before he went to the emergency room . We routinely order [MEDICATION NAME] and [MEDICATION NAME] for comfort and anxiety. Our goal is anxiety reduction, symptom control and pain freedom at end of life. We medicate according to the patient's symptomology and frequently have routine orders and orders for breakthrough pain or anxiety. If I or any other of the hospice Physicians thinks medication more frequently than every four hours is necessary, we would order more frequent routine administration of narcotic [MEDICATION NAME]. Although, in my field I seldom have to worry about [MEDICATION NAME] administration and the concomitant use of benzodiazepines such as [MEDICATION NAME]. There would be a significant CNS (central nervous system) depression and respiratory depression effects particularly acute in a patient with liver and kidney disease. I would not have recommended every two hours around the clock administration of these drugs to (Resident #2's name) especially because of his diagnosis. We did not give or instruct the nurses at Crestwood to administer [MEDICATION NAME] and [MEDICATION NAME] every two hours. In this case he was overmedicated, and I would expect any nurse to call to speak with either the nurses or the doctor on call to determine if the medication should continue at the prescribed times or be adjusted and held. My understanding is (Resident #2's name) was obtunded (lethargy in which the patient has a lessened interest in the environment, slowed responses to stimulation, and tends to sleep more than normal with drowsiness in between sleep states) with a respiratory rate of ,[DATE] with long apneic (cessation of respiration) periods, this was discussed with family and the nursing home and the decision to send the patient out to the hospital for treatment was made by the family, staff and our staff followed the family wishes. Our nurse followed up in the emergency room and the patient had a significant change in alertness with [MEDICATION NAME] administration which overall tells us that he was overmedicated and that was not recognized by the staff at Crestwood. Overdosage and the need to use reversal agents has a profound effect on the patients that I treat, not only physical but psychological as well for both patients and their families. During an interview on [DATE] at 9:37 AM via telephone the DON stated, I did not evaluate (Resident #2's name). The first I heard about it was when the ADON/Educator told me he had been medicated every two hours with [MEDICATION NAME] and he was unarousable with a respiratory rate of 6 or 7 per minute. She stated he needed to be transferred out because we were killing him with medications, that he was obtunded and unable to respond to painful stimuli. The hospice nurse and sister wanted to transfer him to the hospital for evaluation and treatment. I never went to evaluate the resident he was already seen by the hospice nurse and the ADON, so I just started getting the transfer started. I trusted their judgement that he needed to be transferred. I did not do any investigation, there was no time to as I was suspended on [DATE]. I did not review the Narcotic Administration sheets. I did not look at any of the nurses' documentation or check any physician orders. I did not know that it was an adverse incident. I was told that he was administered medication every two hours of [MEDICATION NAME] and [MEDICATION NAME], but that he did not have orders to medicate that frequently. I did not instruct the nurses to make out an incident report. The Administrator knew the patient went to the hospital, got administered [MEDICATION NAME], and the sister did not want him to come back because of this. We were notified that day that he would not be returning. I really did not get to investigate any of this, I just started in (MONTH) and it takes time to determine that processes are broken. We have a lot of work to do to improve the care we deliver. We don't have a code blue sheet that we fill out if a resident codes. I wasn't aware that the policy stated we had one. I would think that if someone has a CPR card, they are proficient according to the American Red Cross. I didn't do anything to assess the staff competency in CPR or their comfort level in CPR. Anyone who is CPR certified can start CPR. I did not look at any of the Code Blues that we started and was not tracking them or looking at the documentation, that is the responsibility of the Unit manager to do that and bring any concerns to me and the Administrator during the morning meetings. I was not aware that a resident did not have CPR started for five minutes. We don't have an AED (Automated External Defibrillator) that I am aware of. I'm not the Risk Manager, that's the ADON's job. I realize that there are problems here and some staff are not liking the changes that I tried to start, I wanted to do a good job and make changes. Ultimately, as the DON I am responsible for those things and everything that the nursing staff does and the interactions between departments to make sure things are done correctly. During an interview on [DATE] at 3:30 PM the ADON stated, The last time I worked was on [DATE], the ,[DATE] AM shift, the morning that (Resident #2's name) medication mistake was found. I was involved because I was finishing up and his sister asked me about medications, and the last time a medication mistake was discovered. An attempt was made to interview the nurse, via telephone to her last known number, who administered [MEDICATION NAME] and [MEDICATION NAME] to Resident #2. The nurse is no longer employed by the facility. The nurse had resigned from her position. The message received was that the number had been changed or was no longer in service. 3) Review of Resident #10's facility record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. The resident had a Full Code Status. Review of the nursing progress note dated [DATE] at 10:45 PM read: While receiving report from off going nurse, nursing assistant called for assistance to patient's room. Upon entering the room patient was assessed with [REDACTED]. Pulse palpated without result. Code Blue called, crash cart was brought to room. At 10:50 PM compressions were started. 911 was called. 6 rounds of compressions and breaths were performed. EMS arrived assessed the patient, transported patient to hospital. Review of Resident #10's record revealed there was no documentation of a Code Blue form. Review of the hospital records for Resident #10 dated [DATE] at 11:28 PM revealed HPI (History of Present Illness) Chief Complaint: [MEDICAL CONDITION], found down. Arrest Circumstances: Unwitnessed arrest. Context: Resuscitation [MEDICATION NAME] IV X 2 (for two doses). Context of Onset: Found unresponsive in [MEDICAL CONDITION]. Severity: Onset Severe. Severity: Current Severe. Free Test HPI Notes: Found unresponsive at nursing home with no pulse, EMS called and found pulseless. Alertness: Unresponsive. Pupils: Dilated, Nonreactive. Resp/Chest: No spontaneous Respirations. Cardiovascular: Pulseless. Neurologic: Unresponsive. Re-Evaluation: After extended effort to resuscitate she never regained pulses. Bedside ultrasound showed no cardiac activity. Patient Discharge & Departure: Condition: Expired. Disposition Decision: 2358 (11:58 PM). Date: [DATE]. During an interview on [DATE] at 2:25 PM Staff B, LPN stated, I work over at our sister facility I'm only helping out here. We share the same policies and procedures. I would not administer [MEDICATION NAME] to a resident that was lethargic or unresponsive. If the doctor did not write a hold for sedation order I would hold the medication and call them so that they could adjust the dose or timing of the medications or send the resident out to be evaluated. I am CPR certified and its current. I don't know where the emergency cart is, I am just helping out here. If I didn't know the resident's code status, I would not start CPR until I checked the chart. There is no other way to know that information. It's on my report sheet, but I don't always have that on me. I don't know how long that would take; maybe five minutes or less. You can't start CPR on a resident who is a DNR, so I would not start CPR until I knew for sure. I haven't gotten any training on code blue policy, medication policy or anything else recently. During an interview on [DATE] at 8:40 AM Staff I, LPN stated, I just started about one month ago, I got a week of orientation. I'm a brand-new nurse and still feel a little overwhelmed at times. My orientation was passing medications with another nurse. They didn't give me any type of check off sheet or competency to have anyone fill out. I did not go over any policies on code blue or any other policy during orientation. If a resident had orders to medicate with [MEDICATION NAME] and [MEDICATION NAME] around the clock, I would not administer the medications if the resident was lethargic or difficult to wake up or had shallow respirations. That would be contraindicated. I would call the doctor or the hospice nurse to let them know. Pain control in a resident who in end of life care is keeping them comfortable, not making them unresponsive. You should not administer more medication when you have respirations at or under 8 or 10, I think. I would let my Charge Nurse know so they can give me direction on what else to do. I have never done CPR, but I would start it as soon as I discovered a resident without a pulse. I don't think they have an emergency cart. I don't know where it is if they do. We don't have an AED we only do CPR until EMS arrives. During an interview on [DATE] at 9:45 AM Staff D, CNA (Certified Nursing Assistant) stated, If I have any issues, I go to the Unit Manager, we don't have a Director of Nursing right now, he quit I guess, and the other Unit Manger quit too. I think it was on Monday. I don't know where the emergency code cart is. I think it's in the supply room, but I don't know. If a patient is unresponsive, I would go get the nurse. I'm CPR certified but I don't feel comfortable doing it. They don't give us any training on that here. I just go get the nurse to check out the resident if I think they have somet

Based on interviews, record reviews, and policy and procedure review the facility failed to ensure care and services provided supported the highest practicable quality of life by not following physician orders [REDACTED].#10. This has the potential to affect 26 of 47 residents with a full code status at risk. Cross reference to F658, F678, F684, F726, F760, and F835 The findings included: 1) Review of Resident #1's facility record revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's lab dated [DATE] revealed Ammonia 100 High. (too much ammonia in the body can cause psychological problems like confusion, tiredness, and possibly coma or death) Review of the physician's orders [REDACTED]. Diagnosis: [REDACTED]. Dated [DATE] at 12:00 AM read: [MEDICATION NAME] 30 ml every 6 hours as needed. Review of the Medication Administration Record [REDACTED]. For the period of [DATE] at 9:00 PM to [DATE] the MAR indicated [REDACTED]. [MEDICATION NAME] 10 GM/15 ML Solution give 30 ML (20GM) by mouth every 6 hours as needed - [MEDICAL CONDITION] of liver. The documentation showed [MEDICATION NAME] was not administered as needed and was documented as discontinued on [DATE] at 9:00 AM. Review of the Discontinued Order - As Needed (Handwritten) form read: [MEDICATION NAME] 10 GM/15 ML (15 grams to 15 milliliters) Solution by mouth. Original Fill Date: [DATE]. Give 30 milligram by mouth as needed every 6 hours as needed. Discontinued Date: [DATE] at 1:14 PM. [MEDICATION NAME] 10 gm/15 ML Solution. Original Fill Date: [DATE]. Give 30 ML (20GM) by mouth every 6 hours as needed. Discontinued Date: [DATE] at 11:03 PM. [MEDICATION NAME] 10 GM/15 ML Solution. Original Fill Date: [DATE]. Give 30 Milliliter by mouth as needed every 6 hours. Discontinued Date: [DATE] at 11:03 PM. The Discontinued Orders were completed by licensed nursing staff and did not have a physician's signature line or signature for the discontinuation of the medication. During an interview on [DATE] at approximately 1:12 PM with Resident #1's daughter she stated, My mother would have periods of confusion and craziness and when that happened, I knew it was the ammonia level and she wasn't getting her [MEDICATION NAME]. During an interview on [DATE] at approximately 2:00 PM with the Administrator a request was made for documentation of the administration of [MEDICATION NAME] as ordered by the physician for the period of [DATE] at 9:00 PM to [DATE] at 9:00 AM (the resident was discharged to the hospital for an unrelated concern at approximately 7:00 PM on [DATE]) or for the physician's orders [REDACTED]. The Administrator stated she would have nursing provide the documentation. During an interview on [DATE] at approximately 10:00 AM with the Administrator a request was made for documentation of the administration of [MEDICATION NAME] as ordered by the physician for the period of [DATE] at 9:00 PM to [DATE] at 9:00 AM (the resident was discharged to the hospital for an unrelated concern at approximately 7:00 PM on [DATE]) or for the physician's orders [REDACTED]. The Administrator stated she let nursing know the documentation was needed. During an interview on [DATE] at approximately 4:00 PM with the Administrator a request was made for documentation of the administration of [MEDICATION NAME] as ordered by the physician for the period of [DATE] at 9:00 PM to [DATE] at 9:00 AM (the resident was discharged to the hospital for an unrelated concern at approximately 7:00 PM on [DATE]) or for the physician's orders [REDACTED]. The Administrator did not respond. No additional documentation was provided. 2) Review of Resident #2's facility record revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the hospice Treatment or Medication Form dated [DATE] [MEDICATION NAME] 1 mg oral every 4 hours PRN (as needed). Dated [DATE] read: [MEDICATION NAME] concentrate 20:1 10 mg = 0.5 ml SL (sublingual) every 4 hours ATC (around the clock). [MEDICATION NAME] 1 mg SL/PO (by mouth) every 4 hours ATC. (MONTH) hold for sedation. Please continue [MEDICATION NAME] sulfate and [MEDICATION NAME] every 4 hours PRN (as needed). Dated: [DATE] Lensin/Mycosamine 0.125 mg SL every 4 hours PRN - secretions. D/C (discontinue) nonessential meds d/t (due to) decline. Review of the Controlled Drug Declining Inventory Sheet for [MEDICATION NAME] ([MEDICATION NAME])1 mg tablet revealed the medication was signed out for administration on [DATE] at 10:00 AM, at 2:00 PM, at 08:00 PM, and at 12:00 AM. On [DATE] at 4:00 AM, at 8:00 AM, at 10:00 AM, at 12:00 PM, at 2:00 PM, at 5:30 PM, at 8:00 PM, and at 10:00 PM. On [DATE] at 12:00 midnight. [MEDICATION NAME] 100 mg/5 ml concentrate was signed out for administration [DATE] at 10:00 AM, at 02:00 PM, at 08:00 PM, [DATE] at 12:00 AM, [DATE] at 04:00 AM, 8:00 AM, at 10:00 AM, at 12:00 PM, at 2:00 PM, at 5:30 PM, at 8:00 PM, and at 10:00 PM. On [DATE] at 12:00 midnight and at 4:15 AM. Review of the care plan revised on [DATE] read: Focus: The resident is on pain medication therapy r/t end stage diagnosis. Goal: The resident will be free of any discomfort or adverse side effects from pain medication. Interventions: Administer [MEDICATION NAME] medications as ordered by physician. Monitor/document side effects and effectiveness Q (every) shift. Ask physician to review medication if side effects persist. Monitor/document/report PRN adverse reactions to [MEDICATION NAME] therapy: altered mental status, respiratory distress/decreased respirations, sedation. Focus: Use of [MEDICAL CONDITION] antianxiety drug places resident at risk for drug-related: Cognitive impairment. Initiated [DATE]. Goal: Resident will receive the least dosage of the prescribed [MEDICAL CONDITION] drug (s) to ensure maximum functional ability both mentally and physically. Interventions: [MEDICATION NAME] as ordered. Observe for side effects and hold medication for increased lethargy. Review of the nursing progress notes dated [DATE] at 2:37 PM New orders from hospice nurse [MEDICATION NAME] 1 mg PO @ HS (by mouth at hour of sleep). Dated: [DATE] at 6:21 AM Resident #2 is not wanting to take his medications ([MEDICATION NAME]) Very lethargic and not wanting to open his mouth. Dated: [DATE] at 9:58 AM Resident tried to get out of bed. Stated he forgot he could not walk. Resident fell on his right side on the floor. Resident did not hit his head. Red marks on right hip and right shoulder. DON (Director of Nursing) and MD (Medical Doctor) notified. Resident was reminded to use call light any time he needs to get up. Dated: [DATE] at 11:11 AM Resident laying in bed sleeping. Easily arousable. No signs of pain or distress. Resident stated he was just tired and wanted to back to sleep. Date: [DATE] at 12:29 AM This nurse writing called hospice due to Resident making changes in mental status. Resident is restless, asking for someone to help him, climbing out of bed, Not eating or drinking sufficient amount. He is c/o (complaint of) abdominal pain. Hospice nurse on called made a visit received new order to increase [MEDICATION NAME], Q4 hrs. PRN (hours as needed). Resident is being monitored closely to prevent resident injuries. Dated: [DATE] at 1:38 PM The resident has had a change is condition. When first observed the resident's jaw was twisted to the right and [MEDICAL CONDITION] is suspected. I obtained vital signs and notified hospice as well as his family. Family has been in to see the resident but hospice has not been in at this time 1:41 PM. (There was no documentation of the physician having been notified of the change in condition). Dated: [DATE] at 10:07 AM read: Resident is nonresponsive. Family notified and in facility. Hospice nurse in facility. Resident is currently on 4 L (liters) of O2 (oxygen) via nasal cannula r/t apnea (cessation of breathing). Dated: [DATE] at 12:23 PM. Resident eyes are no longer reactive to light. RR (respirations) approximately 8 per minutes, on 4 L O2 via nasal cannula. On [DATE] at 2:24 PM Being medicated on schedule every 2 hours as instructed by Hospice. Respirations 7 per minute. Currently unarousable again. On [DATE] at 3:52 PM Resident is wheezing and moaning. Still asleep. Not arousable. Breathing is slow and labored. On [DATE] at 3:3 PM Resident is currently lying in bed quietly sleeping with eyes half open. Responds to painful stimuli. Skin warm and dry to touch except for feet is cool. Respirations with long periods of inhale and exhale. No urine output so far this shift. Requires total assistance with ADL's, turning and repositioning. PO (by mouth) meal intake is zero d/t (due to) decrease alertness. On [DATE] at 9:04 AM Resident only responsive to painful stimuli. Hospice nurse in to see resident and review orders. Upon assessment determined to send resident to ER (emergency room ). Review of the hospice nursing progress notes dated [DATE] at 8:30 AM read, Reason for Focused Visit: Dying process/decline. Medication assessed for: Medicine reconciliation done. Effectiveness. Not taking meds as prescribed. Clinician Narrative Note: When I arrived there patient was unresponsive. Reviewed medications and patient has been getting the [MEDICATION NAME] 1 mg every 2 hours and [MEDICATION NAME] 10 mg every 2 hours instead of every 4 hours as ordered. Spoke with DON (Director of Nursing) and ADON (Assistant Director of Nursing) and they would like the patient to be sent to the ER for medication overdose. Spoke with sister at the bedside and she would like the patient to be sent out as well. Heat rate: 56. Respirations: 8. Blood Pressure ,[DATE]. O2 Sat (saturation) 92% on 2 LPM (liters per minute). Dated: [DATE] at 11:35 AM read, Clinician Narrative Note: Spoke to ER MD and the RN (Registered Nurse) along with sister at the bedside. Patient was given [MEDICATION NAME] to reverse the effects from the [MEDICATION NAME]. Dated: [DATE], unable to read time, Clinician Narrative Note: Patient had decline somewhat over the weekend .possibly transitioning. Pt (Patient) was in hospital ER with sister at Pt's bedside. Cp (Chaplin) spent much time comforting and encouraging pt's sister and later praying with both. Because sister did not want pt to go back to facility from which pt came, sister was looking for other options. Review of the EMS (Emergency Medical Services) note dated [DATE] revealed Chief Complaint: Overdose [MEDICATION NAME]. Meds Admin (Medications Administered) [MEDICATION NAME] 0.4 IV (intravenously). Review of the hospital records dated [DATE] revealed Chief Complaint: Drug overdose. History and Physical: Presents to ED via EMS d/t (due to) accidental overdose. Pt. sister states Pt has end stage liver failure and is on hospice at Crestwood Nursing home. Pt. was supposed to give (sic) 10 mg every 4 hours but they were giving 10 mg every 2 hours per Pt. sister. EMS gave Pt. [MEDICATION NAME] and drastically improved. Pt. denies any other Sx (symptoms) at this time. Free Text: Pt. sister does not like care given to Pt. at Crestwood Nursing home and would like someone else. Re-Evaluation/Progress #1: After [MEDICATION NAME] - Re-Eval Status: Improved. Eval Following Treatment: Pt. feels better, Condition improved. Condition: Stable. Review of the hospital Emergency Patient Record dated [DATE] revealed: Priority: 2/Emergent. Ingestion - Presenting signs/symptoms: Decreased Resp (respirations), Decreased L[NAME] (level of consciousness). Emergency Notes: [DATE] Assumed care of Pt. from previous RN. Pt. is alert when name is spoken to. Pt. has sister and hospice rep (representative) at bedside. Pt. is showing no signs of distress. Per Pt. advocate, Pt's family is requesting new hospice representation. Pt. is to be DC (discharged ) to new facility when it is determined. At 12:04 PM Pt. is resting comfortably with family at his side. No signs of distress noted. During an interview on [DATE] at 2:02 PM Staff A, Unit Manger/LPN (Licensed Practical Nurse) she stated, I am responsible for the unit, both of them since the other Unit Manager quit. I was involved in (Resident #2's name) transfer to the hospital. The hospice nurse came to me and told me the Resident had been given [MEDICATION NAME] and [MEDICATION NAME] every two hours the day before and was obtunded (lethargy in which the patient has a lessened interest in the environment, slowed responses to stimulation, and tends to sleep more than normal with drowsiness in between sleep states) with a very low respiratory rate. We told the DON who said to transfer the resident if that's what the sister wanted. The Administrator was called by the DON and told that the resident had a medication error and needed to go to the ED. So, I called 911 and got him to the hospital. That's all the involvement I had, except that I told The Administrator that the resident wasn't coming back because the sister didn't want him to. I called the hospital for an update and the hospice nurse let us know too. I didn't make out an incident report. When a resident gets medication, we should be monitoring them for any side effects and holding them and calling the doctor or the hospice nurse for any further orders if there are side effects. It is my expectation that I be informed of any changes in the residents' condition so that the resident can be assessed, and the problem can be addressed with the doctor. I expect the nurses to assess the residents for signs of over sedation. If a resident is sedated, hold medications until they check with hospice or the doctor and document all of that in the chart. During an interview on [DATE] at 4:55 PM the Hospice Nurse for Resident #2 stated, I did his initial consult on [DATE], and saw him again on [DATE], and when I saw him on Monday [DATE] there was a big difference, he was unresponsive when I saw him. It was reported to me that he had multiple falls over the weekend and agitation. The Resident's sister told me that he had been given medication every two hours per our orders and I knew that we did not have any orders for medications every two hours. When I checked our orders, we still had [MEDICATION NAME] 0.5 ml every 4 hours and a PRN (as needed) order for every 4 hours. But we did not give orders to medicate every 2 hours. After talking to the Director of Nursing and assessing the patient we were all in agreement that the patient should be sent to the ED and the Resident's sister agreed. I followed up on him once he went to the ED. He received [MEDICATION NAME] and was much more alert when I saw him, he was agitated but responsive. Our goal in pain control in end of life is to provide and promote comfort, we want our patients to be pain free, without anxiety. We want our patients to have enough medication to remain comfortable, not overmedicate them to a point where they require reversal agents. I was shocked because the man I saw on Monday was nowhere near the man I saw on Thursday. That was gross overmedication. The patient's sister did not want him to go back to Crestwood, and because we don't have another facility, we discharged him to another hospice, so the family had a sense of peace and comfort with his care. This Nurse should be reported because this was negligent. During a telephone interview on [DATE] at 10:45 AM the Hospice Doctor stated, I am the Physician for hospice and am aware of (Resident #2's name). He began hospice sometime in July. When he was first on service, he was taking [MEDICATION NAME] I believe and the switch to [MEDICATION NAME] began just a few days before he went to the emergency room . We routinely order [MEDICATION NAME] and [MEDICATION NAME] for comfort and anxiety. Our goal is anxiety reduction, symptom control and pain freedom at end of life. We medicate according to the patient's symptomology and frequently have routine orders and orders for breakthrough pain or anxiety. If I or any other of the hospice Physicians thinks medication more frequently than every four hours is necessary, we would order more frequent routine administration of narcotic [MEDICATION NAME]. Although, in my field I seldom have to worry about [MEDICATION NAME] administration and the concomitant use of benzodiazepines such as [MEDICATION NAME]. There would be a significant CNS (central nervous system) depression and respiratory depression effects particularly acute in a patient with liver and kidney disease. I would not have recommended every two hours around the clock administration of these drugs to (Resident #2's name) especially because of his diagnosis. We did not give or instruct the nurses at Crestwood to administer [MEDICATION NAME] and [MEDICATION NAME] every two hours. In this case he was overmedicated, and I would expect any nurse to call to speak with either the nurses or the doctor on call to determine if the medication should continue at the prescribed times or be adjusted and held. My understanding is (Resident #2's name) was obtunded (lethargy in which the patient has a lessened interest in the environment, slowed responses to stimulation, and tends to sleep more than normal with drowsiness in between sleep states) with a respiratory rate of ,[DATE] with long apneic (cessation of respiration) periods, this was discussed with family and the nursing home and the decision to send the patient out to the hospital for treatment was made by the family, staff and our staff followed the family wishes. Our nurse followed up in the emergency room and the patient had a significant change in alertness with [MEDICATION NAME] administration which overall tells us that he was overmedicated and that was not recognized by the staff at Crestwood. Overdosage and the need to use reversal agents has a profound effect on the patients that I treat, not only physical but psychological as well for both patients and their families. During an interview on [DATE] at 9:37 AM via telephone the DON stated, I did not evaluate (Resident #2's name). The first I heard about it was when the ADON/Educator told me he had been medicated every two hours with [MEDICATION NAME] and he was unarousable with a respiratory rate of 6 or 7 per minute. She stated he needed to be transferred out because we were killing him with medications, that he was obtunded and unable to respond to painful stimuli. The hospice nurse and sister wanted to transfer him to the hospital for evaluation and treatment. I never went to evaluate the resident he was already seen by the hospice nurse and the ADON, so I just started getting the transfer started. I trusted their judgement that he needed to be transferred. I did not do any investigation, there was no time to as I was suspended on [DATE]. I did not review the Narcotic Administration sheets. I did not look at any of the nurses' documentation or check any physician orders. I did not know that it was an adverse incident. I was told that he was administered medication every two hours of [MEDICATION NAME] and [MEDICATION NAME], but that he did not have orders to medicate that frequently. I did not instruct the nurses to make out an incident report. The Administrator knew the patient went to the hospital, got administered [MEDICATION NAME], and the sister did not want him to come back because of this. We were notified that day that he would not be returning. I really did not get to investigate any of this, I just started in (MONTH) and it takes time to determine that processes are broken. We have a lot of work to do to improve the care we deliver. We don't have a code blue sheet that we fill out if a resident codes. I wasn't aware that the policy stated we had one. I would think that if someone has a CPR card, they are proficient according to the American Red Cross. I didn't do anything to assess the staff competency in CPR or their comfort level in CPR. Anyone who is CPR certified can start CPR. I did not look at any of the Code Blues that we started and was not tracking them or looking at the documentation, that is the responsibility of the Unit manager to do that and bring any concerns to me and the Administrator during the morning meetings. I was not aware that a resident did not have CPR started for five minutes. We don't have an AED (Automated External Defibrillator) that I am aware of. I'm not the Risk Manager, that's the ADON's job. I realize that there are problems here and some staff are not liking the changes that I tried to start, I wanted to do a good job and make changes. Ultimately, as the DON I am responsible for those things and everything that the nursing staff does and the interactions between departments to make sure things are done correctly. During an interview on [DATE] at 3:30 PM the ADON stated, The last time I worked was on [DATE], the ,[DATE] AM shift, the morning that (Resident #2's name) medication mistake was found. I was involved because I was finishing up and his sister asked me about medications, and the last time a medication mistake was discovered. An attempt was made to interview the nurse, via telephone to her last known number, who administered [MEDICATION NAME] and [MEDICATION NAME] to Resident #2. The nurse is no longer employed by the facility. The nurse had resigned from her position. The message received was that the number had been changed or was no longer in service. 3) Review of Resident #10's facility record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. The resident had a Full Code Status. Review of the nursing progress note dated [DATE] at 10:45 PM read: While receiving report from off going nurse, nursing assistant called for assistance to patient's room. Upon entering the room patient was assessed with [REDACTED]. Pulse palpated without result. Code Blue called, crash cart was brought to room. At 10:50 PM compressions were started. 911 was called. 6 rounds of compressions and breaths were performed. EMS arrived assessed the patient, transported patient to hospital. Review of Resident #10's record revealed there was no documentation of a Code Blue form. Review of the hospital records for Resident #10 dated [DATE] at 11:28 PM revealed HPI (History of Present Illness) Chief Complaint: [MEDICAL CONDITION], found down. Arrest Circumstances: Unwitnessed arrest. Context: Resuscitation [MEDICATION NAME] IV X 2 (for two doses). Context of Onset: Found unresponsive in [MEDICAL CONDITION]. Severity: Onset Severe. Severity: Current Severe. Free Test HPI Notes: Found unresponsive at nursing home with no pulse, EMS called and found pulseless. Alertness: Unresponsive. Pupils: Dilated, Nonreactive. Resp/Chest: No spontaneous Respirations. Cardiovascular: Pulseless. Neurologic: Unresponsive. Re-Evaluation: After extended effort to resuscitate she never regained pulses. Bedside ultrasound showed no cardiac activity. Patient Discharge & Departure: Condition: Expired. Disposition Decision: 2358 (11:58 PM). Date: [DATE]. During an interview on [DATE] at 2:25 PM Staff B, LPN stated, I work over at our sister facility I'm only helping out here. We share the same policies and procedures. I would not administer [MEDICATION NAME] to a resident that was lethargic or unresponsive. If the doctor did not write a hold for sedation order I would hold the medication and call them so that they could adjust the dose or timing of the medications or send the resident out to be evaluated. I am CPR certified and its current. I don't know where the emergency cart is, I am just helping out here. If I didn't know the resident's code status, I would not start CPR until I checked the chart. There is no other way to know that information. It's on my report sheet, but I don't always have that on me. I don't know how long that would take; maybe five minutes or less. You can't start CPR on a resident who is a DNR, so I would not start CPR until I knew for sure. I haven't gotten any training on code blue policy, medication policy or anything else recently. During an interview on [DATE] at 8:40 AM Staff I, LPN stated, I just started about one month ago, I got a week of orientation. I'm a brand-new nurse and still feel a little overwhelmed at times. My orientation was passing medications with another nurse. They didn't give me any type of check off sheet or competency to have anyone fill out. I did not go over any policies on code blue or any other policy during orientation. If a resident had orders to medicate with [MEDICATION NAME] and [MEDICATION NAME] around the clock, I would not administer the medications if the resident was lethargic or difficult to wake up or had shallow respirations. That would be contraindicated. I would call the doctor or the hospice nurse to let them know. Pain control in a resident who in end of life care is keeping them comfortable, not making them unresponsive. You should not administer more medication when you have respirations at or under 8 or 10, I think. I would let my Charge Nurse know so they can give me direction on what else to do. I have never done CPR, but I would start it as soon as I discovered a resident without a pulse. I don't think they have an emergency cart. I don't know where it is if they do. We don't have an AED we only do CPR until EMS arrives. During an interview on [DATE] at 9:45 AM Staff D, CNA (Certified Nursing Assistant) stated, If I have any issues, I go to the Unit Manager, we don't have a Director of Nursing right now, he quit I guess, and the other Unit Manger quit too. I think it was on Monday. I don't know where the emergency code cart is. I think it's in the supply room, but I don't know. If a patient is unresponsive, I would go get the nurse. I'm CPR certified but I don't feel comfortable doing it. They don't give us any training on that here. I just go get the nurse to check out the resident if I think they have something wrong. I wouldn't start CPR until I got the nurse to see if they needed it. We don't get any training here on code blue policy for resident care. I just get an evaluation every year. I orient new people. They get two days with me. I just watch them do the work, we don't have any sign off sheet or anything. If I don't think they are good I tell the Unit Manager. During an interview on [DATE] at 10:05 AM Staff E, CNA stated The Director of Nursing and the other Unit Manager/ADON both quit. I don't know who to go to except the Nurse Manager. There is no one else to go to. If a resident is not breathing, I'll go get the nurse. I would not start CPR, I've never done it. I would just go get the nurse. I'll look for the medication cart to find the nurse and tell her what's happening and have her check the resident out and do what she tells me to. I'm not comfortable doing CPR. During an interview on [DATE] at 11:00 AM Staff F, CNA stated The Director of Nursing quit or was fired, and the other Unit Manager quit too just yesterday, I think. I think the Director of Nursing got suspended for his behavior like bullying the staff. No one has told us who to call if we have a problem. I guess, if I have any problems, I'll just go to one of the nurses until we have a new DON. If a resident is not breathing, I go get the nurse. I wouldn't feel comfortable doing CPR. I've never done it. We don't have any emergency code cart or equipment. They just do CPR until EMS arrives. Sometimes when we need the nurse to check the resident they don't always come right away if they are in the middle of dressings or something. During an interview on [DATE] at 11:15 AM Staff G, CNA stated, I would get the nurse if I thought someone stopped breathing, call for help. I have never done CPR, so I don't feel comfortable doing it. I just do what the nurses tell me to. I don't think we have an emergency code cart. I would let the Unit Manger know about any problems that I had since we don't have a DON right now. I haven't been told I could call anyone else. During a follow up interview on [DATE] at 2:35 PM Staff A, LPN/Unit Manger (UM) stated, I don't know where the emergency code cart is, the supply room, I think; let's see. Upon entering the supply room there was no emergency cart observed. The UM continued to say, I'm sorry I don't know where it is, this is so bad. A tour was conducted of the entire second floor where all of the residents' rooms are located until the emergency cart was located in the restorative dining room in the corner at 2:48 PM. The cart contained a suction machine on the top and was unlocked with additional suction tubing, gloves and other supplies such as intravenous insertion kits that did not contain needles or sharp objects. The Emergency cart log had no signatures of having been checked since [DATE] and multiple missing signatures from (MONTH) and July. The UM stated, I don't know who is supposed to check this, I didn't know it needed to be checked. I don't know the policy and procedure for checking the emergency cart. I don't even know what is supposed to be in the crash cart. I guess we have an issue that if I don't know where this is others probably don't. I haven't had anyone code since I got here. I expect the staff to start CPR on anyone that's a full code. It is not acceptable to wait five minutes to start CPR. I expect all staff will start CPR immediately on full codes, anyone who is CPR certified can start CPR we just do CPR until EMS arrives. I don't think that we have an AED, I've not seen one here. During an interview on [DATE] at 7:15 AM Staff H, CNA stated, I don't know who besides the Unit Manager that I would call if I had any problems. I haven't seen any other DON here since the other one was suspended. If I found a resident unresponsive, I would check to see if they are breathing and if they have a pulse, and then go get the nurse. I wouldn't start CPR, I don't always know if they are a DNR so I would get the nurse. I'm not comfortable doing CPR, it's scary and I haven't ever done it. We don't have an emergency code cart that I know of. We just call 911 if there is a resident that needs CPR. During an interview on [DATE] at 3:15 PM Staff K, CNA, stated, I do not have BLS/CPR (Basic Life Support) certification. I did once, I can't remember when it expired. They are trying to get me a class. I have worked here for ten years. We don't have an emergency cart so I couldn't go get it for a nurse if the resident is getting CPR or whatever. During an interview on [DATE] at 3:20 PM Staff L, LPN stated, I am CPR certified. If I don't know what the resident's code status is, I would check the chart before I started CPR. Depending on how far away from the nurses' station I am, it might take about five minutes to find out. I would not start CPR until I knew definitely that the resident was not a DNR. I don't know where the emergency cart is. I think it's in the supply room. We don't have a code sheet we fill out we just call 911 and do CPR until they arrive. We only have a suction machine that is on the emergency cart. We have not had any mock drills or mock codes. I would not administer any medication that has a sedating effect to a resident who is not responding, that includes a hospice patient. Hospice usually will give an order to hold narcotics i

Based on interviews, record review and policy and procedure review the facility failed to ensure cardiopulmonary resuscitation (CPR) was initiated immediately for 1 of 3 residents sampled for CPR with a full code status, the resident did not survive, Resident #10. The facility failure to investigate and initiate a plan of correction places 26 of 47 residents with a full code status at risk. Cross reference; F600, F607, F610, F658, F675, F726, F835 The findings included: Review of Resident #10's facility record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. The resident had a Full Code Status. Review of the nursing progress note dated [DATE] at 10:45 PM read: While receiving report from off going nurse, nursing assistant called for assistance to patient's room. Upon entering the room patient was assessed with [REDACTED]. Pulse palpated without result. Code Blue called, crash cart was brought to room. At 10:50 PM compressions were started. 911 was called. 6 rounds of compressions and breaths were performed. EMS arrived assessed the patient, transported patient to hospital. Review of Resident #10's record revealed there was no documentation of a Code Blue form. Review of the hospital records for Resident #10 dated [DATE] at 11:28 PM revealed HPI (History of Present Illness) Chief Complaint: [MEDICAL CONDITION], found down. Arrest Circumstances: Unwitnessed arrest. Context: Resuscitation [MEDICATION NAME] IV X 2 (for two doses). Context of Onset: Found unresponsive in [MEDICAL CONDITION]. Severity: Onset Severe. Severity: Current Severe. Free Test HPI Notes: Found unresponsive at nursing home with no pulse, EMS called and found pulseless. Alertness: Unresponsive. Pupils: Dilated, Nonreactive. Resp/Chest: No spontaneous Respirations. Cardiovascular: Pulseless. Neurologic: Unresponsive. Re-Evaluation: After extended effort to resuscitate she never regained pulses. Bedside ultrasound showed no cardiac activity. Patient Discharge & Departure: Condition: Expired. Disposition Decision: 2358 (11:58 PM). Date: [DATE]. During an interview on [DATE] at 2:25 PM Staff B, LPN stated, I work over at our sister facility I'm only helping out here. We share the same policies and procedures. I would not administer [MEDICATION NAME] to a resident that was lethargic or unresponsive. If the doctor did not write a hold for sedation order I would hold the medication and call them so that they could adjust the dose or timing of the medications or send the resident out to be evaluated. I am CPR certified and its current. I don't know where the emergency cart is, I am just helping out here. If I didn't know the resident's code status, I would not start CPR until I checked the chart. There is no other way to know that information. It's on my report sheet, but I don't always have that on me. I don't know how long that would take; maybe five minutes or less. You can't start CPR on a resident who is a DNR, so I would not start CPR until I knew for sure. I haven't gotten any training on code blue policy, medication policy or anything else recently. During an interview on [DATE] at 8:40 AM Staff I, LPN stated, I just started about one month ago, I got a week of orientation. I'm a brand-new nurse and still feel a little overwhelmed at times. My orientation was passing medications with another nurse. They didn't give me any type of check off sheet or competency to have anyone fill out. I did not go over any policies on code blue or any other policy during orientation. If a resident had orders to medicate with [MEDICATION NAME] and [MEDICATION NAME] around the clock, I would not administer the medications if the resident was lethargic or difficult to wake up or had shallow respirations. That would be contraindicated. I would call the doctor or the hospice nurse to let them know. Pain control in a resident who in end of life care is keeping them comfortable, not making them unresponsive. You should not administer more medication when you have respirations at or under 8 or 10, I think. I would let my Charge Nurse know so they can give me direction on what else to do. I have never done CPR, but I would start it as soon as I discovered a resident without a pulse. I don't think they have an emergency cart. I don't know where it is if they do. We don't have an AED we only do CPR until EMS arrives. During an interview on [DATE] at 9:45 AM Staff D, CNA (Certified Nursing Assistant) stated, If I have any issues, I go to the Unit Manager, we don't have a Director of Nursing right now, he quit I guess, and the other Unit Manager quit too. I think it was on Monday. I don't know where the emergency code cart is. I think it's in the supply room, but I don't know. If a patient is unresponsive, I would go get the nurse. I'm CPR certified but I don't feel comfortable doing it. They don't give us any training on that here. I just go get the nurse to check out the resident if I think they have something wrong. I wouldn't start CPR until I got the nurse to see if they needed it. We don't get any training here on code blue policy for resident care. I just get an evaluation every year. I orient new people. They get two days with me. I just watch them do the work, we don't have any sign off sheet or anything. If I don't think they are good I tell the Unit Manager. During an interview on [DATE] at 10:05 AM Staff E, CNA stated The Director of Nursing and the other Unit Manager/ADON both quit. I don't know who to go to except the Nurse Manager. There is no one else to go to. If a resident is not breathing, I'll go get the nurse. I would not start CPR, I've never done it. I would just go get the nurse. I'll look for the medication cart to find the nurse and tell her what's happening and have her check the resident out and do what she tells me to. I'm not comfortable doing CPR. During an interview on [DATE] at 11:00 AM Staff F, CNA stated The Director of Nursing quit or was fired, and the other Unit Manager quit too just yesterday, I think. I think the Director of Nursing got suspended for his behavior like bullying the staff. No one has told us who to call if we have a problem. I guess, if I have any problems, I'll just go to one of the nurses until we have a new DON. If a resident is not breathing, I go get the nurse. I wouldn't feel comfortable doing CPR. I've never done it. We don't have any emergency code cart or equipment. They just do CPR until EMS arrives. Sometimes when we need the nurse to check the resident they don't always come right away if they are in the middle of dressings or something. During an interview on [DATE] at 11:15 AM Staff G, CNA stated, I would get the nurse if I thought someone stopped breathing, call for help. I have never done CPR, so I don't feel comfortable doing it. I just do what the nurses tell me to. I don't think we have an emergency code cart. I would let the Unit Manager know about any problems that I had since we don't have a DON right now. I haven't been told I could call anyone else. During a follow up interview on [DATE] at 2:35 PM Staff A, LPN/Unit Manager (UM) stated, I don't know where the emergency code cart is, the supply room, I think; let's see. Upon entering the supply room there was no emergency cart observed. The UM continued to say, I'm sorry I don't know where it is, this is so bad. A tour was conducted of the entire second floor where all of the residents' rooms are located until the emergency cart was located in the restorative dining room in the corner at 2:48 PM. The cart contained a suction machine on the top and was unlocked with additional suction tubing, gloves and other supplies such as intravenous insertion kits that did not contain needles or sharp objects. The Emergency cart log had no signatures of having been checked since [DATE] and multiple missing signatures from (MONTH) and July. The UM stated, I don't know who is supposed to check this, I didn't know it needed to be checked. I don't know the policy and procedure for checking the emergency cart. I don't even know what is supposed to be in the crash cart. I guess we have an issue that if I don't know where this is others probably don't. I haven't had anyone code since I got here. I expect the staff to start CPR on anyone that's a full code. It is not acceptable to wait five minutes to start CPR. I expect all staff will start CPR immediately on full codes, anyone who is CPR certified can start CPR we just do CPR until EMS arrives. I don't think that we have an AED, I've not seen one here. During an interview on [DATE] at 7:15 AM Staff H, CNA stated, I don't know who besides the Unit Manager that I would call if I had any problems. I haven't seen any other DON here since the other one was suspended. If I found a resident unresponsive, I would check to see if they are breathing and if they have a pulse, and then go get the nurse. I wouldn't start CPR, I don't always know if they are a DNR so I would get the nurse. I'm not comfortable doing CPR, it's scary and I haven't ever done it. We don't have an emergency code cart that I know of. We just call 911 if there is a resident that needs CPR. During an interview on [DATE] at 3:15 PM Staff K, CNA, stated, I do not have BLS/CPR (Basic Life Support) certification. I did once, I can't remember when it expired. They are trying to get me a class. I have worked here for ten years. We don't have an emergency cart so I couldn't go get it for a nurse if the resident is getting CPR or whatever. During an interview on [DATE] at 3:20 PM Staff L, LPN stated, I am CPR certified. If I don't know what the resident's code status is, I would check the chart before I started CPR. Depending on how far away from the nurses' station I am, it might take about five minutes to find out. I would not start CPR until I knew definitely that the resident was not a DNR. I don't know where the emergency cart is. I think it's in the supply room. We don't have a code sheet we fill out we just call 911 and do CPR until they arrive. We only have a suction machine that is on the emergency cart. We have not had any mock drills or mock codes. I would not administer any medication that has a sedating effect to a resident who is not responding, that includes a hospice patient. Hospice usually will give an order to hold narcotics if a resident is sedated, but really its standard of practice to hold medication if a resident is unarousable or has a low respiratory rate. During an Interview on [DATE] at 3:55 PM Staff J, LPN stated, I don't know where the crash cart is. I think it is in the supply room, but I don't know. I would start CPR immediately on a resident after I called for help. I'm not sure, but I don't think that we have an AED. If I don't know the code status, I would go check the chart before I start CPR. They have not given me any education regarding medications or the code blue policy. An interview was attempted with the nurse responding to the resident. The nurse no longer works at the facility. Messages left at the last known number were not responded to. During an interview on [DATE] at 2:30 PM the Administrator stated, I am in the building two days one week and three the next week and I am always available by phone. They all know they should call me with anything. During our morning meetings we go over all the falls and anything else that happened overnight. I'm not a nurse so I leave it up to them to evaluate that. The DON is the Risk Manager. I don't get a list of all the incident reports that have been written, but I can pull the list myself. My expectation is that the DON inform me of all potential adverse incidents. I don't know what is on the emergency cart and I don't know where the AED is. I'm sure we have one. For the concerns you have gone over with me, we have not started to put anything in place for the plan of correction. We have not done any committee meetings or started addressing how to correct these. I don't have a DON or an ADON. The DON is on suspension and the ADON resigned. The DON from our sister facility is in charge now but she has been sick this week. She will be responsible for both facilities until we determine if the DON is coming back or we need to find a replacement. All staff that are trained in CPR are expected to start CPR on all residents who are not a DNR (Do Not Resuscitate) per our policy. CPR starts immediately with the first person who responds that is CPR certified. I don't determine who can do that and who can't. If they are CPR certified they must be competent. I am not certified in CPR so I wouldn't do it, but all licensed nurses have to be. I don't know if five minutes is to long to wait to start CPR. On [DATE] at 9:25 AM the interim DON arrived and was introduced by the Administrator. The DON stated, I was originally hired for the sister facility. My date of hire was [DATE]. I was sent to Crestwood on the [DATE] and got ill. I returned to work today, [DATE]. I have no expectations at this moment with a clear plan to integrate mock drills for CPR and other skills to make the nursing staff proficient related to the actual events. The Administrator was present and stated, My position is to support the DON in her position. During an interview on [DATE] at 4:00 PM the Administrators stated, My expectation is the staff have competency, follow physicians' orders, if they don't understand an order, they need to call the physician and get clarification. When asked for clarification related to her expectations of the nurses' skills and competencies the Administrator stated, They are licensed, and they should know what they are doing when they come to work. When asked who the Risk Manager was the Administrator stated, The Risk Manager is the DON and he also is the Abuse Coordinator. Review of the policy and procedure titled, Acute Condition Changes - Clinical Protocol Revised (MONTH) 2012 read: Assessment and Recognition: 2. In addition, the Nurse shall assess and document/report the following baseline information: a. Vital Signs, b. Neurological status, c. Current level of pain, and any recent changes in pain level, d. Level of consciousness, e. Cognitive and emotional status, g. Onset, duration, severity, h. Recent labs, j. All active diagnoses, k. All current medications. Review of the policy and procedure titled, CPR/Code Blue creation date ,[DATE] read: Policy: Cardiopulmonary Resuscitation (CPR) will be provided to residents who are identified to be in [MEDICAL CONDITION] unless such resident has DNR order. CPR is performed only by individuals certified in CPR. Licensed Nurses are to maintain CPR certification. Procedure: When a Resident is found without respirations and/or without pulse, the individual finding the resident will identify the Resident's code status. 2. In the event that the Resident is identified as a Full Code and the person finding the Resident is trained in CPR, they will: a. Call for help by stating Code Blue; b. Initiate CPR. 3. The individual responding to the call for help will call Code Blue over the intercom 3 times and identify: a. Floor and Unit; b. Room Number or area in which Resident is located. 5. Clinical Staff will respond to the announced location of the Code Blue with facility AED and closet crash cart. 6. The Nurse Manager/Supervisor/Licensed Nurse will assume the responsibility for the code and delegate the following: a. Calling 911; b. Assign staff to document the ongoing event using the code blue documentation form; c. Notify the MD i. Obtain MD order to transfer to hospital; d. Completion of transfer form i. Call receiving ER with report of resident and event; f. Complete the necessary documentation in the Resident's medical record; g. Restock Crash Cart.

Based on interviews, record reviews, policy and procedure review, the facility failed to ensure 2 of 15 sampled residents were free from significant medication errors, Residents #1 and #2. The facility failed to follow physicians ordered medications when a resident was identified through lab results with a high blood ammonia level, (too much ammonia in the body can cause psychological problems like confusion, tiredness, and possibly coma or death) for the administration of [MEDICATION NAME], (used to reduce the amount of ammonia in the blood) for Resident #1. The facility failed to follow physicians orders and standards of practice with the continuation of the administration of [MEDICATION NAME] (an opioid narcotic used for moderate to severe pain), and [MEDICATION NAME] (used for anxiety which acts on the brain and central nerves system), when a resident was assessed to be unresponsive, with decreased respirations, eyes non-reactive to light; Resident #2, (a major drug interaction exists between [MEDICATION NAME] and [MEDICATION NAME] that can lead to serious side effects including respiratory distress, coma, and even death). Resident #2 was transferred to the hospital emergency room and diagnosed by the hospital with an accidental overdose of [MEDICATION NAME]. The identified significant medication errors places 47 of 47 residents at risk for deficient practice. The findings include: 1) Review of Resident #1's facility record revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Initial dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 15 = no cognitive deficit. Review of the hospital AHCA (Agency for Health Care Administration) Form ,[DATE] dated [DATE] under the section titled, U. Mental/Cognitive Status At Transfer Alert, oriented, follows Instructions, was checked. Review of the Agency for Health Care Administration (AHCA) Nursing Homes Federal Reporting dated [DATE] revealed: Description of the Incident: The resident made an allegation of a staff member while changing her that she was punching her in her arm. Resident cried as Social Service was speaking to her. The Facility's Immediate Response revealed: 4. Statements was done by staff. 5. Interview was done by Social Service. Review of the written statement dated [DATE] by Staff P, CNA (Certified Nursing Assistant) read: At about 6:30 p.m. Sat. [DATE] was passing trays for supper. (Resident #1's name) was yelling she was wet and trying to crawl out of bed calling me all kinds of names that no one was changing her one of my co-worker came into her room to help me and she told him to get out, finally I started to change her bed and she was rowdy that I, when and got another co-worker (Staff V, CNA's name) to come and help me in the process of changing her bed she became mad at me for trying to change her and she begin to hit me and I, tried to catch her hands and arms and she was mad with (Staff V, CNA's name) for not helping her, and we trying to change her wet bed. I, call the nurse to tell her what had happen. Review of the written statement dated [DATE] by Staff V, CNA read: I was helping (Staff P, CNA's name) in room. The Resident became combative and refused care talking about she dieing. Review of the nursing progress notes dated [DATE] at 3:30 PM read: (Resident #1's name) is agitated making false accusations against staff. On [DATE] at 3:44 PM Reach out to hospice regards to behavior, staff is afraid to work with her due to false accusations she is making. During an interview on [DATE] at 8:55 AM with the Administrator a request was made for the complete investigation into the abuse allegation made by Resident #1. The Administrator stated that the corrective actions taken on behalf of Resident 1's abuse allegation, and pointed to a Posted Note and stated, there will be two staff in the room while accommodating her needs. The investigation was completed. Nurses are trained on how to redirect and care for patients. I am not a nurse my expectation is for them to know what they are doing. When asked if other residents residing on the same unit with Resident #1 were interviewed, to determine if they had suffered abuse, as part of the investigation, the Administrator replied she did not feel this was necessary since there was no abuse. When asked about this being part of the corrective action she stated, I was not aware that these were items that needed to be implemented as a corrective action when no alleged abuse had occurred. Review of the POS [REDACTED]. 2 Staff @ all times. All allegations will be reported. Document behaviors. Staff walk away if resident is upset. Ensure resident is safe. During an interview on [DATE] at 3:20 PM Staff P, stated, (Resident #1 name) was screaming she was soiled, I was passing trays at that time. I stopped and got help to clean her up. The resident started screaming 'you are killing me and cussing' and did not want the male CNA to touch her and all he was doing was helping me hold her and I was cleaning her. I went and got (Staff V, CNA's name) that made her mad she started saying that I was punching her. I was trying not to get punched and clean her up quickly, I felt I was the one who got abused. During an interview on [DATE] at 3:45 PM via telephone Staff V, CNA stated, I was called by (Staff P, CNA's name) in to help with this resident. I was supporting the (Resident #1's name) and the resident was looking at me and asking why am I allowing this to happen. I tried to reassure her as much as possible. The resident was swinging and cussing at (Staff P, CNA's name) and fussing at me. During an interview on [DATE] at 12:45 PM the Social Services Director stated, I completed the AHCA 5 day report. I had no training on how to conduct this investigation. I took down the witness statements and asked (Resident #1's name) the questions. Since the DON (Director of Nursing) was gone it was given to me to do. (Resident #1's name) had no recollection about the allegation of abuse. I go in and talk to her and she does not remember anything. Yesterday she was fussing at the staff. I would speak to her and she would say nothing. Review of Resident #1's lab dated [DATE] revealed Ammonia 100 High. (too much ammonia in the body can cause psychological problems like confusion, tiredness, and possibly coma or death) Review of the physician's orders [REDACTED]. Diagnosis: [REDACTED]. Dated [DATE] at 12:00 AM read: [MEDICATION NAME] 30 ml every 6 hours as needed. Review of the Medication Administration Record [REDACTED]. For the period of [DATE] at 9:00 PM to [DATE] the MAR indicated [REDACTED]. [MEDICATION NAME] 10 GM/15 ML Solution give 30 ML (20GM) by mouth every 6 hours as needed - [MEDICAL CONDITION] of liver. The documentation showed [MEDICATION NAME] was not administered as needed and was documented as discontinued on [DATE] at 9:00 AM. Review of the Discontinued Order - As Needed (Handwritten) form read: [MEDICATION NAME] 10 GM/15 ML (15 grams to 15 milliliters) Solution by mouth. Original Fill Date: [DATE]. Give 30 milligram by mouth as needed every 6 hours as needed. Discontinued Date: [DATE] at 1:14 PM. [MEDICATION NAME] 10 gm/15 ML Solution. Original Fill Date: [DATE]. Give 30 ML (20GM) by mouth every 6 hours as needed. Discontinued Date: [DATE] at 11:03 PM. [MEDICATION NAME] 10 GM/15 ML Solution. Original Fill Date: [DATE]. Give 30 Milliliter by mouth as needed every 6 hours. Discontinued Date: [DATE] at 11:03 PM. The Discontinued Orders were completed by licensed nursing staff and did not have a physician's signature line or signature for the discontinuation of the medication. During an interview on [DATE] at approximately 1:12 PM Resident #1's daughter stated, My mother would have periods of confusion and craziness and when that happened, I knew it was the ammonia level and she wasn't getting her [MEDICATION NAME]. During an interview on [DATE] at approximately 2:00 PM with the Administrator a request was made for documentation of the administration of [MEDICATION NAME] as ordered by the physician for the period of [DATE] at 9:00 PM to [DATE] at 9:00 AM (the resident was discharged to the hospital for an unrelated concern at approximately 7:00 PM on [DATE]) or for the physician's orders [REDACTED]. The Administrator stated she would have nursing provide the documentation. During an interview on [DATE] at approximately 10:00 AM with the Administrator a request was made for documentation of the administration of [MEDICATION NAME] as ordered by the physician for the period of [DATE] at 9:00 PM to [DATE] at 9:00 AM (the resident was discharged to the hospital for an unrelated concern at approximately 7:00 PM on [DATE]) or for the physician's orders [REDACTED]. The Administrator stated she let nursing know the documentation was needed. During an interview on [DATE] at approximately 4:00 PM with the Administrator a request was made for documentation of the administration of [MEDICATION NAME] as ordered by the physician for the period of [DATE] at 9:00 PM to [DATE] at 9:00 AM (the resident was discharged to the hospital for an unrelated concern at approximately 7:00 PM on [DATE]) or for the physician's orders [REDACTED]. The Administrator did not respond. No additional documentation was provided. 2) Review of Resident #2's facility record revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the hospice Treatment or Medication Form dated [DATE] [MEDICATION NAME] 1 mg oral every 4 hours PRN (as needed). Dated [DATE] read: [MEDICATION NAME] concentrate 20:1 10 mg = 0.5 ml SL (sublingual) every 4 hours ATC (around the clock). [MEDICATION NAME] 1 mg SL/PO (by mouth) every 4 hours ATC. (MONTH) hold for sedation. Please continue [MEDICATION NAME] sulfate and [MEDICATION NAME] every 4 hours PRN (as needed). Dated: [DATE] Lensin/Mycosamine 0.125 mg SL every 4 hours PRN - secretions. D/C (discontinue) nonessential meds d/t (due to) decline. Review of the Controlled Drug Declining Inventory Sheet for [MEDICATION NAME] ([MEDICATION NAME])1 mg tablet revealed the medication was signed out for administration on [DATE] at 10:00 AM, at 2:00 PM, at 08:00 PM, and at 12:00 AM. On [DATE] at 4:00 AM, at 8:00 AM, at 10:00 AM, at 12:00 PM, at 2:00 PM, at 5:30 PM, at 8:00 PM, and at 10:00 PM. On [DATE] at 12:00 midnight. [MEDICATION NAME] 100 mg/5 ml concentrate was signed out for administration [DATE] at 10:00 AM, at 02:00 PM, at 08:00 PM, [DATE] at 12:00 AM, [DATE] at 04:00 AM, 8:00 AM, at 10:00 AM, at 12:00 PM, at 2:00 PM, at 5:30 PM, at 8:00 PM, and at 10:00 PM. On [DATE] at 12:00 midnight and at 4:15 AM. Review of the care plan revised on [DATE] read: Focus: The resident is on pain medication therapy r/t end stage diagnosis. Goal: The resident will be free of any discomfort or adverse side effects from pain medication. Interventions: Administer [MEDICATION NAME] medications as ordered by physician. Monitor/document side effects and effectiveness Q (every) shift. Ask physician to review medication if side effects persist. Monitor/document/report PRN adverse reactions to [MEDICATION NAME] therapy: altered mental status, respiratory distress/decreased respirations, sedation. Focus: Use of [MEDICAL CONDITION] antianxiety drug places resident at risk for drug-related: Cognitive impairment. Initiated [DATE]. Goal: Resident will receive the least dosage of the prescribed [MEDICAL CONDITION] drug (s) to ensure maximum functional ability both mentally and physically. Interventions: [MEDICATION NAME] as ordered. Observe for side effects and hold medication for increased lethargy. Review of the nursing progress notes dated [DATE] at 2:37 PM New orders from hospice nurse [MEDICATION NAME] 1 mg PO @ HS (by mouth at hour of sleep). Dated: [DATE] at 6:21 AM Resident is not wanting to take his medications ([MEDICATION NAME]) Very lethargic and not wanting to open his mouth. Dated: [DATE] at 9:58 AM Resident tried to get out of bed. Stated he forgot he could not walk. Resident fell on his right side on the floor. Resident did not hit his head. Red marks on right hip and right shoulder. DON (Director of Nursing) and MD (Medical Doctor) notified. Resident was reminded to use call light any time he needs to get up. Dated: [DATE] at 11:11 AM Resident laying in bed sleeping. Easily arousable. No signs of pain or distress. Resident stated he was just tired and wanted to back to sleep. Date: [DATE] at 12:29 AM This nurse writing called hospice due to Resident making changes in mental status. Resident is restless, asking for someone to help him, climbing out of bed, Not eating or drinking sufficient amount. He is c/o (complaint of) abdominal pain. Hospice nurse on called made a visit received new order to increase [MEDICATION NAME], Q 4 hrs. PRN (hours as needed). Resident is being monitored closely to prevent resident injuries. Dated: [DATE] at 1:38 PM The resident has had a change is condition. When first observed the resident's jaw was twisted to the right and [MEDICAL CONDITION] is suspected. I obtained vital signs and notified hospice as well as his family. Family has been in to see the resident but hospice has not been in at this time 1:41 PM. (There was no documentation of the physician having been notified of the change in condition). Dated: [DATE] at 10:07 AM read: Resident is nonresponsive. Family notified and in facility. Hospice nurse in facility. Resident is currently on 4 L (liters) of O2 (oxygen) via nasal cannula r/t apnea (cessation of breathing). Dated: [DATE] at 12:23 PM. Resident eyes are no longer reactive to light. RR (respirations) approximately 8 per minutes, on 4 L O2 via nasal cannula. On [DATE] at 2:24 PM Being medicated on schedule every 2 hours as instructed by Hospice. Respirations 7 per minute. Currently unarousable again. On [DATE] at 3:52 PM Resident is wheezing and moaning. Still asleep. Not arousable. Breathing is slow and labored. On [DATE] at 3:3 PM Resident is currently lying in bed quietly sleeping with eyes half open. Responds to painful stimuli. Skin warm and dry to touch except for feet is cool. Respirations with long periods of inhale and exhale. No urine output so far this shift. Requires total assistance with ADL's, turning and repositioning. PO (by mouth) meal intake is zero d/t (due to) decrease alertness. On [DATE] at 9:04 AM Resident only responsive to painful stimuli. Hospice nurse in to see resident and review orders. Upon assessment determined to send resident to ER (emergency room ). Review of the hospice nursing progress notes dated [DATE] at 8:30 AM read, Reason for Focused Visit: Dying process/decline. Medication assessed for: Medicine reconciliation done. Effectiveness. Not taking meds as prescribed. Clinician Narrative Note: When I arrived there patient was unresponsive. Reviewed medications and patient has been getting the [MEDICATION NAME] 1 mg every 2 hours and [MEDICATION NAME] 10 mg every 2 hours instead of every 4 hours as ordered. Spoke with DON (Director of Nursing) and ADON (Assistant Director of Nursing) and they would like the patient to be sent to the ER for medication overdose. Spoke with sister at the bedside and she would like the patient to be sent out as well. Heat rate: 56. Respirations: 8. Blood Pressure ,[DATE]. O2 Sat (saturation) 92% on 2 LPM (liters per minute). Dated: [DATE] at 11:35 AM read, Clinician Narrative Note: Spoke to ER MD and the RN (Registered Nurse) along with sister at the bedside. Patient was given [MEDICATION NAME] to reverse the effects from the [MEDICATION NAME]. Dated: [DATE], unable to read time, Clinician Narrative Note: Patient had decline somewhat over the weekend .possibly transitioning. Pt (Patient) was in hospital ER with sister at Pt's bedside. Cp (Chaplin) spent much time comforting and encouraging pt's sister and later praying with both. Because sister did not want pt to go back to facility from which pt came, sister was looking for other options. Review of the EMS (Emergency Medical Services) note dated [DATE] revealed Chief Complaint: Overdose [MEDICATION NAME]. Meds Admin (Medications Administered) [MEDICATION NAME] 0.4 IV (intravenously). Review of the hospital records dated [DATE] revealed Chief Complaint: Drug overdose. History and Physical: Presents to ED via EMS d/t accidental overdose. Pt. sister states Pt has end stage liver failure and is on hospice at Crestwood Nursing home. Pt. was supposed to give (sic) 10 mg every 4 hours but they were giving 10 mg every 2 hours per Pt. sister. EMS gave Pt. [MEDICATION NAME] and drastically improved. Pt. denies any other Sx (symptoms) at this time. Free Text: Pt. sister does not like care given to Pt. at Crestwood Nursing home and would like someone else. Re-Evaluation/Progress #1: After [MEDICATION NAME] - Re-Eval Status: Improved. Eval Following Treatment: Pt. feels better, Condition improved. Condition: Stable. Review of the hospital Emergency Patient Record dated [DATE] revealed: Priority: 2/Emergent. Ingestion - Presenting signs/symptoms: Decreased Resp (respirations), Decreased L[NAME] (level of consciousness). Emergency Notes: [DATE] Assumed care of Pt. from previous RN. Pt. is alert when name is spoken to. Pt. has sister and hospice rep (representative) at bedside. Pt. is showing no signs of distress. Per Pt. advocate, Pt's family is requesting new hospice representation. Pt. is to be DC (discharged ) to new facility when it is determined. At 12:04 PM Pt. is resting comfortably with family at his side. No signs of distress noted. During an interview on [DATE] at 2:02 PM Staff A, Unit Manager/LPN (Licensed Practical Nurse) she stated, I am responsible for the unit, both of them since the other Unit Manager quit. I was involved in (Resident #2's name) transfer to the hospital. The hospice nurse came to me and told me the Resident had been given [MEDICATION NAME] and [MEDICATION NAME] every two hours the day before and was obtunded (lethargy in which the patient has a lessened interest in the environment, slowed responses to stimulation, and tends to sleep more than normal with drowsiness in between sleep states) with a very low respiratory rate. We told the DON who said to transfer the resident if that's what the sister wanted. The Administrator was called by the DON and told that the resident had a medication error and needed to go to the ED. So, I called 911 and got him to the hospital. That's all the involvement I had, except that I told The Administrator that the resident wasn't coming back because the sister didn't want him to. I called the hospital for an update and the hospice nurse let us know too. I didn't make out an incident report. When a resident gets medication, we should be monitoring them for any side effects and holding them and calling the doctor or the hospice nurse for any further orders if there are side effects. It is my expectation that I be informed of any changes in the residents' condition so that the resident can be assessed, and the problem can be addressed with the doctor. I expect the nurses to assess the residents for signs of over sedation. If a resident is sedated, hold medications until they check with hospice or the doctor and document all of that in the chart. During an interview on [DATE] at 4:55 PM the Hospice Nurse for Resident #2 stated, I did his initial consult on [DATE], and saw him again on [DATE], and when I saw him on Monday [DATE] there was a big difference, he was unresponsive when I saw him. It was reported to me that he had multiple falls over the weekend and agitation. The Resident's sister told me that he had been given medication every two hours per our orders and I knew that we did not have any orders for medications every two hours. When I checked our orders, we still had [MEDICATION NAME] 0.5 ml every 4 hours and a PRN (as needed) order for every 4 hours. But we did not give orders to medicate every 2 hours. After talking to the Director of Nursing and assessing the patient we were all in agreement that the patient should be sent to the ED and the Resident's sister agreed. I followed up on him once he went to the ED. He received [MEDICATION NAME] and was much more alert when I saw him, he was agitated but responsive. Our goal in pain control in end of life is to provide and promote comfort, we want our patients to be pain free, without anxiety. We want our patients to have enough medication to remain comfortable, not overmedicate them to a point where they require reversal agents. I was shocked because the man I saw on Monday was nowhere near the man I saw on Thursday. That was gross overmedication. The patient's sister did not want him to go back to Crestwood, and because we don't have another facility, we discharged him to another hospice, so the family had a sense of peace and comfort with his care. This Nurse should be reported because this was negligent. During a telephone interview on [DATE] at 10:45 AM the Hospice Doctor stated, I am the Physician for hospice and am aware of (Resident #2's name). He began hospice sometime in July. When he was first on service, he was taking [MEDICATION NAME] I believe and the switch to [MEDICATION NAME] began just a few days before he went to the emergency room . We routinely order [MEDICATION NAME] and [MEDICATION NAME] for comfort and anxiety. Our goal is anxiety reduction, symptom control and pain freedom at end of life. We medicate according to the patient's symptomology and frequently have routine orders and orders for breakthrough pain or anxiety. If I or any other of the hospice Physicians thinks medication more frequently than every four hours is necessary, we would order more frequent routine administration of narcotic [MEDICATION NAME]. Although, in my field I seldom have to worry about [MEDICATION NAME] administration and the concomitant use of benzodiazepines such as [MEDICATION NAME]. There would be a significant CNS (central nervous system) depression and respiratory depression effects particularly acute in a patient with liver and kidney disease. I would not have recommended every two hours around the clock administration of these drugs to (Resident #2's name) especially because of his diagnosis. We did not give or instruct the nurses at Crestwood to administer [MEDICATION NAME] and [MEDICATION NAME] every two hours. In this case he was overmedicated, and I would expect any nurse to call to speak with either the nurses or the doctor on call to determine if the medication should continue at the prescribed times or be adjusted and held. My understanding is (Resident #2's name) was obtunded (lethargy in which the patient has a lessened interest in the environment, slowed responses to stimulation, and tends to sleep more than normal with drowsiness in between sleep states) with a respiratory rate of ,[DATE] with long apneic (cessation of respiration) periods, this was discussed with family and the nursing home and the decision to send the patient out to the hospital for treatment was made by the family, staff and our staff followed the family wishes. Our nurse followed up in the emergency room and the patient had a significant change in alertness with [MEDICATION NAME] administration which overall tells us that he was overmedicated and that was not recognized by the staff at Crestwood. Overdosage and the need to use reversal agents has a profound effect on the patients that I treat, not only physical but psychological as well for both patients and their families. During an interview on [DATE] at 9:37 AM via telephone the DON stated, I did not evaluate (Resident #2's name). The first I heard about it was when the ADON/Educator told me he had been medicated every two hours with [MEDICATION NAME] and he was unarousable with a respiratory rate of 6 or 7 per minute. She stated he needed to be transferred out because we were killing him with medications, that he was obtunded and unable to respond to painful stimuli. The hospice nurse and sister wanted to transfer him to the hospital for evaluation and treatment. I never went to evaluate the resident he was already seen by the hospice nurse and the ADON, so I just started getting the transfer started. I trusted their judgement that he needed to be transferred. I did not do any investigation, there was no time to as I was suspended on [DATE]. I did not review the Narcotic Administration sheets. I did not look at any of the nurses' documentation or check any physician orders. I did not know that it was an adverse incident. I was told that he was administered medication every two hours of [MEDICATION NAME] and [MEDICATION NAME], but that he did not have orders to medicate that frequently. I did not instruct the nurses to make out an incident report. The Administrator knew the patient went to the hospital, got administered [MEDICATION NAME], and the sister did not want him to come back because of this. We were notified that day that he would not be returning. I really did not get to investigate any of this, I just started in (MONTH) and it takes time to determine that processes are broken. We have a lot of work to do to improve the care we deliver. We don't have a code blue sheet that we fill out if a resident codes. I wasn't aware that the policy stated we had one. I would think that if someone has a CPR card, they are proficient according to the American Red Cross. I didn't do anything to assess the staff competency in CPR or their comfort level in CPR. Anyone who is CPR certified can start CPR. I did not look at any of the Code Blues that we started and was not tracking them or looking at the documentation, that is the responsibility of the Unit manager to do that and bring any concerns to me and the Administrator during the morning meetings. I was not aware that a resident did not have CPR started for five minutes. We don't have an AED (Automated External Defibrillator) that I am aware of. I'm not the Risk Manager, that's the ADON's job. I realize that there are problems here and some staff are not liking the changes that I tried to start, I wanted to do a good job and make changes. Ultimately, as the DON I am responsible for those things and everything that the nursing staff does and the interactions between departments to make sure things are done correctly. During an interview on [DATE] at 3:30 PM the ADON stated, The last time I worked was on [DATE], the ,[DATE] AM shift, the morning that (Resident #2's name) medication mistake was found. I was involved because I was finishing up and his sister asked me about medications, and the last time a medication mistake was discovered. An attempt was made to interview the nurse, via telephone to her last known number, who administered [MEDICATION NAME] and [MEDICATION NAME] to Resident #2. The nurse is no longer employed by the facility. The nurse had resigned from her position. The message received was that the number had been changed or was no longer in service. Review of the policy and procedure titled, Acute Condition Changes - Clinical Protocol Revised (MONTH) 2012 read: Assessment and Recognition: 2. In addition, the Nurse shall assess and document/report the following baseline information: a. Vital Signs, b. Neurological status, c. Current level of pain, and any recent changes in pain level, d. Level of consciousness, e. Cognitive and emotional status, g. Onset, duration, severity, h. Recent labs, j. All active diagnoses, k. All current medications. Review of the policy and procedure titled, Physician Medication Orders revised (MONTH) 2010 read: Policy Statement: Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. physician's orders [REDACTED]. No drugs or biologicals shall be administered except upon the order of a person lawfully authorized to prescribe for and treat human illnesses. 2. All drug and biological orders shall be written, dated, and signed by the person lawfully authorized to give such an order. The signing of orders shall be by signature or a personal computer key. Signature stamps may not be used. Review of the policy and procedure titled, Administering Medications Revised (MONTH) 2012 read: Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 2. The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and/or have related functions. 3. Medications must be administered in accordance with the orders, including any required time frame. 5. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication shall contact the resident's Attending Physician or the facility's Medical Director to discuss the concerns. 19. The individual administering the medication must initial the resident's MAR indicated [REDACTED]. 25. If a resident uses PRN medications frequently, the Attending Physician and Interdisciplinary Care Team, with support from the Consultant Pharmacist as needed, shall reevaluate the situation, examine the individual as needed, determine if there is a clinical reason for the frequent PRN use, and consider whether a standing dose of medication is clinically indicated. 27. The Charge Nurse must accompany new nursing personnel on their medication rounds for minimum of three (3) days to ensure established procedures are followed and proper resident identification methods are learned.

Based on observation, interview and record review, the facility failed to implement care plans to avoid accidents for 13 of 13 residents identified as having poor safety awareness/ decreased cognition by failing to provide adequate monitoring and identify hazards that pose a risk for elopement and/or injury. Failure to identify hazards and implement care plan interventions to avoid accidents and provide adequate monitoring resulted in a serious and immediate threat to the health, safety and well being of the 13 residents. Moreover, due to the lack of monitoring in accordance with resident #1's care plan and a non-functioning stairwell door alarm, resident #1, who had a known history of exit seeking behavior, poor safety awareness, and falls, sustained a fracture after falling down the stairs in her wheelchair. FINDINGS: 1.) A review of the medical record revealed resident #1 exited a stairwell door on the 2nd floor and fell down the stairs to the first floor landing. A review of the nurse's notes revealed on 12/18/2011 at 7:55 PM, LPN (Licensed Practical Nurse) #3 was called by LPN #4 to the stairway area on the second floor. She stated she observed resident #1 lying on her left side in her wheelchair at the bottom of the stairway. She stated she observed a moderate amount of blood coming from the left side of the head. She did not move the resident. The resident was alert and talking. Emergency Medical Services (EMS) was notified. At 8:00 PM, EMS arrived and transported the resident to the hospital. A review of the facility's records revealed Certified Nursing Assistant (CNA) # 1 gave a statement on 12/20/2011 that she reported that the door alarm was not working on Palm Court (the exit door which resident #1 accessed) and that the resident was exit seeking on 12/17/2011 to LPN # 1. Review of the statement by LPN #1 dated 12/17/2011 documented that she was not aware that she had a key to activate the alarm on the door. Review of the clinical record for resident #1 revealed the CT scan report of the Cervical Spine conducted on 12/18/2011 at the Hospital ( Hospital #1) revealed a non-displaced [MEDICAL CONDITION] lamina of the 1 vertebral body. The CT scan of the brain conducted on 12/18/2011 at the Hospital revealed "Scalp hematoma over the left frontal bone." Continued review of the information from hospital #1 revealed that, due to the location of the fracture, the resident was transferred to another hospital (Hospital #2). Interview via phone on 12/21/2011 at approximately 9:15AM with the family member (Power of Attorney) of resident #1 revealed that the resident will not be returning to this facility upon discharge from the hospital (Hospital #2). Review of the facility Occurrence forms for resident #1 revealed: 10/20/2011- 6AM the resident was found on floor in her room; 11/17/2011- 12:35 PM the resident went to the exit door and opened the door - alarm initiated; 11/17/2011- 1:00 PM the resident was found on the floor by the hall couch; 11/24/2011- 4:10 AM the resident opened the door to the stairway, initiating the alarm. The staff redirected her. 12/09/2011 -5 AM the resident was found on the floor; 12/13/2011- 9:30 PM the resident tried to exit building, took her belt loose and slid to floor. 12/18/2011- 12:15 PM the seatbelt was plugged in the alarm but did not sound. Resident fell on the floor near the elevator. 12/18/2011- 7 :55 PM found on floor at bottom of the stairs lying on her left side in her wheelchair. A review of resident #1's care plan revealed :11/18/2011; a) Attempted exit of the building. Poor safety awareness and oriented to self only. 11/24/2011-b) Exit seeking The Goals/Objectives were: The resident will have fewer than 1 attempt monthly of exiting the building through the next assessment period as resident is easily redirected 1. encourage participation in activities of choice; 2. monitor location of resident; 3. re-direct when noting that resident is "wandering" without purpose; 4. provide snacks as a diversion to wandering; 5. toilet if resident seems to be seeking a confined/small area; 6. if tired, offer rest periods 2. ) Review of facility documentation revealed that facility staff identified thirteen residents ( #1,2,3,4,5,6,7,8,9,10,11,12,13) through the Minimum Data Set (MDS), and fall risk assessments, completed at admission and as necessary when falls occur, as having poor safety awareness/decrease cognition and as being at risk for falls. Of the thirteen residents identified, residents #1, #11, and #13 were also identified as elopement risks in accordance with the facility's Wandering Resident Policy and Procedure. Review of the care plans for all 13 residents identified problem areas of decreased cognition and falls. Resident's #1, #11, and #13 were found to have a care plan in place related to risk of elopement/wandering that indicated a need to monitor the resident. Review of the Wandering Resident Policy and Procedure dated as modified on 03/11/04 revealed that the facility will monitor any and all residents identified by the care plan team as having the potential to wander. However, no assessment tool for wandering/elopement risk was identified for use. 3.) A general tour of the facility was conducted on 12/21/11 commencing at 9:50 AM and concluding at 10:45 AM. During the tour, the following was identified: The functioning main elevator was entered on the second floor (where all residents reside) and taken to the basement. No lock or other device was identified in the elevator to prevent access to the basement area. A tour of the basement revealed a laundry area, numerous maintenance areas and storage areas all unlocked. One of the storage rooms was entered where numerous bottles of fluids were identified of which approximately 20 bottles and containers were cleaning solutions, some of which the tops were either loose or off. Further tour of the basement revealed an unlocked storage room containing approximately 8 biohazard receptacles that appeared to be full. Each receptacle was approximately 3.5 feet high and 24" in diameter. Interview conducted with staff#6, on 12/21/11 at 10:15 AM revealed that a company (unknown name) was due to pick up the biohazardous material "some time this week". Continued tour of the basement revealed 2 unlocked and unalarmed doors eggressing to the outside of the building. Interview with staff #6 at 10:20AM on 12/21/2011 revealed that there was no monitoring equipment in the basement to his knowledge. Interview conducted on 12/21/2011 at 11:15AM with staff #5, the maintenance supervisor, revealed that there was no monitoring equipment in the basement, and no alarms or locks on the 2 doors leading outside the building. Further interview at this time time revealed that there is no lock on the elevator prohibiting the elevator from being able to access the basement by anyone who entered the elevator. Staff#5 was able to confirm that the neither the door on the 1st floor which is located outside the activity room, that opens out onto a loading dock, or the door across from the administrator's office on the first floor which also has stairwell access from the 2nd floor was alarmed or monitored to prevent elopements. Continued interview on 12/21/2011 11:15 AM, with the Maintenance Supervisor, staff #5, revealed he had ordered 6 alarms to replace the alarms on the second floor. He further stated that he checked the batteries for the alarms on the second floor on June 16, 2011 and again in December 2011 (no specific date given). He stated there is no policy for checking the batteries and no log is maintained. He stated he replaces the batteries twice a year, but does not record it. Moreover, he stated that the alarms currently in place were from different manufacturers and were different ages. 4. The following was identified to have been implemented by the facility prior to exit by the surveyors at 6:15M on 12/21/2011: Each of the 4 doors on the second floor were found to have alarms that were checked by the surveyors and found to be functioning appropriately. The facility administration developed a specific Elopement Policy and Procedure with Elopement Prevention and Management components and implemented a new elopement assessment tool. Review of the the resident Medication Administration Records (MAR) revealed that on each MAR indicated [REDACTED]. The staff in-servicing documentation was reviewed which revealed that not only the nurses are responsible for checking the door alarms, but the floor Certified Nursing Assistants were also to check and chart the 4 exit door alarms on the second floor in addition to checking and charting the personal alarms on residents who are documented as having them in place. Documentation of staff in-servicing was reviewed, dated 12/19/11, which identified training in identification and interventions for exit seeking behavior and monitoring skills for all Certified Nursing Assistants (CNAs), Registered Nurses (RNs), and Licensed Practical Nurses (LPN) on all 3 shifts. Activities (1), and Social Services (1) were also in-serviced at this time. Six new alarms that had been ordered on [DATE], were received 12/21/11 at 5:00 PM. Additional staff was called in to install the alarms. The 2 staff members were observed installing the alarms and had completed the installation as the survey was ended at 6:15 PM on 12/21/11. Additionally, the facility administrator has instructed the Director of Nursing (DON) to oversee daily that these implementations are being followed. The MDS Coordinator was instructed to reassess all 61 residents currently residing in the facility for elopement, utilizing the revised Elopement policy and Procedure and Elopement risk tool, and for fall risks. Interview with the DON on 12/21/11 at 4:00 PM revealed that the facility had placed a Certified Nursing Assistant (CAN) in the elevator to provide supervision and monitoring at all times to residents who utilize the elevator to prevent access to the basement area and any other unsafe or unsecured area. This CNA will be in place 24-7 until bids could be procured for a full alarm system installation or other interventions could be identified and implemented that would better meet the needs for supervision and prevention of accident hazards related to elevator use. The facility also placed a CNA outside the elevator door on the 1st floor to monitor the elevator and the 2 unlocked, unalarmed doors on the 1st floor. The staffing coordinator has been instructed by the administrator to assure the continuation of staffing of these 2 positions with either a CNA or nurse every shift until further notice. The Director of Nurses will assure all CNA's and nurses placed into these positions are adequately in-serviced. Interview conducted with the CNA (R#7) on the elevator on 12/21/11 at 5:00 PM revealed that she had been instructed to remain on the elevator at all times unless relieved for a break by another staff member, and that this would continue with all staff until further notice. Interview conducted with staff #8 (LPN) (hall monitor outside the elevator on the first floor), on 12/21/11 at 5:05 PM revealed that she had been instructed to remain on the 1st floor outside the elevator at all times unless relieved for a break by another staff member, and that this would continue with all staff until further notice. Her "job" as she understood it was to monitor the elevator, but also the 2 unlocked unalarmed doors on the 1st floor. Due to the interventions implemented above, the Immediate Jeopardy was found to have been removed on 12/21/2011 at 6:15PM. However, non-compliance continues at a scope and severity of an E.

Based on observation, interview and record review, the facility failed to provide an environment free of accident hazards and interventions to avoid accidents for 13 of 13 resident identified as having poor safety awareness by failing to provide adequate supervision and a working alarm on the exit door to the stairs on the second floor of the facility and ensuring that the elevator could not be utilized by residents to access unsafe and unsecured areas of the building. This failure to identify and implement interventions to avoid accidents and provide adequate supervision resulted in a serious and immediate threat to the health, safety and well being of the 13 residents. Moreover, due to the lack of supervision and non-functioning stairwell door alarm, resident #1, who had a known history of exit seeking behavior, poor safety awareness, and falls, sustained a fracture after falling down the stairs in her wheelchair. FINDINGS: 1.) A review of the medical record revealed resident #1 exited a stairwell door on the 2nd floor and fell down the stairs to the first floor landing. A review of the nurse's notes revealed on 12/18/2011 at 7:55 PM, LPN (Licensed Practical Nurse) #3 was called by LPN #4 to the stairway area on the second floor. She stated she observed resident #1 lying on her left side in her wheelchair at the bottom of the stairway. She stated she observed a moderate amount of blood coming from the left side of the head. She did not move the resident. The resident was alert and talking. Emergency Medical Services (EMS) was notified. At 8:00 PM, EMS arrived and transported the resident to the hospital. A review of the facility's records revealed Certified Nursing Assistant (CNA) # 1 gave a statement on 12/20/2011 that she reported that the door alarm was not working on Palm Court (the exit door which resident #1 accessed) and that the resident was exit seeking on 12/17/2011 to LPN # 1. Review of the statement by LPN #1 dated 12/17/2011 documented that she was not aware that she had a key to activate the alarm on the door. Review of the clinical record for resident #1 revealed the CT scan report of the Cervical Spine conducted on 12/18/2011 at the Hospital ( Hospital #1) revealed a non-displaced fracture of the right lamina of the 1 vertebral body. The CT scan of the brain conducted on 12/18/2011 at the Hospital revealed "Scalp hematoma over the left frontal bone." Continued review of the information from hospital #1 revealed that, due to the location of the fracture, the resident was transferred to another hospital (Hospital #2). Interview via phone on 12/21/2011 at approximately 9:15AM with the family member (Power of Attorney) of resident #1 revealed that the resident will not be returning to this facility upon discharge from the hospital (Hospital #2). Review of the facility Occurrence forms for resident #1 revealed: 10/20/2011- 6AM the resident was found on floor in her room; 11/17/2011- 12:35 PM the resident went to the exit door and opened the door - alarm initiated; 11/17/2011- 1:00 PM the resident was found on the floor by the hall couch; 11/24/2011- 4:10 AM the resident opened the door to the stairway, initiating the alarm. The staff redirected her. 12/09/2011 -5 AM the resident was found on the floor; 12/13/2011- 9:30 PM the resident tried to exit building, took her belt loose and slid to floor. 12/18/2011- 12:15 PM the seatbelt was plugged in the alarm but did not sound. Resident fell on the floor near the elevator. 12/18/2011- 7 :55 PM found on floor at bottom of the stairs lying on her left side in her wheelchair. A review of resident #1's care plan revealed :11/18/2011; a) Attempted exit of the building. Poor safety awareness and oriented to self only. 11/24/2011-b) Exit seeking The Goals/Objectives were: The resident will have fewer than 1 attempt monthly of exiting the building through the next assessment period as resident is easily redirected 1. encourage participation in activities of choice; 2. monitor location of resident; 3. re-direct when noting that resident is "wandering" without purpose; 4. provide snacks as a diversion to wandering; 5. toilet if resident seems to be seeking a confined/small area; 6. if tired, offer rest periods 2. ) Review of facility documentation revealed that facility staff identified thirteen residents ( #1,2,3,4,5,6,7,8,9,10,11,12,13) through the Minimum Data Set (MDS), and fall risk assessments, completed at admission and as necessary when falls occur, as having poor safety awareness/decrease cognition and as being at risk for falls. Of the thirteen residents identified, residents #1, #11, and #13 were also identified as elopement risks in accordance with the facility's Wandering Resident Policy and Procedure. Review of the care plans for all 13 residents identified problem areas of decreased cognition and falls. Resident's #1, #11, and #13 were found to have a care plan in place related to risk of elopement/wandering that indicated a need to monitor the resident. Review of the Wandering Resident Policy and Procedure dated as modified on 03/11/04 revealed that the facility will monitor any and all residents identified by the care plan team as having the potential to wander. However, no assessment tool for wandering/elopement risk was identified for use. 3.) A general tour of the facility was conducted on 12/21/11 commencing at 9:50 AM and concluding at 10:45 AM. During the tour, the following was identified: The functioning main elevator was entered on the second floor (where all residents reside) and taken to the basement. No lock or other device was identified in the elevator to prevent access to the basement area. A tour of the basement revealed a laundry area, numerous maintenance areas and storage areas all unlocked. One of the storage rooms was entered where numerous bottles of fluids were identified of which approximately 20 bottles and containers were cleaning solutions, some of which the tops were either loose or off. Further tour of the basement revealed an unlocked storage room containing approximately 8 biohazard receptacles that appeared to be full. Each receptacle was approximately 3.5 feet high and 24" in diameter. Interview conducted with staff#6, on 12/21/11 at 10:15 AM revealed that a company (unknown name) was due to pick up the biohazardous material "some time this week". Continued tour of the basement revealed 2 unlocked and unalarmed doors eggressing to the outside of the building. Interview with staff #6 at 10:20AM on 12/21/2011 revealed that there was no monitoring equipment in the basement to his knowledge. Interview conducted on 12/21/2011 at 11:15AM with staff #5, the maintenance supervisor, revealed that there was no monitoring equipment in the basement, and no alarms or locks on the 2 doors leading outside the building. Further interview at this time time revealed that there is no lock on the elevator prohibiting the elevator from being able to access the basement by anyone who entered the elevator. Staff#5 was able to confirm that the neither the door on the 1st floor which is located outside the activity room, that opens out onto a loading dock, or the door across from the administrator's office on the first floor which also has stairwell access from the 2nd floor was alarmed or monitored to prevent elopements. Continued interview on 12/21/2011 11:15 AM, with the Maintenance Supervisor, staff #5, revealed he had ordered 6 alarms to replace the alarms on the second floor. He further stated that he checked the batteries for the alarms on the second floor on June 16, 2011 and again in December 2011 (no specific date given). He stated there is no policy for checking the batteries and no log is maintained. He stated he replaces the batteries twice a year, but does not record it. Moreover, he stated that the alarms currently in place were from different manufacturers and were different ages. 4. The following was identified to have been implemented by the facility prior to exit by the surveyors at 6:15M on 12/21/2011: Each of the 4 doors on the second floor were found to have alarms that were checked by the surveyors and found to be functioning appropriately. The facility administration developed a specific Elopement Policy and Procedure with Elopement Prevention and Management components and implemented a new elopement assessment tool. Review of the the resident Medication Administration Records (MAR) revealed that on each MAR an area was to be filled in by the nurse from each shift, verifying that the 4 alarms on the 2nd floor had been checked and found to be functioning, and, if not functioning, then the administrator was to be informed. The staff in-servicing documentation was reviewed which revealed that not only the nurses are responsible for checking the door alarms, but the floor Certified Nursing Assistants were also to check and chart the 4 exit door alarms on the second floor in addition to checking and charting the personal alarms on residents who are documented as having them in place. Documentation of staff in-servicing was reviewed, dated 12/19/11, which identified training in identification and interventions for exit seeking behavior and monitoring skills for all Certified Nursing Assistants (CNAs), Registered Nurses (RNs), and Licensed Practical Nurses (LPN) on all 3 shifts. Activities (1), and Social Services (1) were also in-serviced at this time. Six new alarms that had been ordered on [DATE], were received 12/21/11 at 5:00 PM. Additional staff was called in to install the alarms. The 2 staff members were observed installing the alarms and had completed the installation as the survey was ended at 6:15 PM on 12/21/11. Additionally, the facility administrator has instructed the Director of Nursing (DON) to oversee daily that these implementations are being followed. The MDS Coordinator was instructed to reassess all 61 residents currently residing in the facility for elopement, utilizing the revised Elopement policy and Procedure and Elopement risk tool, and for fall risks. Interview with the DON on 12/21/11 at 4:00 PM revealed that the facility had placed a Certified Nursing Assistant (CAN) in the elevator to provide supervision and monitoring at all times to residents who utilize the elevator to prevent access to the basement area and any other unsafe or unsecured area. This CNA will be in place 24-7 until bids could be procured for a full alarm system installation or other interventions could be identified and implemented that would better meet the needs for supervision and prevention of accident hazards related to elevator use. The facility also placed a CAN outside the elevator door on the 1st floor to monitor the elevator and the 2 unlocked, unalarmed doors on the 1st floor. The staffing coordinator has been instructed by the administrator to assure the continuation of staffing of these 2 positions with either a CNA or nurse every shift until further notice. The Director of Nurses will assure all CNA's and nurses placed into these positions are adequately in-serviced. Interview conducted with the CNA (R#7) on the elevator on 12/21/11 at 5:00 PM revealed that she had been instructed to remain on the elevator at all times unless relieved for a break by another staff member, and that this would continue with all staff until further notice. Interview conducted with staff #8 (LPN) (hall monitor outside the elevator on the first floor), on 12/21/11 at 5:05 PM revealed that she had been instructed to remain on the 1st floor outside the elevator at all times unless relieved for a break by another staff member, and that this would continue with all staff until further notice. Her "job" as she understood it was to monitor the elevator, but also the 2 unlocked unalarmed doors on the 1st floor. Due to the interventions implemented above, the Immediate Jeopardy was found to have been removed on 12/21/2011 at 6:15PM. However, non-compliance continues at a scope and severity of an E.

Based on observation, interview and record review, the facility was not administered in a manner that enabled effective use of resources to identify and alleviate problems with supervision and environmental hazards that present a serious and immediate threat to the health, safety and well being of 13 of 13 sampled residents identified as having poor safety awareness and were at risk for falls. This failure resulted in resident #1, with a known history of poor safety awareness and exit seeking behavior, to exit, unsupervised, from the 2nd floor stairwell door with (a non-functioning alarm) and fall down the stairs sustaining a fracture. Moreover, the facility failed to identify that the elevator, utilized by all residents of the facility, to include the 13 identified with poor safety awareness, permitted unsupervised, unrestricted access to the basement area that had unmonitored exits to the outside as well as environmental, biological, and accident hazards. Findings: 1.) Review of the medical record for Resident #1 , revealed that on 12/18/11 at 7:55 PM, resident #1 exited a stairwell door on the 2nd floor (where she resided), and fell down 2 flights of stairs to the 1st floor landing. She was discovered by staff #4 at at 7:55 PM laying on her left side, still strapped in her wheel chair. The staff did not move the resident until paramedics arrived at the facility at 8:00 PM; however, the record noted that the resident had a scalp laceration on the left side of her head. Review of the clinical record for resident #1 revealed the CT scan report of the Cervical Spine conducted on 12/18/2011 at the Hospital ( Hospital #1) revealed a non-displaced [MEDICAL CONDITION] lamina of the 1 vertebral body. The CT scan of the brain conducted on 12/18/2011 at the Hospital revealed "Scalp hematoma over the left frontal bone." Continued review of the information from hospital #1 revealed that, due to the location of the fracture, the resident was transferred to another hospital (Hospital #2). Interview via phone on 12/21/2011 at approximately 9:15AM with the family member (Power of Attorney) of resident #1 revealed that the resident will not be returning to this facility upon discharge from the hospital (Hospital #2). Facility record review revealed that since the resident's admission of 10/18/11, she was identified as being an exit seeker, and a fall risk. A review of the occurrence log for resident #1 revealed the following: 10/20/11- Resident fell in room; 11/17/11- 12:35 PM Resident attempted to exit through stairwell door. Alarm sounded and the resident was redirected. 11/17/11-1:00 PM Resident fell in room. 11/24/11- Resident was found exit seeking attempting to exit through stairwell door. Alarm sounded and the resident was redirected. 12/9/11- Resident fell in dayroom. 12/13/11- Resident was found exit seeking attempting to exit through stairwell door. 12/18/11- Resident fell after unbuckling seat belt and standing alone. 12/18/11- Resident exited stairwell door in wheel chair, falling to the 1st floor, still in wheel chair. The resident's care plan dated 10/19/11 revealed that the resident was a fall risk due to a decrease in functional ability and cognition. The approaches put into place were: 1. Monitor medications for side effects; 2 Assist with transfers as needed. 3. Keep pathways free of clutter. 4. Keep call light within reach and answer promptly. 5. Physical and Occupational therapy as ordered by physician 6. Keep items in room in the same place 7. Make sure bed and wheel chair are locked prior to transfers. 8. Make sure call light and personal items are within reach on unaffected side. 9. Safety devices in place as indicated: tag alarm in bed, sensor alarm in bed and seat belt alarm in chair. Updated care plan 11/18/11 includes: 1. Encouraging participation in activities of choice. 2. Monitor location of resident. 3. Re-direct when noticing that resident is "wandering without purpose". 4. Provide snacks as a diversion to wandering. 5. Toilet if resident seems to be seeking a confined small area. 6. If tired, offer rest periods Review of the statement dated 12/18/2011 by Certified Nursing Assistant (CNA), staff #1, revealed that on 12/17/11 she reported to the floor nurse, Licensed Practical Nurse (LPN), Staff #2,, that the resident #1 was exit seeking and that the exit door alarm to the stairwell was not working. On 12/18/11 at 7:15 PM, notes document the resident attempting to exit the same stairwell door where the alarm was not working. On 12/18/11 at 7:55 PM, the floor nurse, staff#4, heard a noise and went to the stairwell, to find the resident at the bottom of the stairs in her wheel chair. 2. ) Review of facility documentation revealed that facility staff identified thirteen residents ( #1,2,3,4,5,6,7,8,9,10,11,12,13) through the Minimum Data Set (MDS), and fall risk assessments, completed at admission and as necessary when falls occur, as having poor safety awareness/decrease cognition and as being at risk for falls. Of the thirteen residents identified, residents #1, #11, and #13 were also identified as elopement risks in accordance with the facility's Wandering Resident Policy and Procedure. Review of the care plans for all 13 residents identified problem areas of decreased cognition and falls. Resident's #1, #11, and #13 were found to have a care plan in place related to risk of elopement/wandering that indicated a need to monitor the resident. Review of the Wandering Resident Policy and Procedure dated as modified on 03/11/04 revealed that the facility will monitor any and all residents identified by the care plan team as having the potential to wander. However, no assessment tool for wandering/elopement risk was identified for use. 3.) A general tour of the facility was conducted on 12/21/11 commencing at 9:50 AM and concluding at 10:45AM During the tour, the following was identified: The functioning main elevator was entered on the second floor (where all residents reside) and taken to the basement. No lock or other device was identified in the elevator to prevent access to the basement area. A tour of the basement revealed a laundry area, numerous maintenance areas and storage areas all unlocked. One of the storage rooms was entered where numerous bottles of fluids were identified of which approximately 20 bottles and containers were cleaning solutions, some of which the tops were either loose or off. Further tour of the basement revealed an unlocked storage room containing approximately 8 biohazard receptacles that appeared to be full. Each receptacle was approximately 3.5 feet high and 24" in diameter. Interview conducted with staff#6, on 12/21/11 at 10:15 AM revealed that a company (unknown name) was due to pick up the biohazardous material "some time this week". Continued tour of the basement revealed 2 unlocked and unalarmed doors eggressing to the outside of the building. Interview with staff #6 at 10:20AM on 12/21/2011 revealed that there was no monitoring equipment in the basement to his knowledge. Interview conducted on 12/21/2011 at 11:15AM with staff #5, the maintenance supervisor, revealed that there was no monitoring equipment in the basement, and no alarms or locks on the 2 doors leading outside the building. Further interview at this time time revealed that there is no lock on the elevator prohibiting the elevator from being able to access the basement by anyone who entered the elevator. Staff#5 was able to confirm that the neither the door on the 1st floor which is located outside the activity room, that opens out onto a loading dock, or the door across from the administrator's office on the first floor which also has stairwell access from the 2nd floor was alarmed or monitored to prevent elopements. Continued interview on 12/21/2011 11:15 AM, with the Maintenance Supervisor, staff #5, revealed he had ordered 6 alarms to replace the alarms on the second floor. He further stated that he checked the batteries for the alarms on the second floor on June 16, 2011 and again in December 2011 (no specific date given). He stated there is no policy for checking the batteries and no log is maintained. He stated he replaces the batteries twice a year, but does not record it. Moreover, he stated that the alarms currently in place were from different manufacturers and were different ages. 4.) The following was identified to have been implemented by the facility prior to exit by the surveyors at 6:15M on 12/21/2011: Each of the 4 doors on the second floor were found to have alarms that were checked by the surveyors and found to be functioning appropriately. The facility administration developed a specific Elopement Policy and Procedure with Elopement Prevention and Management components and implemented a new elopement assessment tool. Review of the the resident Medication Administration Records (MAR) revealed that on each MAR indicated [REDACTED]. The staff in-servicing documentation was reviewed which revealed that not only the nurses are responsible for checking the door alarms, but the floor Certified Nursing Assistants were also to check and chart the 4 exit door alarms on the second floor in addition to checking and charting the personal alarms on residents who are documented as having them in place. Documentation of staff in-servicing was reviewed, dated 12/19/11, which identified training in identification and interventions for exit seeking behavior and monitoring skills for all Certified Nursing Assistants (CNAs), Registered Nurses (RNs), and Licensed Practical Nurses (LPN) on all 3 shifts. Activities (1), and Social Services (1) were also disservice. Six new alarms that had been ordered on [DATE], were received 12/21/11 at 5:00 PM. Additional staff was called in to install the alarms. The 2 staff members were observed installing the alarms and had completed the installation as the survey was ended at 6:15 PM on 12/21/11. Additionally, the facility administrator has instructed the Director of Nursing (DON) to oversee daily that these implementations are being followed. The MDS Coordinator was instructed to reassess all 61 residents currently residing in the facility for elopement, utilizing the revised Elopement policy and Procedure and Elopement risk tool, and for fall risks. Interview with the DON on 12/21/11 at 4:00 PM reveled that the facility had placed a Certified Nursing Assistant (CNA) in the elevator to provide supervision and monitoring at all times to residents who utilize the elevator to prevent access to the basement area and any other unsafe or unsecured area. This CNA will be in place 24-7 until bids could be procured for a full alarm system installation or other interventions could be identified and implemented that would better meet the needs for supervision and prevention of accident hazards related to elevator use. The facility also placed a CNA outside the elevator door on the 1st floor to monitor the elevator and the 2 unlocked, unalarmed doors on the 1st floor. The staffing coordinator has been instructed by the administrator to assure the continuation of staffing of these 2 positions with either a CNA or nurse every shift until further notice. The Director of Nurses will assure all CNA's and nurses placed into these positions are adequately in-serviced. Interview conducted with the CNA (R#7) on the elevator on 12/21/11 at 5:00 PM revealed that she had been instructed to remain on the elevator at all times unless relieved for a break by another staff member, and that this would continue with all staff until further notice. Interview conducted with staff #8 (LPN) (hall monitor outside the elevator on the first floor), on 12/21/11 at 5:05 PM revealed that she had been instructed to remain on the 1st floor outside the elevator at all times unless relieved for a break by another staff member, and that this would continue with all staff until further notice. Her "job" as she understood it was to monitor the elevator, but also the 2 unlocked unalarmed doors on the 1st floor. Due to the interventions implemented above, the Immediate Jeopardy was found to have been removed on 12/21/2011 at 6:15PM. However, non-compliance continues at a scope and severity of an E.