Every finding on record at Spring Lake Rehabilitation Center

Based on record reviews and interviews, the facility failed to obtain an accurate Pre-Admission Screening and Resident Review (PASRR) screen prior to a re-admission for one (#98) resident of thirty sampled residents and failed to ensure residents with Mental Illness or Suspected Mental Illness were referred for Level II screening for two residents (#96 and #15) of thirty sampled residents. Findings included: 1. Review of Resident #98's census information revealed the resident was admitted on [DATE], discharged on [DATE], and readmitted [DATE]. Review of Resident #98's Admission Record revealed the resident was originally admitted on [DATE] and readmitted on [DATE]. The record did not include any mental health diagnoses. Review of Resident #98's Level I PASRR screen dated 7/3/24, did not show the resident had any Mental Illness (MI), Suspected Mental Illness (SMI), Intellectual Disability (ID), or Suspected Intellectual Disability (SID). The PASRR included in the resident record revealed the resident did not require a Level II PASRR screen. Review of Resident #98's July 2024 Medication Administration Record (MAR) showed the resident was prescribed Xanax 0.25 milligram (mg) tablet every 24 hours as needed for anxiety for 14 days. The documentation revealed the resident received psychotropic medication four of twelve days. The MAR showed staff monitored the anti-anxiety behaviors of the resident and behaviors were observed on 7/12/24. Review of Resident #98's care plan revealed the following focuses with initiation dates: - 1/21/25, revised 1/27/25: Resident is a risk for adverse reactions related to (R/T) psychotropic medication use of antianxiety secondary to anxiety. - 1/30/25: Resident has a behavior problem related to (r/t) making self-vomit by placing fingers down throat. Review of Resident #98's January MAR showed the resident received Buspirone 5 mg twice daily for anxiety, started on 1/20/25 and was prescribed Xanax 0.25 mg on 1/20/25 every 24 hours as needed for anxiety for 14 days. The resident received Xanax 0.25 mg three times during the month of January. Review of the Post-Traumatic Stress Disorder (PTSD)/Substance Abuse Screening Tool dated 1/21/25 revealed the resident did not experience any traumatic events or had a current or history of substance abuse. Review of the PTSD/Substance Abuse Screening effective 2/10/25 at 3:10 p.m. showed the resident reported experiencing physical abuse, felt numb or detached from people, activities, or their surroundings, and had a current or history of substance abuse disorder. Review of an updated Level I PASRR on 2/10/25 completed by the Director of Nursing (DON) of the facility showed Resident #98 had diagnoses of anxiety disorder, depressive disorder, adjustment disorder, and history of PTSD. The PASRR showed the resident was not receiving current services, had not previously received, or had been referred to MI services. The findings were based on documented history, medications, and individual, legal representative, or family report. The screening revealed the resident did not have any indications of a disorder resulting in functional limitations in major life activities appropriate for developmental stage, or had any issue with interpersonal functioning, concentration, persistence, and pace, or adaption to change. The updated Level I PASRR showed the resident did not have a diagnosis or suspicion of a SMI or ID and a Level II PASRR was not required. 14161 2. Review of the record for Resident #96 revealed an original admitted [DATE]. Review of Resident #96's Level I PASRR screen completed 5/24/23 revealed under Section I: PASRR Screen Decision Making, Section A: MI or suspected MI, Resident #96 had diagnoses including Depressive Disorder and Other ( Specify ): PTSD. The Level I PASRR showed the resident did not have a diagnosis or suspicion of a SMI or ID and a Level II PASRR was not required. A behavioral health note for Resident #96 dated 10/30/24 and entitled Diagnostic Evaluation was reviewed. The Primary diagnosis listed was Post Traumatic Stress Disorder, Chronic The reason for referral/presenting problem was documented as Resident #96 was referred to psychology due to having a diagnosis of PTSD. He has nightmares, difficulty with sleeping. General comments indicated, He as a [diagnosis] of PTSD. He states he has dealt with it for many years. He will wake up from having nightmares and has difficulty with going back to sleep. Does not happen every night He does not have depression. He gets anxious when he has the nightmares or hears a very loud noise he does not expect. He knows to take deep breaths and redirect his thoughts. During an interview on 2/12/25 at 3:53 p.m., the Director of Nursing (DON) stated Resident #96 has PTSD. She stated he does not qualify for needing a Level II PASRR screening because he is stable and does not exhibit any behaviors. 50434 3. Review of Resident #15's Admission Record revealed an original admitted [DATE] with readmission on 1/7/25. Resident #15's diagnoses included anxiety disorder (initiated 6/1/21), major depressive disorder (initiated 6/1/21), unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (initiated 1/7/25), and adjustment disorder with mixed anxiety and depressed mood (initiated 1/7/25). Review of Resident #15's Level I PASRR screen dated 1/3/25, showed in Section I: PASRR Screen Decision-Making, section A. MI (Mental Illness) or Suspected MI (check all that apply): Anxiety Disorder, was checked. Depressive Disorder was not checked. Section II: Other Indications for PASRR Screen Decision-Making revealed a Level II PASRR evaluation must be completed if the individual has a primary or secondary diagnosis of dementia or related neurocognitive disorder (including Alzheimer's disease), and a suspicion or diagnosis of a Serious Mental Illness. Under Section IV: PASRR Screen Completion, Individual may be admitted to a Nursing Facility (check one of the following): No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required, was marked. During an interview on 2/12/25 at 3:54 p.m., the DON stated Resident #15's PASRR Section I has Anxiety marked. She reviewed the resident's diagnoses in the Electronic Medical Record (EMR) and stated he has Depression, Anxiety, and Dementia. She stated a Level II screen is not needed because his dementia diagnosis is not a primary or a secondary diagnosis. Review of the facility's undated policy titled PASRR Guidance revealed the following: Purpose: A nursing facility must notify the state mental health authority or state intellectual disability authority, as applicable, promptly after a significant change in the mental or physical condition of a resident who has mental illness (MI) or intellectual disability (ID) for resident review. To ensure that individuals with a mental disorder or intellectual disabilities continue to receive the care and services they need and the most appropriate setting, when a significant change in their status occurs. Guidance: As part of the preadmission screening and resident review PASRR process, the facility is required to notify the appropriate state mental health authority of our state intellectual disability authority when a resident with a mental disorder or intellectual disability has a significant change in their physical or mental condition. The nursing facility must notify the state mental health (SMH) /ID authority of significant changes in residents with MD or ID independent of the findings of the Significant Change in Status Assessment (SCSA). PASRR level 2 functions as an independent assessment process for this population with special needs, and parallel with the facilities assessment process. The facility should know their state PASRR policy on referral to the SMH/ID authority, so that these authorities may exercise their expert judgment about when a level 2 evaluation is needed. Referral to the SMH/ID authority should be made as soon as the criteria is indicative of a significant change or evident- the facility should not wait until the SCSA is complete Referral for PASRR level 2 resident review evaluation is required for individuals previously identified by PASRR to have a mental disorder, intellectual disability, or a related condition who experience a significant change.

Based on observations and interviews, the facility failed to ensure appropriate cautionary and safety signs indicating the use of oxygen were posted at 23 out of 23 randomly observed rooms where oxygen was administered. Findings include: During an observation on 2/11/2025 at 2:59 PM, 23 resident rooms where oxygen was observed administered had no oxygen use signage near the resident rooms. During an observation on 2/12/2025 at 4:00 PM, the facility had no smoking signs posted outside the facility next to the front entrance door, but there were no signs addressing the use of oxygen inside the facility. During an interview on 2/13/2025 at 11:45 AM, the Nursing Home Administrator and the Director of Nursing stated the facility did not need oxygen signs on resident doors because they had no smoking signs posted outside the facility. During an interview at 12:00 PM on 2/13/2025 with the [NAME] President of Clinical Services, she stated they were told by life safety they did not have to put oxygen signs outside resident rooms where oxygen is administered because they have no smoking signs posted on the oxygen storage rooms located in the facility. The facility did not have an oxygen policy related to oxygen signs. Photographic Evidence Obtained

Based on observations, record review, and interviews, the facility failed to coordinate communication with a Dialysis center for one resident (#36) of one resident sampled for Dialysis services. Findings included: On 2/12/25 at 12:32 p.m., Resident #36 was observed lying in bed with a lunch tray on the overbed table next to the bed. The resident reported not feeling well and may not go to Dialysis. The resident also stated she has not missed any Dialysis appointments and the facility provided transportation to the Dialysis center. Review of Resident #36's Admission Record revealed the resident was admitted on [DATE] and readmitted on [DATE]. The record included diagnoses of end stage renal disease (ESRD) and dependence on renal dialysis. Review of Resident #36's February 2025 physician orders showed the resident was to receive Hemodialysis three times a week every Monday, Wednesday, and Friday. An interview was conducted on 2/11/25 at 3:41 p.m. with Staff B, Registered Nurse (RN). The staff member stated a face sheet, list of medications, and the communication form was sent to the Dialysis center for dialysis appointments. Staff B, RN also stated the communication forms are filled out before the resident leaves and after the resident returns. They are scanned into the medical record and put into the Dialysis binder. Review of Resident #36's Dialysis Communication forms revealed the Dialysis center did not complete the portion reserved for them to complete, showing any medications given during/after treatment, pre-treatment and post-treatment weights, pre-treatment and post-treatment vital signs, any access problems, snacks/fluids given, any change in condition, or special instructions/comments on 1/24/25, 2/3/25, 2/5/25, and 2/7/25. An interview was conducted with Staff C, Licensed Practical Nurse (LPN)/Unit Manager (UM) on 2/11/25 at 3:48 p.m. Staff C, LPN UM reviewed the Dialysis Communication forms and stated, Guess when these come back without the center information I should have been asking them to complete them. The staff member stated the four forms missing the Dialysis center information were ones in back of the book and explained that was why she liked to scan them in so they didn't get put back behind the physician orders. Review of Resident #36's Progress Notes on 1/24/25, 2/3/25, and 2/5/25 did not reveal the facility attempted to contact the Dialysis center for information regarding the resident's treatment. The facility did not provide Progress Notes for 2/7/25. An interview was conducted with the facility's Director of Nursing (DON) on 2/12/25 at 12:05 p.m. The DON reported they have been having a terrible time getting the Dialysis center to return the Communications forms and they keep calling the center, but they don't receive them. The DON stated she contacted the facility's corporate office and the facility does not have a policy for Dialysis. Review of Resident #36s Dialysis Communication Forms dated 2/5/25 and 2/7/25, sent to the facility by the Dialysis center on 2/12/25 at 10:33 a.m. revealed the completion of the Dialysis Center information, however it did not contain pre or post treatment facility information. The form dated 2/5/25 showed the resident received 100 milligrams of iron during or after the treatment and on 2/7/25 the resident received 100 milligrams of iron and 75 micrograms of Mircera, a long-acting erythropoiesis-stimulating agent (ESA) used for the treatment of anemia (www.mircera.com). Review of the contract between the facility and Dialysis Center, effective May 18, 2017, included the following: 2. Interchange of Information. The Nursing Facility shall provide for the interchange of information useful or necessary for the care of the ESRD Residents, including a Registered Nurse as a contact person at the Nursing Facility. Those responsibilities include oversight of provision of services to the ESRD residents. B. Obligations of the ESRD Dialysis Unit and/or Company. 1. Standards of ESRD Dialysis unit. The ESRD dialysis unit shall conform to standards not less than those required by any applicable laws and regulations of any local, state or federal regulatory body, as the same may be amended from time to time. D. To provide to the Nursing Facility information on all aspects of the management of the ESRD Resident's care related to the provision of Services, including directions on management of medical and non-medical emergencies, including, but not limited to bleeding, infection, and care of dialysis access site. D. Mutual Obligations. 1. Collaboration of Care. Both parties shall ensure that there is documented evidence of collaboration of care and communication between the Nursing Facility and ESRD Dialysis Unit. Documentation shall include, but not be limited to, participation in care conferences, continual quality improvements, and review of infection control of policies and procedures, in the signatures of team members from both parties on a short term care plan (STCP) and long term care plan (LTCP). Team members shall include the physician, nurse, social worker, and dietician from the ESRD dialysis unit and a representative from the nursing facility.

Based on observations, record review, and interviews, the facility failed to provide a dignified dining experience for one resident (#7) out of eight residents sampled for dining. Findings included: During an observation on 2/11/2025 at 11:45 AM, Resident # 7 was observed sitting in his wheelchair in the hallway in a high traffic location eating his lunch with his fingers. Two staff members were observed walking over to him and adjusted him in his chair. One staff member began to assist him with his meal while standing over him. Review of the Admission Record showed Resident # 7 was admitted to the facility on [DATE] with diagnoses to include but not limited to type 2 diabetes mellitus without complications, dementia in other disease classified elsewhere, unspecified severity, with anxiety, and need for assistance with personal care. During an interview on 2/13/2025 at 10:00 AM with Staff G, License Practical Nurse/Unit Manager (LPN UM), Staff G, LPN UM stated Resident # 7 is seated in the hallway during his meals so the staff can monitor him. During an interview on 2/13/2025 at 10:30 AM, with the Director of Nursing (DON), the DON stated Resident # 7 has dementia, so they place him in an area where staff can monitor him with his meals. The DON also stated Resident # 7's daughter wants him to be in a location where the staff who know him best can assist him but acknowledged seating him in the hallway could be a dignity concern. The facility did not have a policy related to dignified dining.

Based on observations, interviews, and record review, the facility did not ensure timely isolation precautions were initiated for one resident (#345) out of 39 residents sampled. Findings included: A review of Resident #345's Admission Record showed an admitted [DATE] with a primary diagnosis of periprosthetic fracture abound internal prosthetic left hip joint, subsequent encounter. On 2/10/2025 at 9:50 a.m., an observation and interview was conducted with Resident #345 in the resident's room. Resident #345 stated he was in the facility for rehabilitation after hip repair surgery. Resident #345 had two dressings on his left lower extremity. Resident #345 did not have any signage indicating the resident was on Enhanced Barrier Precautions (EBP). On 2/11/2025 at 12:45 p.m., an interview was conducted with the Assisted Director of Nursing/Infection Control Preventionist (ADON/ICP). The ADON/ICP stated all residents with any wounds, including surgical wounds, should be on EBP. On 2/12/2025 12:22 p.m., a follow up interview was conducted with the IPC related to Resident #345. The IPC stated based on Resident #345's surgical wounds, the resident should have been placed on EBP upon admission. On 2/13/2025 09:34 a.m., an interview was conducted with the Director of Nursing (DON), who stated she was aware of the lack of EBP for Resident #345 and stated, we have a great deal of turn around with admits and discharges and we could be doing a better job. A review of the facility's policy and procedure titled Isolation - Precautions Overview: SNF (Skilled Nursing Facility) and ALF (Assisted Living Facility), copyright 2013, showed the following Purpose statement: - To provide a system of isolation precautions to prevent the transmission of infection. - To prevent the transmission of infectious diseases. The policy also revealed the following Procedure: Enhanced Barrier Precautions - refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident area activities. EBP are used in conjunction with standard precautions and expand the use of PPE (personal protection equipment) to donning gowns and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs (multi-drug-resistant organisms) to staff hands and clothing. EBP are indicated for residents with any of the following: - Infection or colonization with a CDC-targeted (Centers for Disease Control and Prevention) MDROs when Contact Precautions do not otherwise apply; or - Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with an MDRO.

Based on observations, interviews, and policy review, the facility failed to ensure medications were stored in a safe manner and inaccessible to unauthorized personnel, visitors, and residents on two (800-hall and 200-hall) of seven medication carts. Findings included: On 2/12/25 at 8:49 a.m., an observation was conducted with Staff F, Licensed Practical Nurse (LPN) of medication administration. On 2/12/25 at 9:13 a.m. after the observation of medication administration with Staff F, LPN, an observation was conducted of a thermal cooler sitting on top of the medication cart of the 800-hall with a bottle of over-the-counter medication handwritten labeled Lacto Probiotic. The staff member stated the Lacto was left unattended on the medication cart, but it had to stay refrigerated during the medication pass. On 2/12/25 at 11:41 a.m., an observation was conducted with Staff D, LPN obtaining a blood glucose level and the administration of insulin aspart for Resident #246. The staff member moved the medication cart from the doorway outside of the resident's room to the nursing station where the amount of insulin was verified with Staff C, LPN/Unit Manager. The amount of insulin was verified, the insulin pen was placed in a pharmacy labeled bag, and the medication cart was moved back to the area outside of the resident room, approximately half the medication cart was unseen from the resident room. The staff member entered the resident room, leaving the medication cart unlocked, with the insulin pen and administered the medication while standing over the resident. The medication cart was not visible to staff during the administration. An interview was conducted on 2/13/25 at 12:58 p.m. with the Regional Nurse Consultant (RNC). The RNC stated medications should not be left unattended on top of medication cart. Review of the policy titled Storage of Medications, revised August 2014, showed medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. The Procedure of the policy revealed only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) are permitted to access medications. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. Review of the policy titled Medication Pass Guidelines, copyright 2008, revealed during the administration of medication Lock medication cart when not in direct view of nurse administering medication.

Based on observations, interviews, and record review, the facility failed to assist and provide activities per preference to one resident (#71) of thirty sampled residents. Findings included: On 2/10/25 at 10:31 a.m., an observation and interview was conducted with Resident #71. The resident stated the facility does not ask them to go to activities, because I would probably go. On 2/12/25 at 2:05 p.m., Resident #71 was observed sitting in a wheelchair in a room with a television playing. The resident reported being unaware of an activity calendar in the room. The resident stated they would go to activities, but staff don't tell her. Observation of resident room showed a calendar placed approximately four and a half feet from the floor on a bulletin board in the room. An interview was conducted on 2/12/25 at 2:07 p.m. with Staff A, Certified Nursing Assistant (CNA). The staff member stated Resident #71 does not go to activities but goes to therapy. Staff A, CNA reported the activity department goes into the resident's room to see the resident. Review of Resident #71's Admission Record revealed the resident was originally admitted on [DATE]. The record included diagnoses of unspecified anxiety disorder, hemiplegia and hemiparesis following other cerebrovascular disease affecting left non-dominant side, adult failure to thrive, and other symptoms and signs involving cognitive functions and awareness. Review of Resident #71's Care Plan revealed the resident required invitations, assistance, and some encouragement to attend programs of interest and enjoyed music programs, entertainment, card games, watching television, movies, and social visits, initiated on 12/23/24 and revised on 1/21/25. The interventions included: offer seating close to program leader, provide 1:1 leisure visits of potential interest, provide activity calendar (and) review as needed, provide invitations and offer assistance to programs of assessed interest, and provide set up with activities (and) assist as needed and encourage active participation. Review of Resident #71's Activities Evaluation, effective 12/23/24, revealed the resident had personal strengths: cooperative, cheerful, leisure interests, able to make needs known, and sense of humor. The resident was able to read, write, and speak/comprehend English. The evaluation revealed the resident needed encouragement to participate in activities and the activity environment was groups, own room, day/activity room, inside facility/off unit, and outdoor. The resident's current or past interests included cards, games, arts/crafts, music, shopping, conversation, watching TV, watching movies, political interests, hobbies, and special interests. The sensory adaptations to participate needed assistance, needed reminders, and needed glasses (optical). The resident required assistance for getting to and from activity areas. The consideration comments revealed the resident was a prior resident, alert and oriented with some confusion noted at time of evaluation, was currently room-bound at the time of evaluation, some hearing impairment, and enjoyed music programs, entertainment, card games, watching television and movies, and social and pet visits. Review of Resident #71's Activities Evaluation, effective 1/19/25, showed the resident had no changes noted with activity preferences and staff would continue to assist as needed. Review of Resident #71's Minimum Data Set (MDS) assessment dated [DATE] revealed under Section F - Preferences for Customary Routine and Activities, being around pets, doing things with groups of people, doing favorite activities, and going outside for fresh air was very important and listening to music and keeping up with news was somewhat important to the resident. Section GG - Functional Abilities showed the resident used a wheelchair for mobility and had a range of motion impairment to one side of the upper extremity and one side of lower extremity. Resident #71's Brief Interview of Mental Status (BIMS) assessment dated [DATE] revealed a score of 6/15, indicating severe cognitive impairment. Review of Resident #71's Activity Task documentation for 30 days prior to 2/13/25 revealed the resident had no participation in books and poetry, creative activities, enrichment, games, holiday/special events, women club, physical activity, Resident 1:1 individual participation, resident council/empowerment, sensory, social/discussions/cognitive, spiritual, trips/outings, and/or virtual visitation (14 day look back). The documentation showed the resident participated in entertainment on 1/22/25 at 2:59 p.m., participated in friendly visit/room visit and independent leisure pursuits on 1/22/25 at 2:59 p.m. and on 2/10/25 at 2:59 p.m., and participated in self-image/nail care on 2/10/25 at 2:59 p.m. An interview was conducted with the facility's Activity Director (AD) on 2/13/25 at 9:19 a.m. The AD reported Resident #71 was here for rehab and was admitted to the facility a couple of times before. The staff member reported the resident attended the music program yesterday 2/12/25 between 3-4 p.m. and went to a hair appointment. The AD reported documentation was done electronically in the resident's record. A review of Resident #71's Activity Tasks revealed no documentation of the resident's participation in the music program or any music program in the last 30 days. The AD stated she would have to make a late entry for the resident's participation in 2/12/25 music program. The staff member stated the resident was on isolation and did not know what type (per physician order: Contact precautions from 12/21/24 to 1/6/25) and when the resident was unable to come out of room at the time. The AD stated when resident's first come in, the department does initial evaluations and if the resident's come for short-term/rehabilitation, the department goes around the building to invite them, calendars are placed in each room and lobbies, and during resident council she attempts to get ideas to either add or subtract activities. The AD stated, we can do better documentation. An interview was conducted on 2/13/25 at 10:16 a.m. with the facility's Director of Nursing (DON). The DON stated the facility does welcoming meetings, shows new resident's the activity calendar, and the Activity Department follows up the calendar throughout the day. Review of the February Activity calendar revealed activities are provided daily from morning to afternoon and to early evening on certain days. Review of the policy - Individual Activities, copyright 2021, showed Individual activities are provided for those residents who do not wish to attend group activities. The Procedure revealed: 1. Individual activities are provided because residents have a need for personal identity. Some residents are unable to do or do not wish to participate in Group activities. 2. For those residents who do not wish to participate in Group activities, the activity program provides individual activities that: - Make maximum use of each resident's physical and mental abilities; And - Are interesting to and involve the resident, and which presents a challenge that can be met by the resident.

Based on resident record review and staff interview, the facility did not ensure accurate and timely completion of resident assessments for two residents (#27 and #82) of two residents reviewed for resident assessments. Findings included: Review of the record for Resident #27 revealed he was admitted to the facility on [DATE] and died in the facility on [DATE]. An MDS (Minimum Data Set) assessment dated [DATE] indicated the assessment was for Death in facility. The MDS assessment was completed on [DATE] but was not submitted. Review of the record for Resident #82 revealed he was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. Review of the MDS assessments for Resident #82 revealed the last assessment submitted was an Admission assessment, submitted [DATE]. An interview with Staff E, Resident Care Specialist I RN on [DATE] at 12: 21 p.m. revealed Resident #27's MDS assessment should have been submitted. Staff E, Resident Care Specialist I RN also stated the discharge MDS assessment for Resident #82 was not submitted until [DATE]. She stated there was a switch in electronic medical records in September of 2024 and they were working in two systems at the time. She also stated the assessment should have been completed and submitted.

Based on resident record review, staff interview and review of policy and procedure, it was determined the facility failed to ensure two residents' (#121 and #93) medical records were accurately documented and systematically organized to include documentation of re-evaluation and updates of discharge needs and plans of three residents reviewed for discharge planning and out of a total sample of 36 residents. Findings included : 1. Review of the Admission Record for Resident #121 revealed he was admitted to the facility for rehabilitation on 11/27/22. A Minimum Data Set (MDS) Admission Assessment was completed on 12/1/22. Review of Section C - Cognitive Patterns revealed the Brief Interview for Mental Status (BIMS) indicated a score of 15 out of 15, which indicated cognitively intact mental status. A care plan, initiated 11/29/22 and revised 12/6/22, revealed, [Resident #121] wishes to return/be discharged to community. The goal of the care plan indicated, The resident will verbalize/communicate an understanding of the discharge plan and describe the desired outcome by the review date (Target date 2/27/23). Interventions, initiated 11/29/22 and not revised, indicated: *Establish a pre discharge plan with the resident /family/caregivers and evaluate progress and revise plan. *Evaluate the resident's motivation to return to the community. Wishes to return/ be discharged to community. Review of Resident #121's medical record revealed an Interdisciplinary team note, documented on a form entitled Baseline Care Plan Summary and dated as reviewed with resident/representative on 12/5/22. The note revealed, On task with therapy goals, making progress - states he needs more work on strength and will need another surgery soon. Requests to stay as: Long as insurance is paying. I'm not ready to go yet. Discussed needs upon discharge - has family support. There was no other documentation found in Resident #121's medical record of further re-evaluation of Resident #121's wishes related to discharge. An interview was conducted with Resident #121, on 12/19/22 at 2:02 p.m. Resident #121 stated he was told that he was being discharged home on 12/22/22 because his Medicare funds ran out. He stated he had asked about paying privately. He stated he has not had surgery on his hip and has no hip. He reported he was concerned how he would manage at home as his (spouse) was elderly and could not help him. Resident #121 stated he was told someone would come shower him, but no other help was offered once he was home. An interview was conducted with Staff G, Registered Nurse (RN) Case Manager, on 12/21/22 at 10:21 a.m. She stated that Resident #121 was going home on 12/22/22. She stated his [family members] want him to go home and she had set up DME (Durable Medical Equipment) to be delivered tomorrow and he will have either home health or outpatient therapy. She stated he was supposed to have hip surgery and the plan was for him to have the hip surgery and come back to the facility for rehab (rehabilitation) after the surgery, however the surgeon had postponed the surgery due to the scab on his shin. She stated originally Resident #121 wanted to stay and continue with therapy until the surgery, however, now he and his family have agreed he will go home. There was no documentation in Resident #121's medical record of the current discharge plan of 12/22/22 until 12/21/22 at 10:48 a.m. Staff G documented that she confirmed with Resident #121 and his [family members] that he was going home on 12/22/22 and there had been no concern voiced related to the pending discharge. On 12/21/22 at 11:07 a.m., Staff G stated she just spoke with Resident #121 and his [family member] and she doesn't know what the confusion was as he stated to her he was fine with going home and did not express that he was not ready. Staff G, RN Case Manager stated she just documented this in Resident #121's medical record. Review of the medical record for Resident #121 with Staff G revealed no other documentation related to discharge planning. Staff G confirmed she had not been documenting discharge planning entries in the medical record. She stated she keeps a log for herself where she documents discharge planning conversations and stated she could write late entries in the medical record regarding the conversations she had had with Resident #121 and his family. Staff G provided a copy of her handwritten notes related to Resident #121's discharge plans. Review of Staff G's handwritten notes, written on a Medicare Stay Tracking Log, revealed: 12/8 [family members] to discuss pos discharge 12/12 [family member] called to make me aware of plans/ surgery/discharge/appt. 12/14 [family member] asked for wider walker 12/20 [family member] called to check on equipment, walker, hospital bed, wheelchair. Review of the medical record for Resident #121 revealed a nursing note indicating he was discharged home with his spouse on 12/22/22 at 10:15 a.m. with narcotics sent and no complaints of pain or discomfort from the resident. 37999 2. The Admission Record indicated on 11/08/22 Resident #93 was admitted to the facility. The record included diagnoses not limited to Parkinson's disease and benign prostatic hyperplasia with lower urinary tract symptoms. The 5-day Minimum Data Set (MDS), dated [DATE], identified a Brief Interview for Mental Status score of 15 out of 15, indicating intact cognition. During an initial interview, on 12/19/22 at 1:36 p.m., Resident #93 reported receiving therapy for one hour per day then sitting in the room for the other 23 hours of the day. The resident related speaking with Staff B Licensed Practical Nurse/Unit Manager (LPN/UM) regarding many issues and the case manager [Staff G] would come talk with him. On 12/20/22 at 3:46 p.m., Resident #93 was observed sitting in his wheelchair and was interviewed while in his room. On 12/21/22 at 12:44 p.m., Resident #93 reported the case manager had not been in to speak with him. Staff B, LPN/UM stated, on 12/21/22 at 12:51 p.m., Resident #93 had spoken with her about discharging on Monday (12/19/22) morning and she thought she had informed the case manager but could not be 100% sure if she had. On 12/21/22 at 2:00 p.m., Staff G, Case Manager stated she did not know that the resident wanted to go home. She related that usually the team, which included therapy staff , talked on Wednesdays regarding discharges, then they spoke with the residents. Staff G stated she speaks with residents (regarding discharge plans) at the time of admission. A review of Resident #93's Case Management Narrative Notes identified one note from his admission, dated 12/21/22 at 4:40 p.m., which documented the case manager had called the [family member] to talk about the resident's discharge. The note indicated the resident had called the [family member] informing her of his discharge this week and she told him that it was next week and the spouse had apologized for the confusion. The note identified the resident had informed the case manager he was supposed to go home this week but his [family member] had told him it was next week. On 12/22/22 at 2:05 p.m., an interview was conducted with Resident #93 and his spouse. The spouse stated the resident does get confused at times. The spouse stated they had called the case manager on Monday to discuss discharge and home health. The spouse stated the case manager had called her yesterday and informed her that she had heard the resident wanted to be discharged prior to Christmas and that the [family member] was told if she wanted to come get the resident for the day she could, as long as, the resident was returned to the facility by midnight. The spouse stated the first time she had heard about a discharge date was Monday when she had called the case manager. Staff G, Case Manager stated, on 12/22/22 at 12:28 p.m., a discharge depended on progress in therapy and (the facility) has a big meeting (to discuss) on Wednesdays which includes therapy, nurses, Unit Manager, Director of Nursing, Nursing Home Administrator, and the physician. She stated a pre-discharge plan was done at the time of admission and the plan consists of Durable Medical Equipment (DME), support, medications and if any new medications are needed they get called in, and if there was home health services. She reiterated this is done at the time of admission. Staff G reported making notes on tracker but not consistent with notes in the electronic medical record. She stated on 12/19 she had discussed with the spouse a pickup time on 9 a.m., that the spouse wanted a print out of nursing homes, the family had requested a specific home health agency, and the discharge date was 12/29. A review of the Medicare Stay Tracking Log, which Staff G provided, as it was not part of the medical record, indicated the first note after the resident's admission was on 12/8, [Family member] wants air mattress (special mattress for wounds, no gel pack), trapeze, 12/19. The next note was 12/19: discharge (d/c) date, 9 a.m., print out nursing home. Family home health, and the note dated 12/22, D/C concern?, stated 12/29, DME (same). The log did not indicate a specific discharge date was talked about with the [spouse] until 12/22/22 despite the [spouse] reporting it was talked about on 12/19/22. Resident #93's care plan, created on 11/9/22, indicated Resident wishes to return/be discharged to with no location documented. The revision on 11/17/22 identified the resident wished to return/be discharged home. The intervention to this focus was for staff to Establish a pre-discharge plan with the resident/family/caregivers and evaluate progress and revise plan. The Post-Discharge Plan of Care policy identified that Pre-discharge Planning will be coordinated by the Case Management Social Service Department for the development of post-discharge plan of care. The procedure explained that Upon admission of the resident, the facility team meets to discuss and document in the medical record the resident's discharge plan and anticipate date of discharge.

Based on observations, interviews, and record reviews, the facility failed to maintain an infection control and prevention program to help prevent the development and transmission of communicable diseases and infections by 1) failing to have required signage and clearly identify the type of precautions and personal protective equipment (PPE) necessary to ensure isolation precautions were followed by visitors for one resident (#294), and 2 ) failed to implement isolation precautions in a timely manner for one resident (#17) out of a total of seven sampled residents. Findings included: 1. A review of Resident #294's medical record revealed Resident #294 was admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy and sepsis. A review of Resident #294's physician's orders revealed an order, dated 12/16/2022, for contact precautions for a diagnosis of Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia, every shift. Nurse to verify correct door signage and equipment present. A review of Resident #294's care plan revealed Resident #294 had MRSA bacteremia. Interventions included to implement contact precautions and provide visitors with correct procedures. An observation was conducted on 12/19/2022 at 11:46 a.m. outside of Resident #294's room. The door to Resident #294's room had a caddy hanging from it, which included gowns and gloves. No signage was observed on the inside or outside of the door to indicate Resident #294 was under isolation precautions. Two visitors were observed inside of Resident #294's room. Neither visitor was observed wearing any personal protective equipment (PPE) while inside of the room. An interview was conducted on 12/19/2022 at 1:15 p.m. with Resident #294's resident representative (RR). The RR stated Resident #294 had been in the hospital several times due to various infections and he was receiving antibiotic therapy while at the facility. The RR also stated he was not aware Resident #294 was under any isolation precautions and was not sure why the PPE caddy was hanging from the room door. An observation was conducted on 12/20/2022 at 9:38 a.m. outside of Resident #294's room. The PPE caddy hanging from Resident #294's door was observed to have signage hanging from it indicating Resident #294 was under contact isolation precautions. An interview was conducted following the observation with Staff A, Licensed Practical Nurse (LPN). Staff A, LPN stated Resident #294 was placed on contact isolation precautions on the morning of 12/20/2022 related to a MRSA infection. Staff A, LPN reviewed Resident #294's physician's orders and addressed Resident #294 had an order for contact isolation precautions starting on 12/16/2022. Staff A, LPN stated the signage indicating Resident #294 was under contact isolation precautions should have been posted on the date of the order and family members and visitors should be informed when a resident is under isolation precautions. An interview was conducted 12/22/2022 at 9:33 a.m. with the facility's Infection Control Preventionist (ICP). The ICP stated when a resident is admitted under isolation precautions, they identify the reason for the isolation precautions, put the physician's order into place, and place the appropriate PPE and signage on the resident's door. The signage on the resident's door should also include instructions for visitors to follow before entering the resident's room. Signage should be visible whether the door is open or closed. The ICP stated all visitors should be informed of any isolation precautions and if a resident has an order for isolation precautions, it should be followed. A review of the facility policy titled, Isolation - Isolation Precautions Overview, with no implementation date, revealed under the section titled Guideline two tier transmission based precautions, either airborne, droplet, or contact precautions, will be used for residents with known or suspected infections. The policy also revealed under the section titled Procedure Contact Precautions are designed to reduce the risk of epidemiologically important microorganisms by direct or indirect contact. Indirect-contact transmission involves contact from a susceptible host with a contaminated object in the environment. Direct contact transmission involves skin to skin contact and physical transfer of microorganisms to a susceptible host. Photographic evidence obtained. 14161 2. Review of the Admission Record for Resident #17 revealed he was admitted to the facility on [DATE] . Review of an Admission MDS Assessment, dated 11/25/22, indicated a score of 8 on the Brief Interview for Mental Status (BIMS) assessment, which indicated moderately impaired cognition. The MDS assessment also indicated in Section H Bladder and Bowel that Resident #17 was always incontinent of bladder. Review of Resident #17's physician's orders for December 2022 revealed: *End date of 12/15/22, UA (Urinalysis) with C&S (Culture and Sensitivity). May straight cath (catheterization) if needed, every night shift for increased confusion/voiding for 1 day. *End date of 12/19/22, UA C&S on 12/19/22 one time only for UTI (urinary tract infection) s/s (signs and symptoms) until 12/19/22. *Start date of 12/19/22, Cipro Tablet 500 mg (milligram) (Ciproflaxin HCI) Give 1 tablet by mouth two times a day for UTI for seven days. Review of Laboratory Results in Resident #17's medical record revealed Urine Culture and Sensitivity results were received by the facility on 12/18/22 at 9:10 a.m. Results indicated : >100,000 CFU/ML (colony forming units/milliliter) Gram Negative Rods Pseudomonas aeruginosa (Isolate 1) Enterobacter cloacae complex ( Isolate 2). Additional review of the above Laboratory Results revealed the Culture and Sensitivity results were reviewed by a facility nurse on 12/19/22 at 3:38 p.m. A physician's order, dated 12/20/22, revealed: Contact Precautions for Diagnosis Pseudomonas in urine. Every shift nurse to verify correct door signage and equipment present. Observation outside of Resident #17's room, on 12/21/22 at 11:58 a.m. revealed no door signage and equipment present for contact precautions. (Photographic Evidence Obtained) An interview was conducted with the Infection Control Preventionist, on 12/22/22 at 9:37 a.m. She stated the signage and equipment for contact precautions should be positioned where staff could see it upon entering the resident's room. She confirmed the signage should be visible regardless of whether the resident's room door is open or closed. The Infection Preventionist stated with pseudomonas in the urine they don't put the resident on isolation unless the resident is incontinent of urine. She stated Resident #17 should have been placed on contact isolation when the nurse reviewed the culture and sensitivity results on 12/19/22 as Resident #17 is incontinent of urine. She stated the weekend supervisor should have been aware of the culture and sensitivity results on 12/18/22 and taken action to place the resident on contact isolation and the nurse who reviewed the results on 12/19/22 should have taken action to place the resident on contact isolation. She stated, That process; didn't follow through the whole way.

Based on interview and record review, the facility failed to ensure residents were accurately screened for possible mental disorders or intellectual disabilities prior to admission for one resident (#9) of three residents sampled for Preadmission Screening and Resident Review (PASARR) screenings. Findings included: A review of Resident #9's Admission Record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses of anxiety disorder, depression, and Post-Traumatic Stress Disorder (PTSD). A review of Resident #9's hospital admission History and Physical (H&P), dated 11/12/2022, revealed Resident #9 had a history of PTSD, depression, and anxiety. A review of Resident #9's Level I PASARR assessment, dated 11/17/2022, revealed, under the section titled A. MI (Mental Illness) or suspected MI (check all that apply), the checkboxes for the selections Anxiety Disorder, Depressive Disorder, and Other (specify), were not checked. A review of Resident #9's Minimum Data Set (MDS) assessment, dated 11/28/2022 revealed, under Section I: Active Diagnoses, Resident #9 had psychiatric/mood disorders to include anxiety disorder, depression, and PTSD. An interview was conducted on 12/21/2022 at 1:25 p.m. with the Staff F, Transitional Care Manager (TCM), the facility's Social Services Director (SSD), and the facility's Director of Nursing (DON). Staff F, TCM stated she reviews all resident PASARR assessments prior to admission to the facility to ensure the completion of the PASARR and to verify any findings of the PASARR in comparison to the hospital paperwork. The resident's H&P and progress notes are reviewed and interviews are conducted with the resident and/or resident's family prior to admission to the facility to verify admitting information. Staff F, TCM stated if the PASARR assessment is discovered to be inaccurate during review, it would be sent back to the previous facility in order to be corrected. Staff F, TCM also stated if a resident had a history of PTSD or any other mental disorders, it should be documented on the resident's PASARR assessment. The SSD and DON reviewed Resident #9's PASARR assessment and addressed that the Resident #9's history of PTSD, anxiety, and depression were not documented on the assessment. A policy related to resident PASARR assessments was requested from the DON on 12/21/2022 at 12:28 p.m. The DON stated the facility did not have a policy related to the PASARR process.

Based on observations, record reviews, and interviews the facility failed to ensure a Self-Administration of Medication Evaluation was completed for one resident (#393) of thirty-six sampled residents prior to leaving medications at bedside for the resident to administer without the presence of nursing staff. Findings included: The Admission Record indicated Resident #393 was admitted on [DATE]. The record included diagnoses of unspecified chronic obstructive pulmonary disease, unspecified systemic lupus erythematosus, and a need for assistance with personal care. The Admission/5-day Minimum Data Set (MDS), dated [DATE], indicated Resident #393's Brief Interview for Mental Status (BIMS) score was 15 out of 15, identifying intact cognition. On 12/19/22 at 10:52 a.m., an observation was made of a medication cup containing a thick-looking golden liquid and a small bottle of a topical medication on the over-bed table in Resident #393's room. The medication cup was labeled [Room Number and Bed Identifier] and the resident was not in the room. (Photographic Evidence Obtained) An interview was conducted, at 10:59 a.m. on 12/19/22, with Staff E, Licensed Practical Nurse (LPN). Staff E stated Resident #393 had just left the facility with a family member and the liquid at bedside was Nystatin Swish and Swallow. She stated there should not be any medication at bedside and the staff member had administered 30 milliliters (mL) of Nystatin and Megace, then the resident had asked for a pain pill. Staff E stated she did not notice the resident had not taken all of the Nystatin and there should be three medication cups. Staff E reviewed the photographic evidence of the medications and confirmed the liquid was Nystatin Swish and Swallow and stated, That's not our bottle (of Nystop), you can look, ours don't look like that. On 12/19/22 at 12:05 p.m., Resident #393 was observed in the hallway of the unit speaking with another resident. Resident #393 stated, on 12/19/22 at 12:57 p.m., Oh that's my fault. The resident reported that Nystatin was supposed to be taken after her breathing treatment and a friend had come to take her out of the facility and the breathing treatment had been taken. The resident stated she had told the nurse that she would take the Nystatin Swish and Swallow but had not. A review of Resident #393's previous completed evaluations, on 12/19/22 at 2:26 p.m., revealed an Evaluation for the Self-Administration of Medications had not been completed. A review on 12/19/22 at 2:28 p.m. of the resident's care plan identified that a physician's order had been obtained to allow Resident #393 to self-administer Nystatin powder and instructed staff to assess the resident for the ability to self-administer the medication specified on the admission/re-admission, quarterly, with a change in resident medications, and with significant changes in condition. The review of physician orders, on 12/19/22 at 2:33 p.m. did not reveal the resident had a physician's order to allow for the self-administration of any medication. Staff B, LPN/Unit Manager confirmed, on 12/19/22 at 2:50 p.m., that Resident #393 did not have a physician's order allowing for the self-administration of medications but did have a care plan focus indicating there was a physician's order. On 12/19/22 at 2:57 p.m., the Director of Nursing (DON) reviewed the care plan and confirmed it said Resident #393 had a physician's order for the self-administration of Nystatin topical powder. She reviewed the current orders and confirmed there was no physician order regarding self-administration of medications. She stated the self-administration (assessment) would be conducted by either the therapy or nursing staff. She confirmed the evaluation of self-administration of medications could be done by nursing. She stated she could speak with the physician (regarding an order) for self-administration of medications. The DON did not respond on how the care plan team would know there was a physician order (without it being in the physician orders). The DON stated she would look for Resident #393's self-administration evaluation. On 12/19/22 at 3:27 p.m., a review was conducted of Resident #393's available evaluations. The review identified a Self-Administration Evaluation V2, effective on 12/19/22 at 3:02 p.m., was IN PROGRESS and the score was TBD (to be determined). The evaluation indicated the number of medications considered for self-administration was 1 and the order was for Nystatin powder. This evaluation was effective approximately 4 hours after the observation of the topical powder and Nystatin liquid left at Resident #393's bedside. The evaluation indicated that Interdisciplinary (IDT) met and resident can self-administer Nystatin powder safely and that a physician order had been obtained on 12/19/22. Resident #393's clinical record identified a Self administration of Medication Evaluation V2, effective 12/19/22 at 4:03 p.m., was completed to indicate the resident had been evaluated to administer 1 medication - nystatin swish and swallow. This evaluation was effective 5 hours after the observation of the medication, Nystatin Swish and Swallow had been left at Resident #393's bedside. The evaluation reported that IDT and nursing agree resident can safely self-administer the Nystatin Swish and Swallow, and a physician order had been obtained on 12/19/22. Resident #393's Self-Administration Evaluations, dated 12/19/22 at 3:02 p.m. and 4:03 p.m., identified, Complete this assessment prior to resident initiating self-administration of medication and with any medication order changes, change in function/condition that might affect the resident's ability to safely self administer medications. On going assessment should occur at a minimum quarterly. Use clinical judgement with section B to determine if or what level of self-administration will be allowed. The DON provided, on 12/19/22 at 4:12 p.m., a physician progress note, dated 12/19/22, that indicated Resident #393 could self-administer topical and oral meds. The DON reported the physician was an early bird. The physician order, dated 12/19/22 at 3:58 p.m., identified the resident may self-administer Nystatin powder and Nystatin swish and swallow. The policy title, Self Administration of Medication, copyrighted 2008, indicated the purpose was To provide evaluation process to determine if a resident is capable to self-administration. The procedure identified the following steps: - 1. If a resident desires to participate in self-administration, the interdisciplinary team will assess the competence of the resident to participate, by completing a Self Administration of Medication Evaluation. - 2. The nurse will interview the resident to determine their ability to identify, prepare, and administer Medications. - 3. Based on the interdisciplinary team's assessment, a decision is made as to whether or not the resident is a candidate for self-administration. This will be recorded on the Self Administration of Medication Evaluation. - 4. The nurse will obtain a physician's order for each resident conducting self-administration of medications. - 5. The nurse to educate the resident regarding reaction and side effects of the medication. - 6. Nurses will evaluate compliance of self-administration and document self-administration of medications in the Medication Administration Record (MAR). - 7. Storage of self-administered medications will comply with state and federal requirements for medication storage.

Based on observation, interview, and record review the facility failed to honor one resident's (#83) dignity by not providing appropriate customer service related to communication to the resident from a staff member out of thirty-six sampled residents. Findings included: The Admission Record revealed that Resident #83 was admitted initially on 5/27/20 and readmitted on [DATE]. The record included diagnoses not limited to major depressive disorder, need for assistance with personal care, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and unspecified anxiety disorder. The Admission/5-day Minimum Data Set (MDS), dated [DATE], identified Resident #83 as having a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. The MDS revealed the resident had no identified moods or behaviors, and required extensive assistance with bed mobility, dressing, and personal hygiene. The MDS indicated the resident was always incontinent of bladder and frequently incontinent of bowel requiring total assistance from 1-person for toileting needs. During an interview with Resident #83, on 12/20/22 at 9:58 a.m., the resident related that approximately two weeks prior the resident turned on the call light at 4:30 a.m. to be changed. She reported an unknown certified nursing assistant (CNA) arrived and informed the resident that she (the resident) should have waited another hour so the CNA could have sat for another hour. The resident reported on Thanksgiving night (2022) during the 11 p.m. - 7 a.m. shift, the CNA stated to the resident, It's people like you; why I can't be with my daughter today. On 12/21/22 at 12:56 p.m., Staff B, Licensed Practical Nurse/Unit Manager (LPN/UM) reported Resident #83 had voiced an issue about a CNA on the 11(p.m.)-7 (a.m.) shift, and that she (Staff B) filed a grievance on it, and had provided education (with staff). A review of the November and December 2022 Resident/Family Concern Log did not reveal a grievance had been filed on behalf of Resident #83 in regard to the statements made by the CNA. A continued interview was conducted, at 3:51 p.m. on 12/21/22, with Staff B. Staff B stated the incident occurred on the (past) weekend and a grievance had been written up on Monday (12/19/22). Staff B stated she wrote a grievance but did not remember exactly what it was about, thought it might have been over a brief change. Staff B asked if she could review the grievance and left the nursing station, returning a few minutes later. Staff B related that it seemed like the resident had had diarrhea and the resident had informed her that the CNA was not very nice to her, was not specific on the day it had occurred but it was on the night shift. Staff B stated Resident #83 was on 1-hour observations during the night and had filed a grievance. Staff B reported the resident had not complained of staff prior to this incident. Staff C, CNA stated on 12/21/22 at 3:59 p.m. Resident #83 had complained about the 11-7 shift and weekend staff. Staff C related the complaints were ongoing, involved other residents on the unit, and Resident #83 asked for something to be done and they (staff) did not want to do it. She stated in case of complaints she notified the nurse or Staff B, the unit manager. An interview was conducted, on 12/21/22 at 4:12 p.m., with the Nursing Home Administrator (NHA). The NHA reported a grievance had been filed related to Resident #83. She reported the resident reported call lights were not answered promptly and customer service could be better on the 11-7 shift. The NHA stated the resident was on 1-hour observations that are being documented and education had been provided for customer service. Resident #83's comments were reviewed with the NHA, who stated this was the first time hearing of it and she had not spoken with the resident lately. She stated that it would be easy to find out which staff member had said it and agreed the statement made on Thanksgiving was very specific. On 12/21/22 at 4:56 p.m., the NHA reported Resident #83 was sticking to the story, that it would be investigated, and she could not believe the resident had not said anything to anyone about it. The NHA stated the CNA, who the facility thought it was, had not worked since Thanksgiving. The NHA stated, on 12/22/22 at 9:15 a.m., the facility spoke with the suspected CNA, who reported she knew of the alleged incident and related bantering back and forth with Resident #83. The NHA stated a grievance had been completed for Resident #83 regarding the CNA. The NHA stated all staff had been interviewed and they had known of the incident, the supervisor on 11-7 shift had removed the CNA from the assignment and had not reported it to anyone as she thought she had handled it. The NHA stated the supervisor should have made the NHA aware of it, as it could have been handled three weeks ago. The policy titled, Person Centered Care Statement, copyrighted 2018, indicated that, The very core of Person Centered Care is about the relationships that exist between patients/residents, their loved ones, and staff. We promote patient/resident dignity and self-worth through honoring preferences and choices. The interpretation and implementation of the policy indicated, We support the choice of individually selected wake-up times and individualized morning routines and We support the choice of other individualized requests being honored in practice and documented in the plan of care.

Based on observation, record review, and interview, the facility failed to ensure 1. the medication regimen for one resident (#83) included medications with relevant diagnoses and 2. one resident (#93) received medications appropriately and per directions of the physician out of thirty-six sampled residents. Findings included: 1. The Admission Record for Resident #83 identified an initial admitted [DATE] and a readmission on 11/7/22. The record revealed diagnoses not limited to unspecified chronic obstructive pulmonary disease, and unspecified systolic (congestive) heart failure. The Admission/5-day Minimum Data Set (MDS), dated [DATE], identified Resident #83 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. The MDS indicated the resident received as needed pain medication. A review of Resident #83's active physician orders for December 2022 included the following physician orders: - Acetaminophen 325 milligram (mg) tablet - Give 2 tablet by mouth every 6 hours as needed for diagnosis (dx:) elevated temperature greater than 100 Fahrenheit (F) ** If given for fever, notify MD** Not to exceed (NTE) 3 gram (gm) per 24 hours. Give a total dose of 650 mg. This order started on 11/7/22. - Acetaminophen 325 mg - Give 2 tablet by mouth every 6 hours as needed for diagnosis (dx:) pain scale 1-10 Tylenol (APAP). Not to exceed 3 gm in 24 hours from all sources. - Tylenol 325 mg tablet (Acetaminophen) - Give 2 tablet by mouth every 8 hours for fever. This order started 12/12/22. A progress note, dated 12/12/22 at 7:07 a.m., indicated Resident #83 had a temperature of 104.4 F and the resident had received at 10:46 a.m. the as needed dose of Acetaminophen for fever. The scheduled 650 mg of Tylenol for fever order was to start at 2:00 p.m. on 12/12/22 and continue every 8 hours (6 a.m., 2 p.m. and 10 p.m.). The December 2022 Medication Administration Record (MAR) identified staff were documenting Resident #83's pain level when administering Tylenol for fever. The MAR indicated staff had administered 650 mg of Tylenol every 8 hours daily for the diagnosis of fever. The MAR indicated the resident had a temperature over 99 F three times during the month of December: 99.9 F during the night shift on 12/13, 99.1 F during the day shift on 12/15, and 99 F during the day shift on 12/15/22. A review of the Weights and Vital Summary identified that Resident #83's temperature exceeded 99 F during the month of December: one time on 12/12/22 at 10:46 a.m. (104.4 F), one time on 12/14/22 at 5:23 a.m. and 5:24 a.m. (99.9 F), and one time at 7:30 a.m. on 12/15/22 (99.1 F). The Advanced Registered Nurse Practitioner (ARNP) note, dated 12/12/22, indicated Resident #83 was positive for a fever of 102.9 F and the resident was lethargic, complained of cough, fatigue, muscle aches and dysuria. The note identified the resident was status post antibiotic treated for pseudomonas Urinary Tract Infection, found that morning (12/12/22), an oxygen saturation of 90%, and COVID swab was negative. The plan was to restart antibiotic until repeat urinalysis culture and sensitivity results, STAT (immediate) chest x-ray, STAT COVID swab, STAT respiratory panel including influenza A, B, and RSV (Respiratory syncytial virus), and to add Albuterol and oxygen treatments for hypoxia. The plan indicated to continue treatment for COPD exacerbation with nebulizer, oxygen and Medrol. The note did not include the addition of Tylenol to the resident's regimen. On 12/22/22 at 10:13 a.m., Staff D, Licensed Practical Nurse (LPN), stated Resident #83 was scheduled at 2 p.m. because last week the resident had spiked a fever. Staff D stated that it was not appropriate to give Tylenol for a diagnosis of fever if the resident was not running a fever but the physician did not give a stop date. On 12/22/22 at 10:49 a.m., the Director of Nursing (DON) stated the facility has an as needed standing order for Tylenol for the diagnoses of pain and fever. She stated she would have to clarify Resident #83's order and that staff probably did ask the physician (for clarification). The ARNP stated, on 12/22/22 at 11:53 a.m., she did remember the Tylenol order for Resident #83 and it was meant to be double for pain and fever, as it was a blanket order. She stated yes, the staff should have asked for the diagnosis to be clarified. 2. The Admission Record for Resident #93 identified an original admitted [DATE] with a readmission on 11/8/22. The record included the diagnoses of Parkinson's Disease, Irritable Bowel Syndrome without diarrhea, and rectal abscess. The Minimum Data Set (MDS) assessment, dated 11/12/22, identified a BIMS score of 15 out of 15, indicating intact cognition. The MDS revealed Resident #93 was always continent of bowel and not rated due to an indwelling catheter for bladder continence. Resident #93's MDS indicated the resident required extensive assistance from one person for dressing and toileting and limited one person assistance for transferring. On 12/19/22 at 1:38 p.m., Resident #93 reported having diarrhea for one week about two weeks ago, received Milk of Magnesia today, and he informed he was going to get an enema if no bowel movement (BM) today. The resident reported not having a BM for a week. Resident #93 reported, on 12/20/22 at 3:46 p.m., of just getting back into his wheelchair as he had been in the bathroom, commenting that he felt like I was going to [explicative] myself. The resident stated it was an ongoing issue - having diarrhea then getting a laxative. On 12/21/22 at 12:44 p.m., Resident #93 was sitting in his wheelchair and reported he had been sitting in his chair since 8 a.m. and no one had come from therapy. On 12/21/22 at 12:51 p.m., Staff B, Licensed Practical Nurse/Unit Manager (LPN/UM), stated Resident #93 did complain of bowels sometimes and received Milk of Magnesia when he complained of constipation. A review of the active physician orders, as of the 12/22/22, Medication Review Report, revealed the following bowel protocol orders: - Docusate Sodium 100 milligram (mg) tablet - Give 1 tablet by mouth at bedtime for bowel management. - Milk of Magnesia Concentrate Suspension (Magnesium Hydroxide) - Give 30 milliliter (mL) by mouth every 24 hours as needed for diagnosis (dx:) constipation. Administer if no BM for 3 days. Do not exceed more than 1 dose in 24 hours. If no response from MOM, administer Dulcolax supp(suppository) 10 milligram times 1 as needed (unless on Dialysis). - Bisacodyl -Evac Suppository 10 mg. Insert 1 dose rectally every 24 hours as needed for dx: constipation. Do not exceed 1 dose in 24 hours. Administer if no result from MOM. If no result from Dulcolax, administer Fleets enema rectally times 1 as needed. - Enema disposable enema - Insert 1 dose rectally every 24 hours as needed for dx: constipation. If no response from Dulcolax, administer a disposable enema if no result, notify MD. A review of the Certified Nursing Assistant (CNA) documentation of Resident #93's bowel continence indicated the following: - 12/9/22: medium sized loose/diarrhea at 10:06 p.m. - 12/10/22: large sized loose/diarrhea at 2:59 p.m. - 12/11/22: large sized loose/diarrhea at 4/16 a.m., 1:41 p.m., and twice at 1:43 p.m. - 12/12 and 12/13/22: no bowel movements - 12/14/22: large sized loose/diarrhea at 9:14 p.m. - 12/15/22: no bowel movement - 12/16/22: medium sized formed/normal at 10:14 a.m. - 12/17/22: medium sized loose/diarrhea at 2:59 p.m. - 12/18/22: large sized loose/diarrhea at 2:21 p.m. - 12/19/22: large sized formed/normal at 7:15 p.m. - 12/20/22: medium sized formed/normal at 12:41 p.m. and large sized formed/normal at 8:37 p.m. - 12/21/22: large sized loose/diarrhea at 8:43 p.m. A review of Resident #93's Medication Administration Record (MAR) for December 2022, indicated the resident was scheduled to receive Docusate Sodium at bedtime daily for bowel movement. The MAR identified the resident refused Docusate on 12/3, 12/4, and 12/18/22 and had been administered MOM at 7:47 a.m., following documentation on 12/18 of large sized loose/diarrhea, 12/17 of medium sized loose/diarrhea, and medium sized formed/normal bowel movement on 12/16/22. An interview was conducted on 12/22/22 at 10:15 a.m. with Resident #93's nurse, Staff D, LPN. The nurse reported that It's a big cycle, one day the resident may have diarrhea, the next day it might be constipation and staff give something to make him have a bowel movement. Staff D stated that Colace (Docusate) or Milk of Magnesia (MOM) should not be given if the resident was having diarrhea. Staff D reported that staff do not receive any notification on the electronic record if the residents have or have not had a bowel movement. The resident's nurse reported she has to just ask the aide if the resident has had a bowel movement and if not, she administers MOM, which was part of the facilities protocol. Staff D reviewed the CNA task documentation of bowel movements and stated she did not know she could look in the aide tasks tab for bowel information and does not get information in the nursing report related to bowel movements. The nurse confirmed the resident had diarrhea the night before (12/18), and he had been administered MOM by Staff B, LPN/UM. On 12/22/22 at 10:54 a.m., the Director of Nursing (DON) stated the facility has standing orders (for bowel management) which included Miralax, MOM, suppositories, and enemas. She stated typically or usually the facility will let residents know of the protocol and if they do not want the protocol, they offer alternatives. She stated MOM is given if no BM after 3 days, then a suppository, then an enema. She stated staff ask the residents daily if they have had a BM, assesses the resident, and (are) notified in report. The DON stated if a resident has diarrhea, the facility generally educates, if they are requesting it, it's given if they have a physician order for it. The DON reviewed Resident #93's medical record regarding the administration of MOM, administration of Colace, and physician orders and stated it would be an education piece to done related to the administration of MOM when the resident has diarrhea. The Director of Nursing stated, on 12/22/22 at 12:14 p.m., that she spoke with Resident #93 and he was aware of getting a stool softener every day and had requested MOM. She stated it was given per resident choice and that documentation should be done regarding education of the resident. The DON stated the facility does not have a policy regarding bowel and bladder management. On 12/22/22 at 2:05 p.m., Resident #93 reported getting a cup of pills that he had just taken and the stool softener was in the cup. The spouse of the resident stated the resident takes a stool softener twice a day and probably should not get it if having diarrhea but has always (done so). The spouse stated the resident gets confused and reports to her of not having a bowel movement in days. According to webmd.com (https://www.webmd.com/drugs/2/drug-323/docusate-sodium-oral/details), the use of Docusate Sodium treats occasional constipation as a stool softener. Docusate works by increasing the amount of water the stool absorbs in the gut, making the stool softer and easier to pass. The directions for use indicated to decrease your dose or stop taking this medication if you develop diarrhea. The website revealed that side effects of Docusate include stomach pain, diarrhea, or cramping and if any of these effects last or get worse, tell your doctor or pharmacist promptly and that your doctor has assessed that the benefit to you is greater than the risk of side effects. According to webmd.com (https://www.webmd.com/drugs/2/drug-146276/milk-of-magnesia-concentrated-oral/details) indicated that Milk of Magnesia was a laxative used to treat occasional constipation. Milk of Magnesia is thought to work by drawing water into the intestines. The website instructs users to use as directed and that overuse may also cause diarrhea that doesn't go away, dehydration, and mineral imbalances.

Based on record review, observations, interviews, medical record review and facility policy review the facility failed to ensure adequate supervision was provided to prevent an elopement of one resident (#1) out of five residents sampled for elopement. Resident #1 had diagnoses that included dementia and [CONDITION(S)] with collapse. The resident was known to ambulate freely through the facility. The resident was able to exit through a receptionist monitored door that did not have adequate supervision by staff to detect a resident from leaving unsupervised. Resident #1 was admitted to the facility after a four-day hospital admission. She had an episode of [CONDITION(S)] ([CONDITION(S)], or a sudden temporary loss of consciousness) while at an adult day care program and was taken to the hospital then transferred to the facility for short term rehabilitation. She was at risk for falls and was treated in the physical therapy department of the facility for poor safety awareness. She was prescribed oxygen at 3 liters per minute (lpm) continuously due low oxygen saturations from [CONDITION(S)] and acute [CONDITION(S)] with [CONDITION(S)]. The documentation on her cognition varied in the medical record. She was assessed as having no cognitive deficit on admission. Four days later she scored as having severe cognitive impairment on a mental status screening test; one day later her score on the same instrument with a different provider showed her to be cognitively intact. In multiple places in the facility medical record the resident is described and assessed as confused, or pleasantly confused and forgetful with short term and long-term memory impairments. On 04/04/2022 at approximately 11:00 a.m. Resident #1 exited through the therapy entrance, a receptionist monitored double set of sliding doors. Resident #1 entered the parking lot, then walked approximately 100 yards through a sloping parking lot, then another 100 yards down to a sidewalk. The sidewalk was directly adjacent to a four lane US Highway with no grass or shoulder in between the sidewalk and the road. The resident walked another 100 yards heading north then turned right and continued up a sloped driveway to the car port of a condominium. A Concerned Citizen (CC) approached, and the resident stated she was looking for her car. The CC transported the resident by car through at least two parking lots looking for the resident's vehicle. The CC observed police in the area and requested assistance. The police called EMS (Emergency Medical Services) who found the resident to be hypotensive, administered IV fluids and then transported Resident #1 to the hospital. The facility was notified by police, Resident #1 was in the hospital and the resident was returned to the facility from the hospital. The likelihood of physical harm or death to Resident #1 as a result of being able to exit the facility unsupervised resulted in the findings of Immediate Jeopardy beginning on 4/4/2022 and determined to be removed on 4/23/2022 and the scope and severity reduced to a D. Findings include: 1) A phone interview was conducted on 04/22/2022 at 10:32 a.m. with the CC who found Resident #1. She reported she lived near the facility in a condominium unit. She stated she was going to her car and when she came to the parking area, an elderly gentleman was talking to Resident #1. The CC stated the gentleman appeared upset and frazzled. She said the lady was just talking and talking. She stated the resident seemed ok; the resident was standing up and looked fine and was talking to the elderly gentleman. She said the resident told her she was looking for her car. The CC stated she walked with the resident to the parking lot and they could not find her car. The CC stated the resident told her she left the car parked where they were re-doing a swimming pool. The condominium complex next door was redoing their pool so she thought the resident may have been visiting over there. The CC asked the resident if it was okay to drive her around to find her car. The CC felt the resident was elderly, so she did not want her walking around. The CC stated the resident was not in distress, had no SOB (shortness of breath), and was not sweating at the time. The CC said the resident just looked like Oh, my I cannot find my car. She stated it was around 11:45 a.m. when she encountered the resident in the carport area. The CC stated she thought the resident may have walked out of the next-door parking lot and got into the wrong parking lot out of confusion. The CC asked the resident if she wanted to go with her to the other parking lot to see if they could find her car. The CC indicated the resident stated none of the red cars were hers. The CC explained the condominium is a gated community and people can get out but you cannot get in if you do not live there. The CC stated after driving to the end of the road, the resident still appeared confused. The CC stated she asked Resident #1 if she wanted her to call the police, and that upset the resident who responded, They are not going to arrest me, are they? The CC stated the resident seemed really upset. The CC said when the resident calmed down, she told her she had to go to the bank and asked the resident if she wanted to go, the resident replied yes. The CC stated the resident sat in the car while she was in the bank for 5 minutes. The CC stated the resident started talking about being at a shopping center, she could not believe the resident would cross a major street. The CC stated she took the resident to the parking lot with the theater. She stated they drove through and did not see the resident's car. The CC stated the resident then thought she had been in Lakeland with her children and told the CC her children were on vacation. The CC stated the resident could not tell her where her house was. The CC stated she was driving around the parking lot and saw three police officers standing there talking. She stated she stopped and talked to the police, who were very nice, around 12:30 p.m. and the resident stayed in the car. The CC stated the police took over and the resident became upset again about the police. She stated she held the resident's hand and gave her hugs, while the police were trying to get her name. She stated the resident could not even remember her name or how to spell her name. The CC stated she thought the resident was forgetful like her mother. The police found out she was stayed at (the facility), and by that time, EMS had come. She stated the resident had low B/P (blood pressure) and EMS took her to the hospital. The CC stated the resident did not want to leave her, so she went to the hospital, and they let her right into the back with the resident. The CC stated she stayed with the resident until (the facility) staff showed up at about 2 or 2:30 p.m. and she stayed until 3 or 3:30 p.m. She stated the resident did not know (the facility) people either. The CC stated in the ER (emergency room ) they started the resident on some IV (intravenous) fluids, and they would not release her until she had the fluids. The CC stated (the facility) people had to call the facility to see if they could wait on her, and they could, so it was (the facility) person and me who sat with the resident. The CC stated she stayed another ½ hour after (the facility staff) came and then she left. The CC stated she received a phone call from the Nursing Home Administrator (NHA) and the Director of Nursing (DON) from the facility the next day and they asked similar questions about the incident. The CC stated the facility has the resident on lock down now. On 04/20/2022 at 11:45 a.m. a phone interview was conducted with Resident #1's family member. She stated she became aware of Resident #1 leaving the facility on 04/04/2022 at a little after 1:00 p.m., the police called her to tell her she had been found at (local grocery store); they said she looked dehydrated. She stated she told them she was supposed to be back at the nursing home, and she gave them the name of the nursing home. The police told her they were transferring her to the hospital emergency room for an evaluation. Resident #1's family member said that prior to being admitted to the nursing home, the resident had been attending an Adult Day Care program. She said they had been doing this for a couple of months, to prepare her for the transition into the nursing home. She said the reason Resident #1 was at the Adult Day Care program was because she needed supervision. The family member stated back in October, the family was traveling, and the resident had an event where she wandered off. She stated this happened at a hotel and when the resident wandered from the hotel and was gone for 5 hours until the police found her. She stated the resident needed supervision in order to prevent her from wandering off. She stated no one ever asked her if Resident #1 had wandered off before at the time of admission or prior to the event occurring. She stated after the resident came home from the nursing home, she was readmitted to the Adult Day Care program, but then last Sunday (04/17/2022), she went to the hospital again, and was currently in the hospital. She stated she had talked to the DON on Monday, 04/18/2022, and she was considering placing the resident back at the facility, but she wanted to make sure she was not going to wander off again. The family member stated after the event, they put the resident on 1:1, placed a (wander monitoring device), implemented increased activities, and better hygiene practices. The DON was aware of her concerns. On 04/20/2022, 1:45 p.m., an interview was conducted with Staff E, Licensed Practical Nurse (LPN), she reported her assignment was the 100-hall area. During the interview, in the corner of the rear of the nursing station, a monitor was observed and in working condition. The monitor was observed to be showing real time footage of the therapy entrance exterior sliding doors. Staff E, LPN, confirmed staff could observe who was at the therapy entrance doors. She stated there was a button, and she pointed to a button in the rear of the nursing station and explained it was used after hours to open the doors. Staff E, LPN reported she first learned Resident #1 was not in the facility around noon on 04/04/2022. During med pass she heard them call an overhead page for the resident to come to her room. She stated she locked her cart and went to the nursing station, and they (Staff A, LPN) said they were looking for Resident #1 and doing room checks. Then, someone came in and said it was clear, she did not remember who said it was clear. They did not tell her where the resident was. Staff E, LPN reported after the event, she had received elopement training, and there was a new policy about leave of absence. She reported after the event, no training was conducted about the elopement assessment. She confirmed part of her responsibilities were to conduct admission assessments on newly admitted residents. She stated, for the admission assessment, I try to get information from the family; hospital records; the family is the most important person. The LPN stated further, On the admission assessment, there is a question on the demographic area, which prompts you to answer where you get the admission assessment information. Either family or the resident. She stated she was not sure if that applied to the elopement assessment. She stated, for a resident that has dementia or a wander risk, you can determine if they are ambulatory because this would mean more access, wheelchair mobility might be effective, continent, or incontinent, they might be looking for a bathroom. Staff E, LPN, pulled up an example resident on her computer and reviewed the Elopement/Neurological assessment on the admission evaluation. She pointed out; the assessment is done within 24 hours of admission. A score of 5 or greater means elopement risk. Each question has a number associated with it. She explained she would add up the score for the risk. She stated, if the resident were determined to be an elopement risk, she would tell the supervisor the resident scored as an elopement risk. She stated she would initiate an order for a wander guard. She stated there is a wander guard book. The TAR (Treatment Administration Record) would have the (wander monitoring device), check function on it. She confirmed if the (wander monitoring device) approaches the door, the doors should lock and there should be an alarm. On 04/20/2022 at 2:10 p.m. an interview was conducted with Staff A, LPN. She confirmed her assignment was the 200 hall and reported she first became aware of Resident #1 missing, around 12:00 p.m. (04/04/2022), during medication pass. Staff A, LPN, noticed her food had not been touched in her room. So, Staff A, LPN, went to the Bistro (that was where the food was set up), to see if the resident was there. Then, Staff A, LPN went to the therapy gym, checked to make sure that no one had taken the resident down there. As soon as Staff A, LPN, found out the resident was not there, she called an elopement by paging the resident's name three times over the overhead (pager), please return to your room. Then everyone started to look for the resident. Staff A, LPN, stated she went out to the perimeter (she clarified perimeter, meant she walked outside by [CONDITION(S)]), saying there was a pathway out there, just to see if the resident had gone out there; nothing. Then, Staff A, LPN came back into the building. Staff A, LPN, said she received a message all clear, which meant that they had found the resident. Staff A, LPN said, the Unit Manager, LPN, (Staff B) gave the message. Staff A, LPN, said the DON told her the resident had been found, she had been transferred to (a local hospital), she was going to be checked out, and then brought back to the facility. Staff A, LPN stated, this was the same day, though, she did not remember what time she received the information, but it was before the end of the shift, 3:00 p.m. Staff A, LPN, stated she did not know where the resident had been found. Staff A, LPN confirmed she did not document any information about the event in Resident #1's clinical chart. She stated she wrote her full statement on a report and gave it to the DON. Staff A, LPN, reported after the event, the training she had received was elopement training (policy and what to do), where to find the elopement demographic information, and the elopement book at the nurses' station. Staff A, LPN, said the [wander monitoring device] goes on when we have a resident who is an elopement risk, and we get the physician order. She confirmed this was so the sirens go off at the door and it would alert the staff, someone is trying to exit. Staff A, LPN, said, all the main exits have this feature, and this has not changed since the event. Staff A, LPN, said she did not do the admission assessment on the resident. She reported since the event, she had received training on the admission assessment, the way that they received the information for the assessment, by speaking with the families, to ask what the resident's baseline was, to go over the resident history, to ask all the questions on the assessment. Staff A, LPN reported, for documentation of the source of the information, there was a contact the family area on the form. She said, This area would be filled out to indicate you spoke with the family to obtain the resident history. Staff A, LPN, confirmed if the summary did not document the information for the assessment was obtained from the family, it would be assumed that the information came from the resident, and the contact with the family was just to notify them of the resident admission. Staff A, LPN, reported the resident wore oxygen and she was noncompliant with her oxygen. Staff A, LPN said, it was one of the challenges that we had with her, the resident was ambulatory, independent and yes, we would check her oxygen saturation levels every shift. On 04/20/2022 at 12:45 p.m., an interview was conducted with Staff D, Certified Nursing Assistant (CNA). She confirmed she was present on 04/04/2022 and her assignment was the 100- hall. Staff D, CNA stated, she found out about the resident leaving the facility because of the distress call to have everyone go and look for the resident. Staff D, CNA, reported, she participated in the search for the resident. Staff D, CNA, commented, Resident #1 would go from her room, she pointed to the room mid hall on the wing 200, to the door, look out, and then return either to her room, or sit in her w/c (wheelchair) at the nurses' station. Staff D, CNA, said, she saw the resident do this 2-3 times. Staff D, confirmed after the resident went missing, management asked about this. Staff D, CNA, confirmed, she received training, saying if a resident looks like they want to leave, it should be reported to the nurse. Staff D stated the training she received was that everyone had to check their section of the building for a patient. Everyone had to check in and out of the building, and they have new screeners. Staff D, CNA, said she could not recall who the aide was assigned to Resident #1 on 04/04/2022. On 04/21/2022 at 9:20 a.m., an interview was conducted with the Staffing Coordinator (SC). A review of the 04/04/2022 staffing schedule was conducted. SC reported she would have to research to see who replaced Staff J, CNA on 04/04/2022. She stated Staff J, CNA had called off, she would have been Resident #1's aide. The SC stated, when Resident #1 came back, we put her on 1:1, and then after, a sitter until she was discharged . The SC said, on 04/04/2022, there was a hunt for the resident, until it was cleared. The SC stated she heard the police found the resident, but she did not know the details. The SC further stated, the resident looked like you or me, normal. Yes, she was ambulatory, she would get up and go. The SC said, after the 04/04/2022, the resident was with a sitter, she was taken to activities, and got her hair done. The SC said, we were not going to let her just sit around. The SC said, the resident could do everything for herself, stating, The resident would walk around the building, and no one thought anything of it. It was a surprise (she eloped). On 04/21/2022 at 10:00 a.m., an interview was conducted with Staff K, PCA (Personal Care Assistant), on the phone. She confirmed she had worked on 04/04/2022 and had been assigned to the resident. She stated she had seen Resident #1 at the nurses' station about 11:30 a.m., and the resident was in a wheelchair. Staff K, PCA said the resident was capable of wheeling herself around. Staff K, PCA, reported she had taken the resident's meal tray in her bedroom, the resident was not in the room, she had set the meal tray on the roll around table and continued to deliver the trays. Staff K, PCA said, this was around 12:00 p.m. and she mentioned that it was her 2nd day on the hall. Staff K, PCA, stated, Resident #1 could hold a conversation with her, and she could walk around. Staff K, PCA, said, the reason she knew the resident could walk was because another CNA and she had taken the resident to the bathroom and she got up, and she said, Oh, she can walk. Staff K, PCA said, for my set (the room assignment), the mentor was Staff D, CNA, stating, She and I were assigned the same set, the 200 hall. Staff K, PCA reported another aide was working in the area, Staff I, CNA. Staff K, PCA reported, when the resident was noticed missing, she believed it was at the end of lunch time and she heard them call the code (over the pager system). Staff K, PCA reported she looked for the resident for 30-40 minutes before the search stopped, because of an announcement. Staff K, PCA, stated she normally worked on other halls. Staff K, PCA, said, she had seen the resident on prior occasions at the nurses' station or her room. The times she had seen her the resident had been sitting. Staff K, PCA, commented, the resident seemed so normal to me, like nothing different. An interview was conducted on 04/20/2022 at 3:45 p.m. with Staff C, PTA (Physical Therapy Assistant) and the DOR (Director of Rehabilitation). Staff C, PTA reported Resident #1 had her PT after OT on 04/04/2022 at about 10:00 a.m. Staff C, PTA said he worked with the resident in the rehabilitation gym and afterwards he took her back to her room. Staff C, PTA did not remember how he took her back to her room, whether with a walker or by a wheelchair. Staff C, PTA said, the resident was a little confused but pleasant, stating she was high level. He stated he was going to talk to the PT about getting her a walker. He said she wore oxygen, but she did not have the oxygen on 04/04/022 during therapy. The PTA stated, We were trying to wean her off the oxygen. Staff C, PTA said, his understanding was the resident did not have oxygen at the previous residence. Staff C, PTA stated the resident was taken back to her room before lunch, saying because when I got back from lunch, they were looking for her. The DOR and Staff C, PTA verified the resident's oxygen order was to be continuous at 3 liters per minute. They reported, when ordered like that, if in therapy, we will take them down (remove the oxygen) during therapy to start weaning her off (the oxygen). The DOR, stated, we would have the nurse and physician approval to wean a resident. Staff C, PTA, stated he took her back down to her room, sat her on the bed side, put her oxygen on and call light within reach. He stated she had on regular clothes, shoes, or sticky socks. Then he left the room. Staff C, PTA reported, he found out she was missing when he got back from lunch at approximately 1:00 p.m. The PTA said he was in his car eating lunch, and he did not see her walk by. Staff C, PTA said. they did the announcement overhead and everyone started looking for her. He stated he did not have a specific role for elopements, but the resident was not in the gym. He stated he walked down to the Bistro to see if she was there. got a call the resident had been admitted to the hospital. Staff C reported, for training after the event, management went over if a resident is going to leave, they need to have a Pink Slip and sign out, and turn it in when they come back in, and they were instructed if a resident leaves on the 11-7 shift, someone has to escort them to and from the facility. On 04/20/2022 at 1:44 p.m., an interview was conducted with the DOR, Speech Therapist (ST), the Assistant Director of Rehab (ADOR), and the Certified Occupational Therapy Assistant (COTA). The ADOR stated, Resident #1 was receiving skilled services (therapy sessions) for [CONDITION(S)] and collapse. The ADOR said the resident, upon admission, was assessed for mobility, Activities of Daily Living (ADL), and cognitive ability and as a result, the resident was ordered therapy for those deficits, which included PT (physical therapy) five times a week, OT (occupational therapy) five times a week and ST (speech therapy) four times a week. The DOR stated the resident was seen for ambulation due to poor safety awareness. The resident presented on admission as requiring minimal assistance, and by the time of discharge the resident was supervision to contact guard assistance for ambulation. The DOR stated, the resident had progressed to being able to ambulate with a two wheeled walker but not safely. The DOR reported, Staff C, Physical Therapist Assistant (PTA) was her PT (Physical Therapist) and Staff G, was her OT (Occupational Therapist). The DOR reported the therapists provided services with the resident the morning of 04/04/2022. ST (Speech Therapist) did not see her that day. The DOR reviewed the resident's therapy performance notes for the morning of 04/04/2022, which included the resident had ambulated with the PT for 150 feet with a 2 wheeled walker, standby assist was provided with 15% verbal cues to promote safety awareness and obstacle negotiation. The PT also worked on the resident's lower body strength with exercises, transfers, and standing tolerance while maintaining balance. The DOR stated the OT worked on the resident's ADLs of the upper and lower body. The task of upper dressing required supervision with stand by assist for the lower body. The DOR said, the therapists completed ADL tasks at the edge of the bed and extra time was provided due to SOB (shortness of breath). She was wearing oxygen via nasal canula at 3 liters / minute. Her oxygen saturation was monitored both pre and post task. The DOR stated, Resident #1 was provided stand-by-assist for ROM (range of motion) and transfers from bed to wheelchair with safety awareness cues provided during the task. The resident was provided upper extremity exercise using the (exercise) equipment with rest breaks provided due to fatigue and SOB. The DOR stated, the therapy entrance doors have a security function now and they had companies come and fixed the doors. She said based on the video the resident went out those doors (therapy entrance doors). The DOR reported she was not aware if she went out walking or with a wheelchair, or walker. The DOR stated, she may have not used a walker, she may have just walked out. She was in room (#), which was only two hallways away. On 04/22/2022 at 11:06 p.m., an interview was conducted with the Social Services Director (SSD). She confirmed she had assessed Resident #1 related to the resident's history, and advanced directives. She stated, she would do education with them, related to advance directives, resident rights, and discharge planning. She said typically, this was done within 0-7 days from the admission. The SSD confirmed she conducted the 03/21/2022 and 04/06/2022 assessments for Resident #1, and she had interviewed the resident for the assessments. The SSD said, Resident #1 said she was living alone at home, and she was here for rehab. The SSD said the resident had short term and long-term memory impairment, but was cooperative, appeared friendly, and she had a vision challenge. The SSD stated, she asked the resident about important life roles, and the resident could not really answer. The SSD said it would take a higher level of thinking to answer those questions. The SSD said the resident was her own decision maker and she had obtained this information from the resident and chart. The SSD said, the Discharge Plan for Resident #1 was for her to return home, which was the prior living arrangement. The SSD stated she had a lengthy conversation with the family member on 03/25/2022 regarding insurance. The SSD clarified the discharge plan for the resident was discussed, and an Assisted Living Facility (ALF) was discussed. The SSD stated she did not recall asking the family member if the resident was her own decision maker. The SSD stated, if there was nothing documented indicating the resident was not their own decision maker, they were their own decision maker. The SSD confirmed her assessment was conducted on 03/21/2022, and it did not mention the adult day care program. The SSD said during the conversation conducted with the family member on 03/25/2022, the adult day care participation of the resident did not come up. The SSD stated after the elopement, during a discharge planning phone call conversation with the designated discharge planning facility's representative, was when she found out the resident had participated in a day care program. On 04/20/22 at 4:11 p.m., an interview was conducted with Staff F, Registered Nurse (RN) with the DON present. Staff F, RN, confirmed she had completed the admission evaluation for Resident #1 on 03/18/2022 and the evaluation was done at 7:20 p.m. She reported the information for the admission evaluation was obtained from the nurse-to-nurse report given from the hospital, the chart information, and the packet when the resident came in. Staff F, RN reported she performs a direct assessment and interview, face to face during the evaluation. During the interview, Resident #1's admission evaluation was reviewed. Staff F, RN, reported to answer the level of consciousness for the resident, she did an interview with the resident, and it consisted of if they are alert (name, where they came from, where she is now, here for rehabilitation). For the cognitive deficit decision area, Staff F, RN, said when the resident first comes in, if there is not a diagnosis from the hospital record, she would have to observe the resident. Staff F, RN, stated a diagnosis such as dementia, may be mentioned on the nurse-to-nurse call, or on the paperwork. When completing the evaluation, if there was a not a cognitive deficit, the no box would be marked, and if there was a cognitive deficit, the yes box would be marked; it would score the evaluation and give you another drop down box and prompt you to look at an elopement care plan. The DON reported training was done during orientation with the admission evaluation, and if we find someone was not doing admissions correctly they would do one-on-one with the employee. The DON felt the admission evaluation completed on 03/18/2022 for Resident #1 was accurate. A review of Resident #1's record from the hospital, the AHCA 3008 form and the Medical Doctor's orders, which had been available at the time of the admission evaluation was reviewed with Staff F, RN. She said she looked at those, and stated, I would have assessed the resident for dementia, and cognition. She said, the resident's family came in the night of the admission. Staff F, RN, reported she talked about oxygen with them, and she stated she would have asked about her wandering, and her home situation. Staff F, RN, stated the AHCA 3008 form did say to order a walker, we would not decide (to order the walker) until after I had seen her. Due to [CONDITION(S)] episode, we would not want her to ambulate alone. On 04/21/22 at 10:14 a.m. an interview was conducted with the Maintenance Director (M Dir). He stated all facility exits have wander monitoring device systems, on all 11 doors. He said these were checked daily for the functionality in general. The M Dir confirmed, a log of the daily checks was kept in the building management software system. The M Dir. reported the doors were checked within the 7 days prior to 04/04/2022. He stated the wander monitoring device alarm would sound and they were loud. The M Dir said When the alarm happens, we are supposed to report to the exit, go outside the exit and look, report to the DON, perform a resident head count, and go out and look in the immediate area. The alarm was to alert the staff to come to that area to check on the resident. The siren part was working on the 04/04/2022. It was a standalone system on the doors/ [wander monitoring alarm device]. The [Company name] glass and door came out, they tested the doors, the doors would shut and lock with the software. The M Dir said they had to replace the locking system on the doors. The M Dir stated the facility video was real time and it had a playback system, with the camera was positioned on the outside door. He said the interior therapy entrance door camera was down. He stated, the management team did look at the video replay, and confirmed he watched the video as well, he could see the resident had walked up to the doors, the doors opened, and she walked out. He stated, the resident walked normal, walked to the edge of the parking lot, she stood there a while, then we lost her because she walked out the camera [range]. For the missing resident response, the M Dir reported, they paged overhead three times for the resident to come back to her room. He said the video box showed 10:30 a.m. as the time of exit and stated, but it was actually around 12:00 p.m. something or 1:00 p.m., right after lunch. The M Dir said he could not remember the page time, stating We dropped everything and reacted, my assistant and I searched the property, while the other staff were inside. An observation, conducted on 04/21/22 at 10:35 a.m. of the therapy entrance doors near the Rehabilitation Therapy gym, with the M Dir. He used a wander monitoring transmitter device to activate the doors, and the alarms went off and continued until he reset the system. He then exited the building and stated, Resident #1 walked out without a walker, per what was seen on the cameras. Continuing, he [TRUNCATED]

Based on record review, observations, interviews, and facility policy review the facility failed to report to the Adult Protective Services Agency a failure to provide adequate supervision to prevent an unwitnessed and unsupervised exit from the facility for one (#1) of five sampled residents. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was known to ambulate freely through the facility. The resident was able to exit through a receptionist monitored door that did not have adequate supervision by staff to detect a resident from leaving unsupervised. Resident #1 was admitted to the facility after a four-day hospital admission. She had an episode of [CONDITION(S)] ([CONDITION(S)], or a sudden temporary loss of consciousness) while at an adult day care program and was taken to the hospital then transferred to the facility for short term rehabilitation. She was at risk for falls and was treated in the physical therapy department of the facility for poor safety awareness. She was prescribed oxygen at 3 liters per minute (lpm) continuously due low oxygen saturations from [CONDITION(S)] and acute respiratory failure with [CONDITION(S)]. The documentation on her cognition varied in the medical record. She was assessed as having no cognitive deficit on admission. Four days later she scored as having severe cognitive impairment on a mental status screening test; one day later her score on the same instrument with a different provider showed her to be cognitively intact. In multiple places in the facility medical record the resident is described and assessed as confused, or pleasantly confused and forgetful with short term and long-term memory impairments. On 04/04/2022 at approximately 11:00 a.m. Resident #1 exited through the therapy entrance, a receptionist monitored double set of sliding doors. Resident #1 entered the parking lot, then walked approximately 100 yards through a sloping parking lot, then another 100 yards down to a sidewalk. The sidewalk was directly adjacent to a four lane US Highway with no grass or shoulder in between the sidewalk and the road. The resident walked another 100 yards heading north then turned right and continued up a sloped driveway to the car port of a condominium. A Concerned Citizen (CC) approached, and the resident stated she was looking for her car. The CC transported the resident by car through at least two parking lots looking for the resident's vehicle. The CC observed police in the area and requested assistance. The police called EMS (Emergency Medical Services) who found the resident to be hypotensive, administered IV fluids and then transported Resident #1 to the hospital. The facility was notified by police, Resident #1 was in the hospital and the resident was returned to the facility from the hospital. The likelihood of physical harm or death to Resident #1 as a result of being able to exit the facility unsupervised resulted in the findings of Immediate Jeopardy beginning on 4/4/2022 and determined to be removed on 4/23/2022 and the scope and severity reduced to a D. Findings include: 1) A review of the Resident Mistreatment, Abuse and Neglect Prohibition, copyright 2017, Clear Choice Health Care, documented the Purpose: This facility is committed to protecting the physical and emotional well-being and personal possessions of every resident. Each facility has systems, procedures and a program of employee training and supervision in place to foster dignified treatment, respect, and compassion for residents. Any form of mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . All allegations of mistreatment, abuse, neglect, injuries of unknown origin and misappropriation of resident property are to be reported immediately and investigated by the Administrator, Risk Manager, or designee. The Guidelines included . Training: Upon hire, annually, and additionally if determined appropriate by facility management, each employee will be trained on the following topics: Resident mistreatment, neglect and abuse Prohibition guidelines; Appropriate interventions to deal with aggressive and/or potentially dangerous behaviors; What constitutes mistreatment, abuse, neglect, unreasonable confinement, injuries of unknown origin and misappropriation of resident property; How to recognize signs of burnout, frustration and stress that may lead to abuse; Employee responsibilities as a mandated reporter; How staff should report their knowledge of allegations without fear of reprisal . Definitions included: .Mandated reporter includes any person who has assumed full or intermittent responsibility for care or custody of an elderly person, whether or not that person receives compensation, such as administrators, supervisors, and any licensed staff of a facility that provides care or services for elderly adults, or any care custodian, health practitioner, clergy member, or employee of a county adult protection services agency or local law enforcement agency. Mandated reporting is a legal obligation for mandated reporters to formally report suspected, believed, or witnessed abuse, neglect or mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Neglect is failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness . Prevention: Each facility is required to identify, correct, and intervene in situations where abuse, neglect, and/or misappropriation of resident property are likely to occur, or are suspected to have occurred. Each facility should identify, analyze, and assess the following situations to minimize the likelihood of prohibited behaviors occurring. Areas of the physical environment that may make abuse or neglect more likely to occur, such as secluded areas of the facility. The facility, to the best of its ability, will take appropriate steps so that personnel are provided in sufficient numbers, with adequate knowledge to meet the individual needs of residents. Staff shall be regularly monitored to determine whether inappropriate behaviors are occurring such as derogatory language, rough handling, ignoring resident while giving care, or directing residents who need toileting assistance to urinate or defecate in their beds. Behaviors or interactions with individuals not directly employed by the facility (including family, visitors, contractors, etc.) which prompt concern or suspicion over resident abuse or misappropriation of resident property should be monitored, and interventions put in place as appropriate. Assess care plan and monitor residents with needs or behaviors that my likely lead to conflict, altercation, abuse, or neglect, such as residents: Exhibiting physically aggressive or self-injurious behaviors; Exhibiting verbally abusive behavior towards others; Exhibiting socially inappropriate or disruptive behaviors; Wandering an/or entering the rooms or personal space of others; or with communication disorders. Identification: Residents, families, and staff shall be informed that they may report any concerns, incidents, or grievances without fear of reprisal or retribution. The facility goal is to assure that any person making such a report is provided a non-threatening environment, and anonymity (if desired) to express identified concerns, with feed-back regarding the concerns expressed. Facility practices which assist in monitoring/ identifying potential abuse and neglect include but are not limited to: grievances; complaint-resolution processes; facility theft and loss reporting; resident council; incident reporting; internal audits of resident trust accounts; daily staffing practices; and regular direct/indirect supervision of nursing home employees and resident care by Supervisory and Administrative staff. Investigation: Each facility will thoroughly investigate injuries of unknown origin and any suspected or alleged abuse, neglect, misappropriation of resident property in accordance with federal and state regulations. The electronic incident report and investigation system forms (name of system) should be completed for all incidents of suspected or alleged m8istreatment, abuse, neglect, misappropriation of resident property and for injuries of unknown origin. Protection: To protect residents and employees from harm or retribution during an investigation each facility should ensure that: Measures are promptly taken to remove any resident from immediate harm or danger as indicated; Staff member(s) believed to be involved may be suspended pending the outcome of an investigation; If resident-to resident abuse is witnessed or alleged, reasonable measures are taken to separate the residents involved; If family or visitors are suspected, the facility reserves the right to prevent, restrict, or require supervised visitation while investigative efforts commence. Reporting/Response: Regulations require employees who provide services to elderly persons and dependent adults (mandatory reports) to report instances of abuse neglect, exploitation or mistreatment, injuries of an unknown source and misappropriation of resident property. If the events that cause the allegation involve abuse or result in serious bodily harm, the allegations must be reported immediately, but not later than two hours after the allegation is made. All events that cause the allegation that do not involve abuse and do not result in serious bodily injury must be reported not later than 24 hours after the allegation is made. Quality Assurance and Performance Improvement: All incident information such as investigative forms, witness interviews, information reported to state or other agencies, and any other pertinent information should be maintained in a separate, locked file as these documents are prepared as an integral part of the quality Assurance & performance improvement Committee to identify, assess and evaluation, through self-critical analysis, quality and care issues and to develop initiatives for the improvement of care and quality of life for our residents. On 04/20/2022 at 11:30 a.m. an interview was conducted with the NHA. She reported Resident #1, had an unplanned exit from the facility. She reported she did not file an abuse report, or federal report for the event. She reported no one saw the resident leave the facility, and stated it was believed the resident left through the entrance doors near the therapy end of the building. She stated the resident was not identified as a wanderer; she showed no exit seeking behaviors. She stated the resident had been in therapy that morning, and she had been taken back to the room. She stated the resident was pushed in a wheelchair, but she was also ambulatory, and she would go around the facility on her own. At lunch, Staff A, LPN, (Licensed Practical Nurse) noticed the resident's lunch was not eaten. This was around 12:15 p.m. The NHA stated when the resident was noticed missing, they did a missing person drill. The NHA confirmed she was not in the building at the time of the event, but the DON and Regional Nurse, RN (Registered Nurse) were in the building. She went on to state the resident walked out of the therapy (entrance) door, toward the back parking lot, and a tenant in the adjacent property then took the resident around looking for her car. A phone interview was conducted on 04/22/2022 at 10:32 a.m. with the CC who found Resident #1. She reported she lived near the facility in a condominium unit. She stated she was going to her car and when she came to the parking area, an elderly gentleman was talking to Resident #1. The CC stated the gentleman appeared upset and frazzled. She said the lady was just talking and talking. She stated the resident seemed ok; the resident was standing up and looked fine and was talking to the elderly gentleman. She said the resident told her she was looking for her car. The CC stated she walked with the resident to the parking lot and they could not find her car. The CC stated the resident told her she left the car parked where they were re-doing a swimming pool. The condominium complex next door was redoing their pool so she thought the resident may have been visiting over there. The CC asked the resident if it was okay to drive her around to find her car. The CC felt the resident was elderly, so she did not want her walking around. The CC stated the resident was not in distress, had no SOB (shortness of breath), and was not sweating at the time. The CC said the resident just looked like Oh, my I cannot find my car. She stated it was around 11:45 a.m. when she encountered the resident in the carport area. The CC stated she thought the resident may have walked out of the next-door parking lot and got into the wrong parking lot out of confusion. The CC asked the resident if she wanted to go with her to the other parking lot to see if they could find her car. The CC indicated the resident stated none of the red cars were hers. The CC explained the condominium is a gated community and people can get out but you cannot get in if you do not live there. The CC stated after driving to the end of the road, the resident still appeared confused. The CC stated she asked Resident #1 if she wanted her to call the police, and that upset the resident who responded, They are not going to arrest me, are they? The CC stated the resident seemed really upset. The CC said when the resident calmed down, she told her she had to go to the bank and asked the resident if she wanted to go, the resident replied yes. The CC stated the resident sat in the car while she was in the bank for 5 minutes. The CC stated the resident started talking about being at a shopping center, she could not believe the resident would cross a major street. The CC stated she took the resident to the parking lot with the theater. She stated they drove through and did not see the resident's car. The CC stated the resident then thought she had been in Lakeland with her children and told the CC her children were on vacation. The CC stated the resident could not tell her where her house was. The CC stated she was driving around the parking lot and saw three police officers standing there talking. She stated she stopped and talked to the police, who were very nice, around 12:30 p.m. and the resident stayed in the car. The CC stated the police took over and the resident became upset again about the police. She stated she held the resident's hand and gave her hugs, while the police were trying to get her name. She stated the resident could not even remember her name or how to spell her name. The CC stated she thought the resident was forgetful like her mother. The police found out she was stayed at (the facility), and by that time, EMS had come. She stated the resident had low B/P (blood pressure) and EMS took her to the hospital. The CC stated the resident did not want to leave her, so she went to the hospital, and they let her right into the back with the resident. The CC stated she stayed with the resident until (the facility) staff showed up at about 2 or 2:30 p.m. and she stayed until 3 or 3:30 p.m. She stated the resident did not know (the facility) people either. The CC stated in the ER (emergency room ) they started the resident on some IV (intravenous) fluids, and they would not release her until she had the fluids. The CC stated (the facility) people had to call the facility to see if they could wait on her, and they could, so it was (the facility) person and me who sat with the resident. The CC stated she stayed another ½ hour after (the facility staff) came and then she left. The CC stated she received a phone call from the Nursing Home Administrator (NHA) and the Director of Nursing (DON) from the facility the next day and they asked similar questions about the incident. The CC stated the facility has the resident on lock down now. On 04/20/2022 at 11:45 a.m. a phone interview was conducted with Resident #1's family member. She stated she became aware of Resident #1 leaving the facility on 04/04/2022 at a little after 1:00 p.m., the police called her to tell her she had been found at (local grocery store); they said she looked dehydrated. She stated she told them she was supposed to be back at the nursing home, and she gave them the name of the nursing home. The police told her they were transferring her to the hospital emergency room for an evaluation. Resident #1's family member said that prior to being admitted to the nursing home, the resident had been attending an Adult Day Care program. She said they had been doing this for a couple of months, to prepare her for the transition into the nursing home. She said the reason Resident #1 was at the Adult Day Care program was because she needed supervision. The family member stated back in October, the family was traveling, and the resident had an event where she wandered off. She stated this happened at a hotel and when the resident wandered from the hotel and was gone for 5 hours until the police found her. She stated the resident needed supervision in order to prevent her from wandering off. She stated no one ever asked her if Resident #1 had wandered off before at the time of admission or prior to the event occurring. She stated after the resident came home from the nursing home, she was readmitted to the Adult Day Care program, but then last Sunday (04/17/2022), she went to the hospital again, and was currently in the hospital. She stated she had talked to the DON on Monday, 04/18/2022, and she was considering placing the resident back at the facility, but she wanted to make sure she was not going to wander off again. The family member stated after the event, they put the resident on 1:1, placed a (wander monitoring device), implemented increased activities, and better hygiene practices. The DON was aware of her concerns. On 04/20/2022, 1:45 p.m., an interview was conducted with Staff E, Licensed Practical Nurse (LPN), she reported her assignment was the 100-hall area. During the interview, in the corner of the rear of the nursing station, a monitor was observed and in working condition. The monitor was observed to be showing real time footage of the therapy entrance exterior sliding doors. Staff E, LPN, confirmed staff could observe who was at the therapy entrance doors. She stated there was a button, and she pointed to a button in the rear of the nursing station and explained it was used after hours to open the doors. Staff E, LPN reported she first learned Resident #1 was not in the facility around noon on 04/04/2022. During med pass she heard them call an overhead page for the resident to come to her room. She stated she locked her cart and went to the nursing station, and they (Staff A, LPN) said they were looking for Resident #1 and doing room checks. Then, someone came in and said it was clear, she did not remember who said it was clear. They did not tell her where the resident was. Staff E, LPN reported after the event, she had received elopement training, and there was a new policy about leave of absence. She reported after the event, no training was conducted about the elopement assessment. She confirmed part of her responsibilities were to conduct admission assessments on newly admitted residents. She stated, for the admission assessment, I try to get information from the family; hospital records; the family is the most important person. The LPN stated further, On the admission assessment, there is a question on the demographic area, which prompts you to answer where you get the admission assessment information. Either family or the resident. She stated she was not sure if that applied to the elopement assessment. She stated, for a resident that has dementia or a wander risk, you can determine if they are ambulatory because this would mean more access, wheelchair mobility might be effective, continent, or incontinent, they might be looking for a bathroom. Staff E, LPN, pulled up an example resident on her computer and reviewed the Elopement/Neurological assessment on the admission evaluation. She pointed out; the assessment is done within 24 hours of admission. A score of 5 or greater means elopement risk. Each question has a number associated with it. She explained she would add up the score for the risk. She stated, if the resident were determined to be an elopement risk, she would tell the supervisor the resident scored as an elopement risk. She stated she would initiate an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The TAR (Treatment Administration Record) would have the (wander monitoring device), check function on it. She confirmed if the (wander monitoring device) approaches the door, the doors should lock and there should be an alarm. On 04/20/2022 at 2:10 p.m. an interview was conducted with Staff A, LPN. She confirmed her assignment was the 200 hall and reported she first became aware of Resident #1 missing, around 12:00 p.m. (04/04/2022), during medication pass. Staff A, LPN, noticed her food had not been touched in her room. So, Staff A, LPN, went to the Bistro (that was where the food was set up), to see if the resident was there. Then, Staff A, LPN went to the therapy gym, checked to make sure that no one had taken the resident down there. As soon as Staff A, LPN, found out the resident was not there, she called an elopement by paging the resident's name three times over the overhead (pager), please return to your room. Then everyone started to look for the resident. Staff A, LPN, stated she went out to the perimeter (she clarified perimeter, meant she walked outside by [CONDITION(S)]), saying there was a pathway out there, just to see if the resident had gone out there; nothing. Then, Staff A, LPN came back into the building. Staff A, LPN, said she received a message all clear, which meant that they had found the resident. Staff A, LPN said, the Unit Manager, LPN, (Staff B) gave the message. Staff A, LPN, said the DON told her the resident had been found, she had been transferred to (a local hospital), she was going to be checked out, and then brought back to the facility. Staff A, LPN stated, this was the same day, though, she did not remember what time she received the information, but it was before the end of the shift, 3:00 p.m. Staff A, LPN, stated she did not know where the resident had been found. Staff A, LPN confirmed she did not document any information about the event in Resident #1's clinical chart. She stated she wrote her full statement on a report and gave it to the DON. Staff A, LPN, reported after the event, the training she had received was elopement training (policy and what to do), where to find the elopement demographic information, and the elopement book at the nurses' station. Staff A, LPN, said the [wander monitoring device] goes on when we have a resident who is an elopement risk, and we get the physician order. She confirmed this was so the sirens go off at the door and it would alert the staff, someone is trying to exit. Staff A, LPN, said, all the main exits have this feature, and this has not changed since the event. Staff A, LPN, said she did not do the admission assessment on the resident. She reported since the event, she had received training on the admission assessment, the way that they received the information for the assessment, by speaking with the families, to ask what the resident's baseline was, to go over the resident history, to ask all the questions on the assessment. Staff A, LPN reported, for documentation of the source of the information, there was a contact the family area on the form. She said, This area would be filled out to indicate you spoke with the family to obtain the resident history. Staff A, LPN, confirmed if the summary did not document the information for the assessment was obtained from the family, it would be assumed that the information came from the resident, and the contact with the family was just to notify them of the resident admission. Staff A, LPN, reported the resident wore oxygen and she was noncompliant with her oxygen. Staff A, LPN said, it was one of the challenges that we had with her, the resident was ambulatory, independent and yes, we would check her oxygen saturation levels every shift. On 04/20/2022 at 12:45 p.m., an interview was conducted with Staff D, Certified Nursing Assistant (CNA). She confirmed she was present on 04/04/2022 and her assignment was the 100- hall. Staff D, CNA stated, she found out about the resident leaving the facility because of the distress call to have everyone go and look for the resident. Staff D, CNA, reported, she participated in the search for the resident. Staff D, CNA, commented, Resident #1 would go from her room, she pointed to the room mid hall on the wing 200, to the door, look out, and then return either to her room, or sit in her w/c (wheelchair) at the nurses' station. Staff D, CNA, said, she saw the resident do this 2-3 times. Staff D, confirmed after the resident went missing, management asked about this. Staff D, CNA, confirmed, she received training, saying if a resident looks like they want to leave, it should be reported to the nurse. Staff D stated the training she received was that everyone had to check their section of the building for a patient. Everyone had to check in and out of the building, and they have new screeners. Staff D, CNA, said she could not recall who the aide was assigned to Resident #1 on 04/04/2022. On 04/21/2022 at 9:20 a.m., an interview was conducted with the Staffing Coordinator (SC). A review of the 04/04/2022 staffing schedule was conducted. SC reported she would have to research to see who replaced Staff J, CNA on 04/04/2022. She stated Staff J, CNA had called off, she would have been Resident #1's aide. The SC stated, when Resident #1 came back, we put her on 1:1, and then after, a sitter until she was discharged . The SC said, on 04/04/2022, there was a hunt for the resident, until it was cleared. The SC stated she heard the police found the resident, but she did not know the details. The SC further stated, the resident looked like you or me, normal. Yes, she was ambulatory, she would get up and go. The SC said, after the 04/04/2022, the resident was with a sitter, she was taken to activities, and got her hair done. The SC said, we were not going to let her just sit around. The SC said, the resident could do everything for herself, stating, The resident would walk around the building, and no one thought anything of it. It was a surprise (she eloped). On 04/21/2022 at 10:00 a.m., an interview was conducted with Staff K, PCA (Personal Care Assistant), on the phone. She confirmed she had worked on 04/04/2022 and had been assigned to the resident. She stated she had seen Resident #1 at the nurses' station about 11:30 a.m., and the resident was in a wheelchair. Staff K, PCA said the resident was capable of wheeling herself around. Staff K, PCA, reported she had taken the resident's meal tray in her bedroom, the resident was not in the room, she had set the meal tray on the roll around table and continued to deliver the trays. Staff K, PCA said, this was around 12:00 p.m. and she mentioned that it was her 2nd day on the hall. Staff K, PCA, stated, Resident #1 could hold a conversation with her, and she could walk around. Staff K, PCA, said, the reason she knew the resident could walk was because another CNA and she had taken the resident to the bathroom and she got up, and she said, Oh, she can walk. Staff K, PCA said, for my set (the room assignment), the mentor was Staff D, CNA, stating, She and I were assigned the same set, the 200 hall. Staff K, PCA reported another aide was working in the area, Staff I, CNA. Staff K, PCA reported, when the resident was noticed missing, she believed it was at the end of lunch time and she heard them call the code (over the pager system). Staff K, PCA reported she looked for the resident for 30-40 minutes before the search stopped, because of an announcement. Staff K, PCA, stated she normally worked on other halls. Staff K, PCA, said, she had seen the resident on prior occasions at the nurses' station or her room. The times she had seen her the resident had been sitting. Staff K, PCA, commented, the resident seemed so normal to me, like nothing different. An interview was conducted on 04/20/2022 at 3:45 p.m. with Staff C, PTA (Physical Therapy Assistant) and the DOR (Director of Rehabilitation). Staff C, PTA reported Resident #1 had her PT after OT on 04/04/2022 at about 10:00 a.m. Staff C, PTA said he worked with the resident in the rehabilitation gym and afterwards he took her back to her room. Staff C, PTA did not remember how he took her back to her room, whether with a walker or by a wheelchair. Staff C, PTA said, the resident was a little confused but pleasant, stating she was high level. He stated he was going to talk to the PT about getting her a walker. He said she wore oxygen, but she did not have the oxygen on 04/04/022 during therapy. The PTA stated, We were trying to wean her off the oxygen. Staff C, PTA said, his understanding was the resident did not have oxygen at the previous residence. Staff C, PTA stated the resident was taken back to her room before lunch, saying because when I got back from lunch, they were looking for her. The DOR and Staff C, PTA verified the resident's oxygen order was to be continuous at 3 liters per minute. They reported, when ordered like that, if in therapy, we will take them down (remove the oxygen) during therapy to start weaning her off (the oxygen). The DOR, stated, we would have the nurse and physician approval to wean a resident. Staff C, PTA, stated he took her back down to her room, sat her on the bed side, put her oxygen on and call light within reach. He stated she had on regular clothes, shoes, or sticky socks. Then he left the room. Staff C, PTA reported, he found out she was missing when he got back from lunch at approximately 1:00 p.m. The PTA said he was in his car eating lunch, and he did not see her walk by. Staff C, PTA said. they did the announcement overhead and everyone started looking for her. He stated he did not have a specific role for elopements, but the resident was not in the gym. He stated he walked down to the Bistro to see if she was there. got a call the resident had been admitted to the hospital. Staff C reported, for training after the event, management went over if a resident is going to leave, they need to have a Pink Slip and sign out, and turn it in when they come back in, and they were instructed if a resident leaves on the 11-7 shift, someone has to escort them to and from the facility. On 04/20/2022 at 1:44 p.m., an interview was conducted with the DOR, Speech Therapist (ST), the Assistant Director of Rehab (ADOR), and the Certified Occupational Therapy Assistant (COTA). The ADOR stated, Resident #1 was receiving skilled services (therapy sessions) for [CONDITION(S)] and collapse. The ADOR said the resident, upon admission, was assessed for mobility, Activities of Daily Living (ADL), and cognitive ability and as a result, the resident was ordered therapy for those deficits, which included PT (physical therapy) five times a week, OT (occupational therapy) five times a week and ST (speech therapy) four times a week. The DOR stated the resident was seen for ambulation due to poor safety awareness. The resident presented on admission as requiring minimal assistance, and by the time of discharge the resident was supervision to contact guard assistance for ambulation. The DOR stated, the resident had progressed to being able to ambulate with a two wheeled walker but not safely. The DOR reported, Staff C, Physical Therapist Assistant (PTA) was her PT (Physical Therapist) and Staff G, was her OT (Occupational Therapist). The DOR reported the therapists provided services with the resident the morning of 04/04/2022. ST (Speech Therapist) did not see her that day. The DOR reviewed the resident's therapy performance notes for the morning of 04/04/2022, which included the resident had ambulated with the PT for 150 feet with a 2 wheeled walker, standby assist was provided with 15% verbal cues to promote safety awareness and obstacle negotiation.

Based on record review, observations, interviews, and facility policy review the facility failed to conduct an investigation that determined all factors that led to an elopement of one (#1) of five sampled residents sampled for elopement. This led to a failure to determine education and system changes needed to protect other residents in the building. Resident #1 was admitted to the facility after a four-day hospital admission. She had an episode of [CONDITION(S)] ([CONDITION(S)], or a sudden temporary loss of consciousness) while at an adult day care program and was taken to the hospital then transferred to the facility for short term rehabilitation. She was at risk for falls and was treated in the physical therapy department of the facility for poor safety awareness. She was prescribed oxygen at 3 liters per minute (lpm) continuously due low oxygen saturations from [CONDITION(S)] and acute respiratory failure with [CONDITION(S)]. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was known to ambulate freely through the facility. The documentation on her cognition varied in the medical record. She was assessed as having no cognitive deficit on admission. Four days later she scored as having severe cognitive impairment on a mental status screening test; one day later her score on the same instrument with a different provider showed her to be cognitively intact. In multiple places in the facility medical record the resident is described and assessed as confused, or pleasantly confused and forgetful with short term and long-term memory impairments. On 04/04/2022 at approximately 11:00 a.m. Resident #1 exited through the therapy entrance, a receptionist monitored double set of sliding doors. Resident #1 entered the parking lot, then walked approximately 100 yards through a sloping parking lot, then another 100 yards down to a sidewalk. The sidewalk was directly adjacent to a four lane US Highway with no grass or shoulder in between the sidewalk and the road. The resident walked another 100 yards heading north then turned right and continued up a sloped driveway to the car port of a condominium. A Concerned Citizen (CC) approached, and the resident stated she was looking for her car. The CC transported the resident by car through at least two parking lots looking for the resident's vehicle. The CC observed police in the area and requested assistance. The police called EMS (Emergency Medical Services) who found the resident to be hypotensive, administered IV fluids and then transported Resident #1 to the hospital. The facility was notified by police, Resident #1 was in the hospital and the resident was returned to the facility from the hospital. The likelihood of physical harm or death to Resident #1 as a result of being able to exit the facility unassisted resulted in the findings of Immediate Jeopardy beginning on 4/4/2022 and determined to be removed on 4/23/2022 and the scope and severity reduced to a D. Findings include: 1) A review of the Resident Mistreatment, Abuse and Neglect Prohibition, copyright 2017, Clear Choice Health Care, documented the Purpose: This facility is committed to protecting the physical and emotional well-being and personal possessions of every resident. Each facility has systems, procedures and a program of employee training and supervision in place to foster dignified treatment, respect, and compassion for residents. Any form of mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . All allegations of mistreatment, abuse, neglect, injuries of unknown origin and misappropriation of resident property are to be reported immediately and investigated by the Administrator, Risk Manager, or designee. The Guidelines included . Training: Upon hire, annually, and additionally if determined appropriate by facility management, each employee will be trained on the following topics: Resident mistreatment, neglect and abuse Prohibition guidelines; Appropriate interventions to deal with aggressive and/or potentially dangerous behaviors; What constitutes mistreatment, abuse, neglect, unreasonable confinement, injuries of unknown origin and misappropriation of resident property; How to recognize signs of burnout, frustration and stress that may lead to abuse; Employee responsibilities as a mandated reporter; How staff should report their knowledge of allegations without fear of reprisal . Definitions included: .Mandated reporter includes any person who has assumed full or intermittent responsibility for care or custody of an elderly person, whether or not that person receives compensation, such as administrators, supervisors, and any licensed staff of a facility that provides care or services for elderly adults, or any care custodian, health practitioner, clergy member, or employee of a county adult protection services agency or local law enforcement agency. Mandated reporting is a legal obligation for mandated reporters to formally report suspected, believed, or witnessed abuse, neglect or mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Neglect is failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness . Prevention: Each facility is required to identify, correct, and intervene in situations where abuse, neglect, and/or misappropriation of resident property are likely to occur, or are suspected to have occurred. Each facility should identify, analyze, and assess the following situations to minimize the likelihood of prohibited behaviors occurring. Areas of the physical environment that may make abuse or neglect more likely to occur, such as secluded areas of the facility. The facility, to the best of its ability, will take appropriate steps so that personnel are provided in sufficient numbers, with adequate knowledge to meet the individual needs of residents. Staff shall be regularly monitored to determine whether inappropriate behaviors are occurring such as derogatory language, rough handling, ignoring resident while giving care, or directing residents who need toileting assistance to urinate or defecate in their beds. Behaviors or interactions with individuals not directly employed by the facility (including family, visitors, contractors, etc.) which prompt concern or suspicion over resident abuse or misappropriation of resident property should be monitored, and interventions put in place as appropriate. Assess care plan and monitor residents with needs or behaviors that my likely lead to conflict, altercation, abuse, or neglect, such as residents: Exhibiting physically aggressive or self-injurious behaviors; Exhibiting verbally abusive behavior towards others; Exhibiting socially inappropriate or disruptive behaviors; Wandering an/or entering the rooms or personal space of others; or with communication disorders. Identification: Residents, families, and staff shall be informed that they may report any concerns, incidents, or grievances without fear of reprisal or retribution. The facility goal is to assure that any person making such a report is provided a non-threatening environment, and anonymity (if desired) to express identified concerns, with feed-back regarding the concerns expressed. Facility practices which assist in monitoring/ identifying potential abuse and neglect include but are not limited to: grievances; complaint-resolution processes; facility theft and loss reporting; resident council; incident reporting; internal audits of resident trust accounts; daily staffing practices; and regular direct/indirect supervision of nursing home employees and resident care by Supervisory and Administrative staff. Investigation: Each facility will thoroughly investigate injuries of unknown origin and any suspected or alleged abuse, neglect, misappropriation of resident property in accordance with federal and state regulations. The electronic incident report and investigation system forms (name of system) should be completed for all incidents of suspected or alleged m8istreatment, abuse, neglect, misappropriation of resident property and for injuries of unknown origin. Protection: To protect residents and employees from harm or retribution during an investigation each facility should ensure that: Measures are promptly taken to remove any resident from immediate harm or danger as indicated; Staff member(s) believed to be involved may be suspended pending the outcome of an investigation; If resident-to resident abuse is witnessed or alleged, reasonable measures are taken to separate the residents involved; If family or visitors are suspected, the facility reserves the right to prevent, restrict, or require supervised visitation while investigative efforts commence. Reporting/Response: Regulations require employees who provide services to elderly persons and dependent adults (mandatory reports) to report instances of abuse neglect, exploitation or mistreatment, injuries of an unknown source and misappropriation of resident property. If the events that cause the allegation involve abuse or result in serious bodily harm, the allegations must be reported immediately, but not later than two hours after the allegation is made. All events that cause the allegation that do not involve abuse and do not result in serious bodily injury must be reported not later than 24 hours after the allegation is made. Quality Assurance and Performance Improvement: All incident information such as investigative forms, witness interviews, information reported to state or other agencies, and any other pertinent information should be maintained in a separate, locked file as these documents are prepared as an integral part of the quality Assurance & performance improvement Committee to identify, assess and evaluation, through self-critical analysis, quality and care issues and to develop initiatives for the improvement of care and quality of life for our residents. A phone interview was conducted on 04/22/2022 at 10:32 a.m. with the CC who found Resident #1. She reported she lived near the facility in a condominium unit. She stated she was going to her car and when she came to the parking area, an elderly gentleman was talking to Resident #1. The CC stated the gentleman appeared upset and frazzled. She said the lady was just talking and talking. She stated the resident seemed ok; the resident was standing up and looked fine and was talking to the elderly gentleman. She said the resident told her she was looking for her car. The CC stated she walked with the resident to the parking lot and they could not find her car. The CC stated the resident told her she left the car parked where they were re-doing a swimming pool. The condominium complex next door was redoing their pool so she thought the resident may have been visiting over there. The CC asked the resident if it was okay to drive her around to find her car. The CC felt the resident was elderly, so she did not want her walking around. The CC stated the resident was not in distress, had no SOB (shortness of breath), and was not sweating at the time. The CC said the resident just looked like Oh, my I cannot find my car. She stated it was around 11:45 a.m. when she encountered the resident in the carport area. The CC stated she thought the resident may have walked out of the next-door parking lot and got into the wrong parking lot out of confusion. The CC asked the resident if she wanted to go with her to the other parking lot to see if they could find her car. The CC indicated the resident stated none of the red cars were hers. The CC explained the condominium is a gated community and people can get out but you cannot get in if you do not live there. The CC stated after driving to the end of the road, the resident still appeared confused. The CC stated she asked Resident #1 if she wanted her to call the police, and that upset the resident who responded, They are not going to arrest me, are they? The CC stated the resident seemed really upset. The CC said when the resident calmed down, she told her she had to go to the bank and asked the resident if she wanted to go, the resident replied yes. The CC stated the resident sat in the car while she was in the bank for 5 minutes. The CC stated the resident started talking about being at a shopping center, she could not believe the resident would cross a major street. The CC stated she took the resident to the parking lot with the theater. She stated they drove through and did not see the resident's car. The CC stated the resident then thought she had been in Lakeland with her children and told the CC her children were on vacation. The CC stated the resident could not tell her where her house was. The CC stated she was driving around the parking lot and saw three police officers standing there talking. She stated she stopped and talked to the police, who were very nice, around 12:30 p.m. and the resident stayed in the car. The CC stated the police took over and the resident became upset again about the police. She stated she held the resident's hand and gave her hugs, while the police were trying to get her name. She stated the resident could not even remember her name or how to spell her name. The CC stated she thought the resident was forgetful like her mother. The police found out she was stayed at (the facility), and by that time, EMS had come. She stated the resident had low B/P (blood pressure) and EMS took her to the hospital. The CC stated the resident did not want to leave her, so she went to the hospital, and they let her right into the back with the resident. The CC stated she stayed with the resident until (the facility) staff showed up at about 2 or 2:30 p.m. and she stayed until 3 or 3:30 p.m. She stated the resident did not know (the facility) people either. The CC stated in the ER (emergency room ) they started the resident on some IV (intravenous) fluids, and they would not release her until she had the fluids. The CC stated (the facility) people had to call the facility to see if they could wait on her, and they could, so it was (the facility) person and me who sat with the resident. The CC stated she stayed another ½ hour after (the facility staff) came and then she left. The CC stated she received a phone call from the Nursing Home Administrator (NHA) and the Director of Nursing (DON) from the facility the next day and they asked similar questions about the incident. The CC stated the facility has the resident on lock down now. On 04/20/2022 at 11:45 a.m. a phone interview was conducted with Resident #1's family member. She stated she became aware of Resident #1 leaving the facility on 04/04/2022 at a little after 1:00 p.m., the police called her to tell her she had been found at (local grocery store); they said she looked dehydrated. She stated she told them she was supposed to be back at the nursing home, and she gave them the name of the nursing home. The police told her they were transferring her to the hospital emergency room for an evaluation. Resident #1's family member said that prior to being admitted to the nursing home, the resident had been attending an Adult Day Care program. She said they had been doing this for a couple of months, to prepare her for the transition into the nursing home. She said the reason Resident #1 was at the Adult Day Care program was because she needed supervision. The family member stated back in October, the family was traveling, and the resident had an event where she wandered off. She stated this happened at a hotel and when the resident wandered from the hotel and was gone for 5 hours until the police found her. She stated the resident needed supervision in order to prevent her from wandering off. She stated no one ever asked her if Resident #1 had wandered off before at the time of admission or prior to the event occurring. She stated after the resident came home from the nursing home, she was readmitted to the Adult Day Care program, but then last Sunday (04/17/2022), she went to the hospital again, and was currently in the hospital. She stated she had talked to the DON on Monday, 04/18/2022, and she was considering placing the resident back at the facility, but she wanted to make sure she was not going to wander off again. The family member stated after the event, they put the resident on 1:1, placed a (wander monitoring device), implemented increased activities, and better hygiene practices. The DON was aware of her concerns. On 04/20/2022, 1:45 p.m., an interview was conducted with Staff E, Licensed Practical Nurse (LPN), she reported her assignment was the 100-hall area. During the interview, in the corner of the rear of the nursing station, a monitor was observed and in working condition. The monitor was observed to be showing real time footage of the therapy entrance exterior sliding doors. Staff E, LPN, confirmed staff could observe who was at the therapy entrance doors. She stated there was a button, and she pointed to a button in the rear of the nursing station and explained it was used after hours to open the doors. Staff E, LPN reported she first learned Resident #1 was not in the facility around noon on 04/04/2022. During med pass she heard them call an overhead page for the resident to come to her room. She stated she locked her cart and went to the nursing station, and they (Staff A, LPN) said they were looking for Resident #1 and doing room checks. Then, someone came in and said it was clear, she did not remember who said it was clear. They did not tell her where the resident was. Staff E, LPN reported after the event, she had received elopement training, and there was a new policy about leave of absence. She reported after the event, no training was conducted about the elopement assessment. She confirmed part of her responsibilities were to conduct admission assessments on newly admitted residents. She stated, for the admission assessment, I try to get information from the family; hospital records; the family is the most important person. The LPN stated further, On the admission assessment, there is a question on the demographic area, which prompts you to answer where you get the admission assessment information. Either family or the resident. She stated she was not sure if that applied to the elopement assessment. She stated, for a resident that has dementia or a wander risk, you can determine if they are ambulatory because this would mean more access, wheelchair mobility might be effective, continent, or incontinent, they might be looking for a bathroom. Staff E, LPN, pulled up an example resident on her computer and reviewed the Elopement/Neurological assessment on the admission evaluation. She pointed out; the assessment is done within 24 hours of admission. A score of 5 or greater means elopement risk. Each question has a number associated with it. She explained she would add up the score for the risk. She stated, if the resident were determined to be an elopement risk, she would tell the supervisor the resident scored as an elopement risk. She stated she would initiate an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The TAR (Treatment Administration Record) would have the (wander monitoring device), check function on it. She confirmed if the (wander monitoring device) approaches the door, the doors should lock and there should be an alarm. On 04/20/2022 at 2:10 p.m. an interview was conducted with Staff A, LPN. She confirmed her assignment was the 200 hall and reported she first became aware of Resident #1 missing, around 12:00 p.m. (04/04/2022), during medication pass. Staff A, LPN, noticed her food had not been touched in her room. So, Staff A, LPN, went to the Bistro (that was where the food was set up), to see if the resident was there. Then, Staff A, LPN went to the therapy gym, checked to make sure that no one had taken the resident down there. As soon as Staff A, LPN, found out the resident was not there, she called an elopement by paging the resident's name three times over the overhead (pager), please return to your room. Then everyone started to look for the resident. Staff A, LPN, stated she went out to the perimeter (she clarified perimeter, meant she walked outside by [CONDITION(S)]), saying there was a pathway out there, just to see if the resident had gone out there; nothing. Then, Staff A, LPN came back into the building. Staff A, LPN, said she received a message all clear, which meant that they had found the resident. Staff A, LPN said, the Unit Manager, LPN, (Staff B) gave the message. Staff A, LPN, said the DON told her the resident had been found, she had been transferred to (a local hospital), she was going to be checked out, and then brought back to the facility. Staff A, LPN stated, this was the same day, though, she did not remember what time she received the information, but it was before the end of the shift, 3:00 p.m. Staff A, LPN, stated she did not know where the resident had been found. Staff A, LPN confirmed she did not document any information about the event in Resident #1's clinical chart. She stated she wrote her full statement on a report and gave it to the DON. Staff A, LPN, reported after the event, the training she had received was elopement training (policy and what to do), where to find the elopement demographic information, and the elopement book at the nurses' station. Staff A, LPN, said the [wander monitoring device] goes on when we have a resident who is an elopement risk, and we get the physician order. She confirmed this was so the sirens go off at the door and it would alert the staff, someone is trying to exit. Staff A, LPN, said, all the main exits have this feature, and this has not changed since the event. Staff A, LPN, said she did not do the admission assessment on the resident. She reported since the event, she had received training on the admission assessment, the way that they received the information for the assessment, by speaking with the families, to ask what the resident's baseline was, to go over the resident history, to ask all the questions on the assessment. Staff A, LPN reported, for documentation of the source of the information, there was a contact the family area on the form. She said, This area would be filled out to indicate you spoke with the family to obtain the resident history. Staff A, LPN, confirmed if the summary did not document the information for the assessment was obtained from the family, it would be assumed that the information came from the resident, and the contact with the family was just to notify them of the resident admission. Staff A, LPN, reported the resident wore oxygen and she was noncompliant with her oxygen. Staff A, LPN said, it was one of the challenges that we had with her, the resident was ambulatory, independent and yes, we would check her oxygen saturation levels every shift. On 04/20/2022 at 12:45 p.m., an interview was conducted with Staff D, Certified Nursing Assistant (CNA). She confirmed she was present on 04/04/2022 and her assignment was the 100- hall. Staff D, CNA stated, she found out about the resident leaving the facility because of the distress call to have everyone go and look for the resident. Staff D, CNA, reported, she participated in the search for the resident. Staff D, CNA, commented, Resident #1 would go from her room, she pointed to the room mid hall on the wing 200, to the door, look out, and then return either to her room, or sit in her w/c (wheelchair) at the nurses' station. Staff D, CNA, said, she saw the resident do this 2-3 times. Staff D, confirmed after the resident went missing, management asked about this. Staff D, CNA, confirmed, she received training, saying if a resident looks like they want to leave, it should be reported to the nurse. Staff D stated the training she received was that everyone had to check their section of the building for a patient. Everyone had to check in and out of the building, and they have new screeners. Staff D, CNA, said she could not recall who the aide was assigned to Resident #1 on 04/04/2022. On 04/21/2022 at 9:20 a.m., an interview was conducted with the Staffing Coordinator (SC). A review of the 04/04/2022 staffing schedule was conducted. SC reported she would have to research to see who replaced Staff J, CNA on 04/04/2022. She stated Staff J, CNA had called off, she would have been Resident #1's aide. The SC stated, when Resident #1 came back, we put her on 1:1, and then after, a sitter until she was discharged . The SC said, on 04/04/2022, there was a hunt for the resident, until it was cleared. The SC stated she heard the police found the resident, but she did not know the details. The SC further stated, the resident looked like you or me, normal. Yes, she was ambulatory, she would get up and go. The SC said, after the 04/04/2022, the resident was with a sitter, she was taken to activities, and got her hair done. The SC said, we were not going to let her just sit around. The SC said, the resident could do everything for herself, stating, The resident would walk around the building, and no one thought anything of it. It was a surprise (she eloped). On 04/21/2022 at 10:00 a.m., an interview was conducted with Staff K, PCA (Personal Care Assistant), on the phone. She confirmed she had worked on 04/04/2022 and had been assigned to the resident. She stated she had seen Resident #1 at the nurses' station about 11:30 a.m., and the resident was in a wheelchair. Staff K, PCA said the resident was capable of wheeling herself around. Staff K, PCA, reported she had taken the resident's meal tray in her bedroom, the resident was not in the room, she had set the meal tray on the roll around table and continued to deliver the trays. Staff K, PCA said, this was around 12:00 p.m. and she mentioned that it was her 2nd day on the hall. Staff K, PCA, stated, Resident #1 could hold a conversation with her, and she could walk around. Staff K, PCA, said, the reason she knew the resident could walk was because another CNA and she had taken the resident to the bathroom and she got up, and she said, Oh, she can walk. Staff K, PCA said, for my set (the room assignment), the mentor was Staff D, CNA, stating, She and I were assigned the same set, the 200 hall. Staff K, PCA reported another aide was working in the area, Staff I, CNA. Staff K, PCA reported, when the resident was noticed missing, she believed it was at the end of lunch time and she heard them call the code (over the pager system). Staff K, PCA reported she looked for the resident for 30-40 minutes before the search stopped, because of an announcement. Staff K, PCA, stated she normally worked on other halls. Staff K, PCA, said, she had seen the resident on prior occasions at the nurses' station or her room. The times she had seen her the resident had been sitting. Staff K, PCA, commented, the resident seemed so normal to me, like nothing different. An interview was conducted on 04/20/2022 at 3:45 p.m. with Staff C, PTA (Physical Therapy Assistant) and the DOR (Director of Rehabilitation). Staff C, PTA reported Resident #1 had her PT after OT on 04/04/2022 at about 10:00 a.m. Staff C, PTA said he worked with the resident in the rehabilitation gym and afterwards he took her back to her room. Staff C, PTA did not remember how he took her back to her room, whether with a walker or by a wheelchair. Staff C, PTA said, the resident was a little confused but pleasant, stating she was high level. He stated he was going to talk to the PT about getting her a walker. He said she wore oxygen, but she did not have the oxygen on 04/04/022 during therapy. The PTA stated, We were trying to wean her off the oxygen. Staff C, PTA said, his understanding was the resident did not have oxygen at the previous residence. Staff C, PTA stated the resident was taken back to her room before lunch, saying because when I got back from lunch, they were looking for her. The DOR and Staff C, PTA verified the resident's oxygen order was to be continuous at 3 liters per minute. They reported, when ordered like that, if in therapy, we will take them down (remove the oxygen) during therapy to start weaning her off (the oxygen). The DOR, stated, we would have the nurse and physician approval to wean a resident. Staff C, PTA, stated he took her back down to her room, sat her on the bed side, put her oxygen on and call light within reach. He stated she had on regular clothes, shoes, or sticky socks. Then he left the room. Staff C, PTA reported, he found out she was missing when he got back from lunch at approximately 1:00 p.m. The PTA said he was in his car eating lunch, and he did not see her walk by. Staff C, PTA said. they did the announcement overhead and everyone started looking for her. He stated he did not have a specific role for elopements, but the resident was not in the gym. He stated he walked down to the Bistro to see if she was there. got a call the resident had been admitted to the hospital. Staff C reported, for training after the event, management went over if a resident is going to leave, they need to have a Pink Slip and sign out, and turn it in when they come back in, and they were instructed if a resident leaves on the 11-7 shift, someone has to escort them to and from the facility. On 04/20/2022 at 1:44 p.m., an interview was conducted with the DOR, Speech Therapist (ST), the Assistant Director of Rehab (ADOR), and the Certified Occupational Therapy Assistant (COTA). The ADOR stated, Resident #1 was receiving skilled services (therapy sessions) for [CONDITION(S)] and collapse. The ADOR said the resident, upon admission, was assessed for mobility, Activities of Daily Living (ADL), and cognitive ability and as a result, the resident was ordered therapy for those deficits, which included PT (physical therapy) five times a week, OT (occupational therapy) five times a week and ST (speech therapy) four times a week. The DOR stated the resident was seen for ambulation due to poor safety awareness. The resident presented on admission as requiring minimal assistance, and by the time of discharge the resident was supervision to contact guard assistance for ambulation. The DOR stated, the resident had progressed to being able to ambulate with a two wheeled walker but not safely. The DOR reported, Staff C, Physical Therapist Assistant (PTA) was her PT (Physical Therapist) and Staff G, was her OT (Occupational Therapist). The DOR reported the therapists provided services with the resident the morning of 04/04/2022. ST (Speech Therapist) did not see her that day. The DOR reviewed the resident's therapy performance notes for the morning of 04/04/2022, which included the resident had ambulated with the PT for 150 feet with a 2 wheeled walker, standby assist was provided with 15% verbal cues to promote safety awareness and obstacle negotiation. The PT also worked on the resident's lower body strength with exercises, transfers, and standing tolerance while maintaining balance. The DOR stated the OT worked on the resident's ADLs of the upper and lower body. The task of upper dressing required supervision with stand by assist for the lower body. The DOR said, the therapists completed ADL tasks at the edge of the bed and extra time was provided due to SOB (shortness of breath). She was wearing oxygen via nasal canula at 3 liters / minute. Her oxygen saturation was monitored both pre and post task. The DOR stated, Resident #1 was provided stand-by-assist for ROM (range of motion) and transfers from bed to wheelchair with safety awareness cues provided during the task. The resident was provided upper extremity exercise using the (exercise) equipment with rest breaks provided due to fatigue and SOB. The DOR stated, the therapy entrance doors have a security function now and they had companies come and fixed the doors. She said based on the video the resident went out those doors (therapy entrance doors). The DOR reported she was not aware if she went out walking or with a wheelchair, or walker. The DOR stated, she may have not used a walker, she may have just walked out. She was in room (#), which was only two hallways away. On 04/22/2022 at 11:06 p.m., an interview was conducted with the [NAME] [TRUNCATED]

Based on observations, record review, interviews, and facility policy and procedure, the facility failed to ensure medical records were completed accurately and timely in accordance with accepted professional standards or one (#1) of five sampled residents in regard to Resident #1's elopement event that occurred on 04/04/2022. Findings include: A review of the Resident Elopement Risk Management Guidelines, copyright 2017, Clear Choice Health Care, LLC, documented the Purpose: The facility will strive to provide a safe environment for residents and implement measures to identify residents at risk for elopement, as well as preventative measures to minimize elopement occurrences. Definitions: An elopement occurs when a resident, who is not alert/oriented, is found outside the property line of the facility without the knowledge of staff, or when a resident is identified as missing from the facility. An exit occurs when a resident attempts to leave the premises and is directly observed by staff or when a previously identified wanderer attempts to leave the premises and sets off the access control system and is immediately returned to the facility without harm. The Procedure included: 1. Upon admission each resident will be evaluated by a licensed nurse for risk of elopement by utilizing the electronic Elopement Risk Evaluation. Residents exhibiting new onset of exit seeking behavior will also be re-evaluated by utilizing the Electronic Elopement Risk Evaluation. If the resident scores a 5 or higher (meaning at higher risk) a 48-hour Resident Evaluation checklist will be initiated to determine patterns of behavior and individualized interventions for redirection. Residents exhibiting active exit seeking behaviors will have a Wander Tracking Device applied and 48-hour check sheet initiated. 2. Residents with Wander Tracking Devices will have Resident Identification form completed with picture and face sheet . 3. A care plan will be developed, as appropriate for all residents identified as at risk for elopement. 4. All residents identified . 5. When a resident is observed to be wandering to an unsafe situation or exiting the facility, the nearest staff should intervene or summon help if unable to safely manage the event. 6. If a resident is missing from the facility, the following protocol should be initiated when the location of the resident is unknown: . 7. Notify the Administrator and the Director of Nursing Immediately . 8. Notify the Chief Operating Officer . 9. If the resident is not located . 10. If local neighborhood searches are not successful . 11. At the time the resident is located, the following steps should be completed: a. Assess the resident's physical condition and mental status. If there appears to be any change in condition, notify the primary care physician immediately . 12. Document the following elements in the resident's medical record: a. The condition of the resident prior to the elopement. b. The time the resident was discovered missing. c. Complete description of the search effort including areas searched inside and outside of the facility, all parties notified and time of arrival of police. d. Time resident was found and returned to the facility e. Findings of the nurses' assessment of the resident upon return to the facility. 13. The resident should be re-evaluated using the electronic Elopement Risk Evaluation and the resident's care plan should be updated as appropriate. 14. An electronic Incident Report & Investigation form and a Resident Elopement Risk Management Investigation Tool should be completed. All appropriate state and federal reporting requirements should be followed as well. A review of medical record for Resident #1 reflected an admission to the facility on [DATE] from an acute care hospital. The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of an EMS (Emergency Medical Services) Run Report, dated 04/04/2022, revealed the following: EMS was called on 04/04/2022 at 12:56 p.m., dispatched at 12:57 p.m., and was at the patient at 13:06 (1:06 p.m.) The narrative revealed: Upon arrival found [AGE] year-old (y/o) female (f) sitting in the passenger seat of a car. Pt (patient) is confused and lost at this time. Upon arrival, found 86 y/o f, alert to her normal status due to dementia per the officer on the scene. The pt. was found walking on the side of the road and was picked up by a bystander who attempted to help the pt. find her car. Pt is in no distress at this time. The officer on scene stated that she is trying to get a hold of the pts family to get her. Pt was placed on the monitor to assess her due to not knowing how long she had been outside walking. Pts sats (oxygen saturations) were found to be low and pt. was hypotensive on the monitor. Pt is normal sinus 12 lead was unremarkable. Pt was assisted from the car to the stretcher without incident. An IV (intravenous line) was established, pt. was given fluids wide open with no improvement. A second line was established and pt. was placed on 2 fluid bags wide open, there was improvement to pts BP (blood pressure). Pts BP is now stable. Pt denies any pain. Pt was placed on O2 (oxygen) at 2 LPM (liters per minute) to show improvement. Pt was monitored in the hospital without further changes. Upon arrival at the hospital Pt was transferred to the bed via sliding over without incident. Pt care given to nurse at bedside. Further review of the vital signs recorded by EMS, reflected the following blood pressure (BP) readings: 13:10:00, BP 102/38 13:15:00, BP 108/68 13:20:00, BP 72/40 A review of the hospital Physician Notes dated 04/04/2022, 13:54, revealed the following: Resident #1 arrived at the hospital via ambulance, and the resident had cognitive impairment. The chief complaint: found wandering on the side of the road. HX (history) of dementia. On arrival of EMS was hypotensive . History is limited due to dementia. A review of the Nursing Progress Notes for the month of April 2022 reflected no documentation of the elopement event that occurred for Resident #1 on 04/04/2022, when the resident left the facility unwitnessed, was located off of the facility property by the police, was transferred to the hospital for an evaluation, was subsequently returned to the facility on [DATE], and the clinical record reflected no documentation of a reassessment of the resident upon return to the facility. On 04/20/2022 at 2:10 p.m. an interview was conducted with Staff A, LPN. She confirmed her assignment was the 200 hall and reported she first became aware of Resident #1 missing, around 12:00 p.m. (04/04/2022), during medication pass. Staff A, LPN, noticed her food had not been touched in her room. So, Staff A, LPN, went to the Bistro (that was where the food was set up), to see if the resident was there. Then, Staff A, LPN went to the therapy gym, checked to make sure that no one had taken the resident down there. As soon as Staff A, LPN, found out the resident was not there, she called an elopement by paging the resident's name three times over the overhead (pager), please return to your room. Then everyone started to look for the resident. Staff A, LPN, stated she went out to the perimeter (she clarified perimeter, meant she walked outside by [CONDITION(S)]), saying there was a pathway out there, just to see if the resident had gone out there; nothing. Then, Staff A, LPN came back into the building. Staff A, LPN, said she received a message all clear, which meant that they had found the resident. Staff A, LPN said, the Unit Manager, LPN, (Staff B) gave the message. Staff A, LPN, said the DON told her the resident had been found, she had been transferred to (a local hospital), she was going to be checked out, and then brought back to the facility. Staff A, LPN stated, this was the same day, though, she did not remember what time she received the information, but it was before the end of the shift, 3:00 p.m. Staff A, LPN, stated she did not know where the resident had been found. Staff A, LPN confirmed she did not document any information about the event in Resident #1's clinical chart. She stated she wrote her full statement on a report and gave it to the DON. On 04/21/2022 at 12:00 p.m., the DON was interviewed regarding Resident #1's elopement. She reported she received a call from a (local) police officer at 1:41 p.m. (on 04/04/2022). She stated, the police officer indicated he had received a call from a Concerned Citizen (CC). The citizen had called to notify police department they had found a person, that happened to be our resident. The DON stated, the CC had taken the resident to the parking lot of a (store name). The DON said the police report was received within the week after the elopement, she could not remember exactly when they gave it to her. The DON confirmed she was the Risk Manager for the building. The DON said, the CC had picked up the resident, and took the resident to the bank with her. At this time, Resident #1's clinical record was reviewed with the DON. She stated she called the family member at the time the resident went missing and left a message, then, she stated the family member called, and the family member said she had been contacted by the police and told the resident had been found. The DON confirmed there was no information in the clinical chart regarding the resident having left the facility, unwitnessed, being found by police, being transferred to a higher level of care (hospital for evaluation), or the return assessment of the resident after the elopement. The DON stated the resident was released at 5:30 p.m. that day (from the hospital) and she got back to the facility around 5:30 p.m. or 6 p.m. For documentation of the findings of the nurse for the assessment of the resident upon return from the hospital, the DON reported there was a neurological assessment, done by the nurse that night. DON confirmed it was her expectation documentation of the event would be entered prior to the end of the shift. For the person that would have responsibility to enter the information pertaining to the resident's elopement into the resident's chart, the DON reported, typically, we would have done a change in condition.

Based on record reviews and interviews, the facility failed to notify the resident representatives and families of four (Residents #11, #107, #61, and #416) sampled residents of confirmed COVID-19 cases in the facility in a timely manner. Findings included: On 1/4/22 at 9:42 a.m., during the entrance conference, it was identified that seven employees had tested positive for COVID between 12/31/21 and 1/3/22. A review of the testing log for employees confirmed that five employees had tested positive for COVID on 12/31/21 and two employees had tested positive on 1/3/22. During record reviews of Resident #11, #107, #61, and #416, it was noted that the records indicated no notification was sent to the representatives or family members from 12/30/21 to 1/5/22 of the positive COVID-19 cases. On Friday, 1/7/22 at 10:22 a.m., an interview was conducted with the Nursing Home Administrator (NHA). She confirmed she was the person who notified representatives of residents and family members by electronic method and the notifications were automatically loaded into the residents' electronic clinical documents. She said the department heads were the residents' Guardian Angels who met with the residents twice a day and notified them when there was a positive case of COVID in the facility. The residents were also notified by the electronic method through the cell phone with the automated message. The Administrator stated that the electronic method was usually sent out within 24-48 hours, I try to get (it) out within 24 hours, residents are notified that day by Guardian Angels. The NHA confirmed that the facility had seven positive staff members during the period of 12/31/21 to 1/3/22. She stated that two staff had tested positive on Wednesday (1/5/22), So I will be sending it out today. The NHA reported that due to the holiday, 1/1/22, notifications were not sent till Tuesday. She confirmed that the facility had seven positive staff between 12/31/21 and 1/3/22 and representatives were not notified until Wednesday 1/5/22. She said, But the residents were notified. The NHA confirmed that not all residents were self-responsible or alert and oriented. The NHA stated she did not know the regulation regarding notification to residents, representatives, or family members of COVID positivity in the facility. On 1/7/22 at 11:58 a.m., the NHA stated, with the Director of Nursing and the Regional Director of Clinical Services (RDCS) in attendance, that she believed she sent out an electronic message on Saturday (1/1/22) . The RDCS stated she remembered a text from the NHA stating she was going to send one. The NHA stated she did not know why it did not show up in the electronic medical record of the residents. The facility provided the policy for Staff and Resident Testing, copyright date 2020. The policy did not identify when the facility should notify residents, the representatives, and/or family members of its COVID status.

Based on observations, record reviews, and interviews, the facility failed to ensure one (Resident #11) of five residents sampled for skin conditions (pressure and non-pressure related) received weekly skin assessments. Findings included: The policy titled, Weekly and As Needed (PRN) Skin Check, copyright 2008, identified the purpose was To provide care to reduce the risk of pressure ulcers and to manage the treatment and to promote healing. The Weekly and PRN Skin Check is used to document skin condition through the Resident's stay in the facility. It is recommended that designated staff members of the nursing team complete the weekly skin checks for Residents in order to ensure continuity. If a new area of impairment is, it should be documented on the Weekly and PRN Skin Check and the appropriate Weekly Skin Grid initiated. A review of the policy procedure indicated that A Weekly Skin Grid will be initiated when an area of skin impairment is identified. The procedure instructed staff that a Skin check should be documented on the Weekly and PRN Skin Check. If a new area is identified the appropriate Weekly Skin Grid should be initiated and to Document actions taken based on the Skin Check. a) Check new skin impairment if new are identified, B) no new areas of skin impairment, c) Weekly Skin Grid pressure or other for both previously identified and newly identified areas, d) Nursing Progress Note document skin impairment. Resident #11 was admitted on [DATE]. The Admission Record did not identify any medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated the resident had not rejected care, was at risk of developing pressure ulcers, did not have any unhealed pressure ulcer or injuries, venous/arterial ulcers, and did not have any skin issues on the feet. The care plan for Resident #11 identified the resident had a potential for further impaired skin integrity. The focus indicated that the resident was admitted to the facility with MASD (Moisture Associated Skin Damage) to bilateral buttocks, back, thighs, groin, open area to left and right buttock, left hip, and a surgical incision to left lower leg. The plan was initiated on 9/29/21 and revised on 1/7/22. The care plan included an intervention, initiated 9/29/21 that instructed staff to administer treatments as ordered and monitor for effectiveness. The focus identified that on 12/20/21 a blister was identified on the top of the residents left foot. During an interview and observation, on Tuesday 1/04/22 at 12:25 p.m., with the resident, it was identified that the resident was wearing a black orthotic boot on the left lower extremity (LLE). Resident #11 stated that a blister had opened up on the left foot, under the boot. An observation indicated that the area under the boot was wrapped in an elastic bandage. The resident stated that the blister had opened up on Saturday and was told that the wound physician would visit on Wednesday (1/5/22). The resident identified that he had been admitted following a broken ankle. A review, on 1/6/22 at 2:49 p.m., of Resident #11's clinical record indicated that the most recent Weekly Skin Observation Tool was completed on 11/29/21. The record indicated that the Weekly Skin Grid Pressure - Non-pressure was 38 days overdue. Photographic evidence obtained. An observation, on 1/6/22 at 2:54 p.m. revealed that Resident #11 was not in his room. On 1/6/22 at 2:56 p.m., Staff B, Licensed Practical Nurse (LPN), stated that Resident #11's blister looked normal and was unable to report whether the blister was intact, fluid-filled, blood-filled, or how big the blister was. The Director of Nursing (DON) stated, at 3:01 p.m. on 1/6/22, that Staff B doesn't remember how big the blister was and reported that weekly skin evaluations were to done for Resident #11 on Mondays during the 3:00 p.m.-11:00 p.m. shift. On 1/6/22 at 3:02 p.m., Staff A, Unit Manager (UM), stated that she had put the order (for skin prep) in the electronic record after the nurse told her about the blister. On 1/6/22 at 3:02 p.m. the DON stated that there was documentation of Resident #11 having redness and discoloration but was unable to report the location of the redness and discoloration. The UM stated that the weekly skin evaluations were documented under the clinical tab of Evaluations. The DON and UM reviewed the Weekly Skin Tool Evaluations and would not confirm that the last skin assessment was completed on 11/29/21. A review of Resident #11's progress notes and evaluations for 12/20/21 did not include a description and/or measurement of the residents left foot blister. A Quarterly Nursing Evaluation, dated 12/20/21 and signed by Staff C on 12/28/21, indicated that the resident was at risk for pressure ulcers and had excoriation/MASD. The evaluation did not indicate the location of the resident's MASD. The Quarterly Evaluation did not identify that the resident had a blister. A review of the Weekly Skin Observation Tool that was provided by the facility indicated that a Weekly Skin Observation Tool, dated 12/6/21 and signed by Staff D, Registered Nurse, on 1/7/22, identified Resident #11 had a surgical wound and discoloration that was pre-existing and did not have any new areas of skin irregularities. The review of the Weekly Skin Grid Pressure- Non Pressure Evaluation indicated one was completed on 10/14/21 and then at 5:21 p.m. on 1/6/22. The Pressure/Non-pressure Evaluation, dated 1/6/22, identified that the resident had a blister measuring 3 x 2 x 0 centimeter (cm) that was non-pressure related, in-house acquired, and identified on 12/20/21.

Based on resident record review, nursing staff interviews, interviews with the attending physician and the medical director, the facility failed to provide necessary care and services in accordance with each resident ' s written plan of care. Based on a review of all current residents receiving [MEDICATION NAME] within the facility and one closed record of a resident receiving [MEDICATION NAME] one of twenty sampled residents (Resident #1) did not have her care plan implemented relative to Anticoagulant Therapy. Resident #1 was receiving 3 mg of [MEDICATION NAME] daily without adequate monitoring of the high risk medication. Resident #1 developed elevated liver enzymes, and then developed an acute [MEDICAL CONDITION] related to " Coagulopathy secondary to [MEDICATION NAME] " and severe [MEDICAL CONDITION]. Per facility audits, nineteen current residents receiving [MEDICATION NAME] were potentially affected. The actions of the facility nursing staff who failed to implement the written plan of care relative to Anticoagulants resulted in the findings of Immediate Jeopardy existing in the facility as of 11/6/13. The Immediate Jeopardy was removed on 12/3/13 at 5:50 PM and the scope and severity was reduced to a " D. " The findings included: Review of Resident #1 ' s Care Plan, dated 11/6/13, revealed a problem area related to bleeding and anticoagulant use with approaches including " labs as ordered, notify MD of lab results out of expected range, check PT/INR ([MEDICATION NAME]/International Normalizing Ratio; a measure of blood clotting times) prior to administering anticoagulant medication, observe for unusual bleeding, blood in stool or urine ..., encourage, remind and assist to avoid activities that may cause injury and encourage and assist as needed to use soft toothbrush ... " Facility staff however, did not make any attempt to contact the physician for PT/INR orders in accordance with the plan of care. During an interview on 12/5/13 at 11:35 AM, Resident #1 ' s family member stated that Resident #1 was admitted to the facility for rehabilitation services and was supposed to be discharged home. She also stated that the resident did not have any previous history of [MEDICAL CONDITION] and developed an acute bleed at the facility. The facility admitted Resident #1 on 11/6/13 with [DIAGNOSES REDACTED]. The resident was admitted to the facility for Short Term Subacute Care. The resident was receiving Physical and Occupational Therapy for function and strengthening. Review of the Hospital History and Physical, dated 10/29/13, revealed the resident was receiving Aspirin 81 mg daily and [MEDICATION NAME] 75 mg twice daily for anticoagulation. The resident ' s Aspiring and [MEDICATION NAME] were discontinued in the hospital and she was started on [MEDICATION NAME] as a new therapy. Review of the hospital laboratory data revealed a PT/INR was collected on 11/5 with a result of 1.8. On 11/6 the PT/INR was 2.4 indicating an upward trend, however still within therapeutic range (between 2.0 and 3.5). Review of Wittkowsky, Ann, The American Society of Health System Pharmacists, Chapter 24 [MEDICATION NAME], pages 358 revealed: " The intensity of [MEDICATION NAME] therapy is monitored by evaluation of the [MEDICATION NAME] time (PT), expressed as the INR ... " Table 24.7 summarizes the Frequency of INR Monitoring and Patient Assessment. If the initiation of the therapy utilized the flexible initiation method, then after administration of the first dose of [MEDICATION NAME]/[MEDICATION NAME], monitor the INR daily through day four of administration. If utilizing the Average daily dosing method, monitor the INR every 3-5 days until the INR is greater than the lower limit of the desired therapeutic range then within 1 week. After hospital discharge: if the patient is stable, monitor the INR within 3-5 days, if the patient is unstable monitor the INR within 1-3 days. During the first month of treatment, monitor the INR at least weekly. The routine follow up for an INR of a medically unstable is every 1-2 weeks. Review of the Geriatric Dosage Handbook 12th Edition 2007, pg. 1179, Initiation of Oral Anticoagulation With [MEDICATION NAME] revealed: " Dosing of [MEDICATION NAME] ([MEDICATION NAME]) must be individualized according to patient response to the drug as indicated by the INR ... " " Step 1. Obtain baseline INR. Begin therapy with [MEDICATION NAME] with a dose of 2-5 mg per day with dosage adjustments based on results of INR determinations. " " Step 2. Day that INR is stabilized in the therapeutic range: Check INR daily. Adjust [MEDICATION NAME] dose based on the results of INR determinations. Patients stabilized in the therapeutic range: Intervals between subsequent INR determinations should be based upon the physician ' s judgment of the patient ' s reliability and response to [MEDICATION NAME] in order to maintain the individual within therapeutic range. Acceptable intervals for INR determinations are normally within the range of 1-4 weeks after a stable dosage has been determined. Most patients are satisfactorily maintained on [MEDICATION NAME] at a dose of 2-10 mg daily. " Review of the admission orders [REDACTED]. There were no orders for a PT/INR. Review of the Physician ' s Telephone Orders from 11/6/13 through 11/22/13 revealed no orders were obtained for a PT/INR. Review of the facility ' s policy entitled " Anticoagulant Therapy " with a copyright date of 2008 revealed the Purpose of the policy was " To effectively monitor residents receiving anticoagulant therapy and reduce the risk of bleeding by maintaining therapeutic blood levels in accordance with physician orders. " Under Procedure, Item 3. " Confirm with the physician the desired INR/PT testing schedule and therapeutic range at the time of the anticoagulant therapy order. " Item 11 revealed " Document lab results, current dosage and physician orders [REDACTED]. " Review of the Attending Physician ' s " PT/INR Protocol " given to the facility in 2012 revealed: " All new admissions who are on [MEDICATION NAME], you must use the Anticoagulant MAR " (no longer valid with eMAR). " Category A- New admissions- if the resident doesn ' t come with a current PT/INR, you are to write an order to be done the next day. " " Category B -New admissions- if the resident does come with a current (the day of admission) PT/INR result, then you are to write an order for [REDACTED]." " Once you determine what category the resident goes under then. You must write an order for [REDACTED]. Review of the Narrative Nurses Notes revealed the resident was admitted on [DATE] and was alert and oriented times three and required moderate 1-2 person assistance with her activities of daily living. The facility nurses did not document the resident ' s admitting PT/INR lab on the admission note. The resident reported diarrhea upon admission. Review of the nurses ' note, dated 11/22/13 at 3:57 PM, revealed " at approx(imately). 2:30 PM, MD (Medical Doctor) responded to page and instructed to send pt (patient) out to (local hospital) non-emergent for eval(uation) pt has abnormal lab values, c/o (complains of) diarrhea and nausea and blood in stool from hemorrhoids. Pt has yellow tinged skin. Contacted sister to inform of pts condition. Pts skin is warm, dry and intact. Redness to inner buttocks. Pts family members requested to be sent by emergency 911, so 911 was called. Will wait with pt until EMS (Emergency Medical Services) arrives. " Review of the daily Clinical Nursing Assessments revealed between 11/7-11/18/13 there was no documentation of resident reported pain or blood in the resident ' s stool. Her skin was normal in appearance. On 11/19/13 the resident had " hemorrhoids and blood when having BM. " No pain was reported on 11/19/13. On 11/20 the resident did not report any pain and did not have any rectal bleeding. On 11/20 the resident did not report any pain and did not have any rectal bleeding. On 11/21 the resident was assessed with [REDACTED]. On 11/22/13 the resident was assessed at 2:25 PM. Her vital signs were 97.8, 99 beats per minute, 24 respirations per minute, 110/70 blood pressure, her pulse oximetry was 94% and her pain level was a 7/10. Her pain was generalized and she was medicated. The resident was alert and oriented times three and was verbally coherent. The resident ' s urine was amber in color. The resident last had a bowel movement on 11/22/13 and was noted to have bright red blood " from hemorrhoids. MD paged. " The resident ' s skin was jaundiced. There was no documented evidence that the nursing staff attempted to contact the attending physician to obtain orders for a PT/INR. Review of the Transfer Form dated 11/22/13 revealed the resident was transferred to the ER for abnormal labs, jaundice, diarrhea and nausea. When an order for [REDACTED]. She was discharged prior to her 11/22/13 dose. The eMAR did not include the lab box for the entry of the INR lab value. The nurses that administered the [MEDICATION NAME] at 5 PM were Employees D, E, F (LPNs). Record review revealed the resident did not have an Anticoagulation Flow sheet. The flow sheet was utilized by the facility for tracking and trending the PT/INR, current [MEDICATION NAME] dose and adjustments and physician and responsible party notification per facility protocol. Review of the physician's order [REDACTED]. On 11/14 the resident had a CMP (Comprehensive Metabolic Panel) and BNP (B-Type Naturetic Peptide, used to measure fluid volume) was ordered. On 11/18/13 the resident had a CMP ordered and her [MEDICATION NAME] was discontinued as well as her [MEDICATION NAME] was increased due to an increase in her liver enzymes and a decrease in her kidney function. On 11/20/13 an order was obtained for a BNP and a CMP, the resident ' s liver and kidney functions were still compromised. On 11/22/13 an order was obtained to send the resident to the ER (emergency room ). There were no orders for a PT/INR. Review of the Physician ' s Progress Notes revealed the resident was " doing ok " on 11/18/13. On 11/21/13 the resident was " doing ok. " There was no documented evidence the physician addressed the resident ' s [MEDICATION NAME] administration or lack of a PT/INR. Review of the laboratory data dated 11/19/13 revealed the resident ' s renal and liver functions were elevated. The lab data dated 11/22/13 and received by the facility at 11:37 AM revealed the resident ' s renal and liver functions were elevated. No PT/INRs were obtained or ordered. A resident with elevated renal and liver function is indicative of kidney and liver failure. Medications are broken down by the liver and excreted through the kidneys, when either of the organs are not functioning appropriately, the medication accumulates in the body causing increased medication levels and potentially harmful side effects. In addition, one of the functions of the liver is the production of blood clotting factors that [MEDICATION NAME] directly inhibits. If the liver functions are compromised and not producing the clotting factors, the [MEDICATION NAME] effects could also intensify (i.e. increased bleeding times.) Review of the hospital records obtained on 12/2/13 from the hospital revealed the PT on 11/22/13 was >120 seconds and the " INR was not done " due to the lack of clotting. The therapeutic range for the [MEDICATION NAME] indicated for clot prevention is 9-12.5 seconds and a therapeutic INR is between 2.0 and 3.5. The resident ' s hemoglobin level was 5.3 g/dL, normal range is 11.3-15.6 g/dL. Both lab values (the PT and the hemoglobin) were critical lab values that required immediate intervention. Review of the Hospital History and Physical dated 11/23/13 revealed the resident was admitted to the hospital for abdominal pain, elevated liver enzymes. While in the ER, the resident was also diagnosed with [REDACTED]. The INR was supratherapeutic. The family gave consent for blood [MEDICAL CONDITION] and blood pressure support. The resident received 10 mg of Vitamin K in the emergency room as an antidote to the [MEDICATION NAME]. Her blood pressure was 85/43. The physician ' s impression was " 1. GI Bleed 2. Coagulopathy secondary to [MEDICATION NAME] 3. Severe [MEDICAL CONDITION]. " The plan was to admit to the ICU and transfuse Fresh Frozen Plasma and 2 units of packed red blood cells. The resident ' s prognosis was poor. Per a family interview on 12/5/13 at 11.35 AM, the resident was transfused with 2 units of Fresh Frozen Plasma and 4 Units of Packed Red Blood Cells. She stated that the resident ' s kidneys ' did not regain function and she was unable to remove the excess fluid from the [MEDICAL CONDITION] (potentially 2 extra liters of fluid). Because the resident could not remove the fluid, the excess fluid caused an exacerbation of her underlying [MEDICAL CONDITION] which in turn caused respiratory distress and then her death. During an interview on 12/2/13 10:05 AM the Pharmacy Consultant, stated that he completed a 100% audit of all residents currently in house once a month. He stated that he routinely checked for drug interactions, irregularities, unnecessary medications and reviews labs. He also stated that for a resident receiving [MEDICATION NAME], he would check the PT/INRs. He stated that if no labs were in the chart he would request a PT/INR from the physician. He stated that he was last in the facility on 11/14/13. Review of the 11/14/13 Pharmacy Consultant Recommendations revealed Resident #1 was reviewed with no recommendations for a PT/INR were requested. During a follow up interview on 12/2/13 at 11:10 AM, the Pharmacy Consultant stated that he " must have seen the hospital INR " and " it must have been within limits. " He stated that there was no literature that defined how often an PT/INR should be collected and stated that he was not aware of any facility policy regarding anticoagulation therapy. He stated that he was not aware of Resident #1 ' s Attending Physician ' s PT/INR protocol. During an interview on 11/27/13 at 11:30 AM the attending physician stated that he assessed the resident frequently related to her co-morbid conditions. He stated that he was monitoring her for her increased liver enzymes. The physician stated that he thought her elevated liver enzymes were a result of the [MEDICATION NAME] and he discontinued the [MEDICATION NAME]. He stated that on 11/22/13 he was called and it was reported that she was pale. He stated that the resident was sent to the ER due to her abnormal labs. Lab work was completed at the hospital and she was anemic. He also stated that she had blood in her stool. The physician confirmed she was on [MEDICATION NAME] and that she had a high PT at the hospital; " greater than 120 seconds. " He stated again that the resident was in liver failure. He also stated that the elevated liver enzymes could have been a contributing factor to the increased PT/INR. He confirmed that no orders were written or obtained for a PT/INR and no labs were collected for the PT/INR. He also confirmed facility staff did not contact him for lab orders regarding the PT/INR. He stated that he had a written protocol for when to order PT/INRs and the facility staff were supposed to follow his protocol. During an interview on 11/27/13 at 3:05 PM the Medical Director stated he saw the resident in the hospital on 11/22 and she had a GI Bleed, Acute [MEDICAL CONDITION] and [MEDICAL CONDITION]. The " PT/INR was very elevated " and she received FFP (Plasma) and Vitamin K. The Medical Director was asked regarding the facility ' s policy on PT/INR lab draws. He stated that it was up to the attending physician to set his own protocols. He stated that he checked his residents every Monday and Thursday. He also stated that " everyone should be checked when they come in and every three to four days. " He stated that if the PT/INR was stable " it was ok to check every week. " If the resident required a dosage change, then " check the INR every three to four days. " He stated that the nurses would be responsible for contacting the physician for the PT/INR orders. He also stated the nurses should have called the doctor and asked what the plan is for checking the PT/INR for Resident #1. He stated a resident that was newly started on [MEDICATION NAME] should have had PT/INR checked in one week or less from admission. He stated that Resident #1 was a " system failure. " The Medical Director stated that he was the Medical Director of the facility and did not have specific contact with the resident prior to 11/22. He also stated that the facility did not have any specific policy regarding the frequency of PT/INR draws, however he stated again that it should be done at least weekly if stable and more frequently if warranted. During an interview on 11/27/13 at 11:47 AM Employee A (CNA) stated she routinely cared for Resident #1. She stated the resident was continent but would not get up to go to the bathroom. She had diarrhea one day. The resident had bright red blood in the toilet. The resident stated that she had hemorrhoids. Employee A reported the bleeding to the nurse. The nurse (Employee B) came in and looked at the resident. She stated that the resident did not have any pain. The CNA stated that the resident was later sent to the ER. During an interview on 11/27/13 at 12 PM with Employee B (LPN) and Employee G (LPN Unit Manager), Employee B stated that she cared for Resident #1 and had noticed some jaundice, abnormal labs and diarrhea; she paged the doctor and he ordered a non-emergent transfer. However, the family insisted on 911. Called 911 and the resident left via ambulance. She stated the resident hadn ' t left by end of shift, but she left around 3:30 PM with the EMS personnel. The LPN stated that the resident had blood from hemorrhoids, and she could visibly see the hemorrhoids. The resident also complained of her rectum hurting. She did not have any other complaints of pain. The LPN stated that she first paged the doctor around lunch time with the abnormal labs and he said he would come and see her. The unit manager notified the sister. The sister arrived and agreed that she was yellow. The sister called her daughter around 2 PM, and she was coming in the 30 minutes and requested the doctor send her to the ER. She paged the doctor back, assessed the resident again, and her vital signs were stable, the resident was not hurting and was alert and oriented. The physician said to send her out non-emergently. The DON (Director of Nurses) met with the niece around 3 PM and she wanted the resident sent out via 911. The DON notified the unit manager to call the doctor and request to send 911. The LPN called the physician back and he agreed to 911 transport. 911 was called and the resident left via stretcher at approximately 3:30 PM. The nurse stated that the resident was receiving [MEDICATION NAME] at 5 PM daily. She stated that the attending physician specialized his care for each patient. She stated that the other attending physician ' s in the facility would order PT/INRs based on admission and were typically drawn on Mondays and Thursdays. She stated that the resident did not have any PT/INRs drawn or ordered. She stated that if an PT/INR was not ordered, the nurses would notify the doctor that the PT/INR not scheduled and get them scheduled. She stated that Employee C (Desk Nurse on East) takes care of all of the attending physician's order [REDACTED]. She stated that the attending physician preferred to go through one nurse (Employee C) for all of his orders. During an interview on 11/27/13 at 12:15 PM with Employee C (Desk Nurse) and the DON, Employee C stated that she acted as a liaison between the doctors and the staff. She stated that she attempted to group the issues and the labs and make one phone call a day to the physician if possible and get the information together for rounds. She stated that the attending physician was in the facility 3-4 times per week. The attending physician gave his orders to Employee C and she entered the items into the computer. She stated the labs were typically routine with [MEDICATION NAME] and some of the doctors had Monday and Thursday standing orders for labs. However, Resident #1 ' s attending physician ordered his own labs for his residents. If a resident had an PT/INR completed in the hospital then the attending physician decided when the next one would be completed. She stated that it was unknown if anyone asked the physician regarding the INR. The DON stated that attending physician could be difficult and liked to order his own labs. He also stated that the physician " individualized care " to each resident. The DON also stated that the attending physician had a guideline with when to order the PT/INR that was written up " a while back. " During an interview 11/27/13 at 3:36 PM Employee D (LPN) stated that she routinely worked the 3-11 shift and was responsible for administering [MEDICATION NAME] to the residents. She stated Resident #1 was on 3 mg of [MEDICATION NAME] and the medication was given during the evening med pass. The nurse confirmed no PT/INRs were ordered or drawn. She stated that the attending physician ordered his own labs. She stated that this physician was " very strict regarding his patients. " She stated that she didn ' t question him " because he was a stickler. " She also stated that he had a strong personality. The nurse stated again that she didn ' t question the physician regarding the lack of an PT/INR and confirmed that she administered the medication to the resident. The nurse also confirmed that she did not inform the unit manager or the DON of the lack of PT/INRs. During an interview on 11/27/13 at 3:47 PM Employee E (LPN Evening Supervisor) stated that the resident was alert and oriented, diabetic, on [MEDICATION NAME]. The resident had hemorrhoids. Employee E confirmed that she administered [MEDICATION NAME] to Resident #1 at 5 PM. Employee E stated that she didn ' t see any PT/INR ' s on the chart and stated that the attending physician ordered his own labs. She stated that it was " not unusual to not have an order for [REDACTED]. However, confirmed again that the resident did not have an PT/INR and she administered the medication to the resident. She also confirmed that she didn ' t inform anyone (Physician, Unit Manager, Director of Nurses or the Medical Director) of the lack of PT/INRs. She stated that the attending physician only went through one person (Employee C) and he had a certain way he liked things done. Employee E also confirmed she didn ' t speak with Employee C regarding orders for an PT/INR. During an interview on 12/2/13 at 11:45 AM Employee F (LPN) stated that she typically worked the weekend evening shift and was trained to document " see chart " and not the actual lab value on the eMAR. She stated that she did not ever check the PT/INR since she worked the weekends. Surveyor informed DON and he stated he expected the nurses to check the PT/INR prior to [MEDICATION NAME] administration. During an interview on 11/27/13 at 12:50 PM the DON (Director of Nurses), stated that Resident #1 ' s attending physician " was very difficult to deal with and he created an aura of no one to question him. " The DON stated that the attending physician was monitoring her liver enzymes. The resident was jaundiced. The attending physician was informed again of the labs and ordered the resident out to the hospital non-emergently. The resident was stable with no active signs of bleeding. The DON called the unit and got the resident out 911 per the family ' s request. The DON stated that he did not see the resident but had the unit manager go assess her. The resident was admitted to the hospital (he stated he was informed on 11/23 of her admission). The resident was admitted with a possible a GI bleed. The DON was informed on 11/25/13 of the resident ' s hospital course. The DON stated that he " looked into the issue. " Review and discussion of the DON ' s review of the incident revealed: the PT/INR was last done on 11/6 while at the hospital. The resident was receiving [MEDICATION NAME] 3 mg. She was on [MEDICATION NAME] in the hospital and resident didn ' t want to be on [MEDICATION NAME] and she was switched to [MEDICATION NAME] during the most recent admission. No further PT/INRs were drawn. The DON stated that there was " no rhyme or reason for his (the attending physician ' s) orders. " Review of the in-service documentation revealed 14 direct care nursing staff were not in-serviced including one of the three nurses that administered the [MEDICATION NAME] without notifying the physician of the lack of an INR. (Employee E). During an interview on 12/2/13 at 1 PM the ADON, confirmed the 14 staff members who were not educated, including one of the nurses involved in the incident. She stated that she did not have any plans for additional education related to anticoagulant therapy. The facility implemented the following measures which resulted in the removal of the Immediate Jeopardy on 12/3/13 at 5:50 PM. The measures included: All current residents on [MEDICATION NAME] have been sampled with no additional resident identified with any concerns. All residents have orders for [MEDICATION NAME], orders for PT/INRs that were collected routinely, a [MEDICATION NAME] Flow sheet, and an Anticoagulant Care Plan. During an interview on 12/3/13 at 9:30 AM the Director of Nurses stated that 100% current staff members were educated on 12/2/13 per the ADON. Four PRN staff members were terminated due to not working within 3 months. Three have been removed from the schedule until the in-service has been completed. An audit was conducted on 12/2/13 of all residents receiving [MEDICATION NAME]. All residents had a PT/INR collected on 12/2/13 per physician's order [REDACTED]. The PT/INRs and the [MEDICATION NAME] Flow Sheets were validated on 12/3/13 by the survey team. Review of the Lab Data collected on 12/2/13 on all residents receiving [MEDICATION NAME] revealed no resident had a supratherapeutic INR (greater than 3.5). On 12/3/13 all nurses on the first and second shift of all three units were interviewed. The nurses were able to articulate the facility ' s physician order [REDACTED]. They were able to state all residents had orders for PT/INRs to be drawn either on Mondays or Mondays and Thursdays. They also stated that the each resident had a [MEDICATION NAME] Flow Sheet. All of the nurses were able to describe the signs and symptoms of a high PT/INR (i.e. bleeding). The nurses also stated that they were would contact the physician regarding an abnormal lab value. The nurses stated that they would contact the physician for lab orders if no PT/INR was available for review and had not been ordered. The eMAR system has now been revised to include a hard stop on the lab entry prior to initialing the [MEDICATION NAME] as given.

Based on resident record review, interviews with facility nursing staff, the Attending Physician, Medical Director, facility Administration and review of the facility ' s policies and procedures related to Anticoagulant Therapy, the facility failed to assure each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug that is used without adequate monitoring. Based on a review of all current residents receiving [MEDICATION NAME] within the facility and one closed record of a resident receiving [MEDICATION NAME] one of twenty sampled residents (Resident #1) did not have adequate monitoring of the PT/INRs ([MEDICATION NAME] time/International Normalizing Ratio; a measure of blood clotting time) that were indicated for [MEDICATION NAME] Therapy. Resident #1 was receiving 3 mg of [MEDICATION NAME] daily without adequate monitoring of the high risk medication. Resident #1 developed elevated liver enzymes, and then developed an acute [MEDICAL CONDITION] related to " Coagulopathy secondary to [MEDICATION NAME] " and severe [MEDICAL CONDITION]. Per facility audits, nineteen current residents receiving [MEDICATION NAME] were potentially affected. The actions of the medical and nursing staff who failed to order the necessary laboratory tests to monitor the clotting times and the resident subsequently developed an acute [MEDICAL CONDITION], coagulopathy and severe [MEDICAL CONDITION] resulted in the findings of Immediate Jeopardy existing in the facility as of 11/6/13. The Immediate Jeopardy was removed on 12/3/13 at 5:50 PM and the scope and severity was reduced to a " D. " The findings included: Review of the Hospital History and Physical dated 11/23 revealed Resident #1 was admitted to the hospital for abdominal pain, elevated liver enzymes. While in the ER, the resident was also diagnosed with [REDACTED]. The INR was supratherapeutic. The family gave consent for blood [MEDICAL CONDITION] and blood pressure support. The resident received 10 mg of Vitamin K in the emergency room as an antidote to the [MEDICATION NAME]. Her blood pressure was 85/43. The physician ' s impression was " 1. GI Bleed 2. Coagulopathy secondary to [MEDICATION NAME] 3. Severe [MEDICAL CONDITION]. " The plan was to admit to the ICU and transfuse Fresh Frozen Plasma and 2 units of packed red blood cells. The resident ' s prognosis was poor. Per a family interview on 12/5/13 at 11.35 AM, the resident was transfused with 2 units of Fresh Frozen Plasma and 4 Units of Packed Red Blood Cells. She stated that the resident ' s kidneys ' did not regain function and she was unable to remove the excess fluid from the [MEDICAL CONDITION] (potentially 2 extra liters of fluid). Because the resident could not remove the fluid, the excess fluid caused an exacerbation of her underlying [MEDICAL CONDITION] which in turn caused respiratory distress and then her death. Review of the hospital records obtained on 12/2/13 from the hospital revealed Resident #1 ' s PT on 11/22/13 was >120 seconds and the " INR was not done " due to the lack of clotting. The therapeutic range for the [MEDICATION NAME] time indicated for clot prevention is 9-12.5 seconds and a therapeutic INR is between 2.0 and 3.5. The resident ' s hemoglobin level was 5.3 g/dL, normal range is 11.3-15.6 g/dL. Both lab values (the PT and the hemoglobin) were critical lab values that required immediate intervention. During an interview on 12/5/13 at 11:35 AM, Resident #1 ' s family member stated that Resident #1 was admitted to the facility for rehabilitation services and was supposed to be discharged home. She also stated that the resident did not have any previous history of [MEDICAL CONDITION] and developed an acute bleed at the facility. The facility admitted Resident #1 on 11/6/13 with [DIAGNOSES REDACTED]. The resident was admitted to the facility for Short Term Sub Acute Care. The resident was receiving Physical and Occupational Therapy for function and strengthening. Review of the Hospital History and Physical, dated 10/29/13, revealed the resident was receiving Aspirin 81 mg daily and [MEDICATION NAME] 75 mg twice daily for anticoagulation. The resident ' s Aspirin and [MEDICATION NAME] were discontinued in the hospital and she was started on [MEDICATION NAME] as a new therapy. Review of the hospital laboratory data revealed a PT/INR was collected on 11/5 with a result of 1.8. On 11/6 the PT/INR was 2.4 indicating an upward trend, however still within therapeutic range (between 2.0 and 3.5). Review of Wittkowsky, Ann, The American Society of Health System Pharmacists, Chapter 24 [MEDICATION NAME], page 358 revealed: " The intensity of [MEDICATION NAME] therapy is monitored by evaluation of the [MEDICATION NAME] time (PT), expressed as the INR ... " Table 24.7 summarizes the Frequency of INR Monitoring and Patient Assessment. If the initiation of the therapy utilized the flexible initiation method, then after administration of the first dose of [MEDICATION NAME]/[MEDICATION NAME], monitor the INR daily through day four of administration. If utilizing the average daily dosing method, monitor the INR every 3-5 days until the INR is greater than the lower limit of the desired therapeutic range then within 1 week. After hospital discharge: if the patient is stable, monitor the INR within 3-5 days, if the patient is unstable monitor the INR within 1-3 days. During the first month of treatment, monitor the INR at least weekly. The routine follow up for an INR of a medically unstable is every 1-2 weeks. Review of the Geriatric Dosage Handbook 12th Edition 2007, pg. 1179, Initiation of Oral Anticoagulation With [MEDICATION NAME] revealed: " Dosing of [MEDICATION NAME] ([MEDICATION NAME]) must be individualized according to patient response to the drug as indicated by the INR ... " " Step 1. Obtain baseline INR. Begin therapy with [MEDICATION NAME] with a dose of 2-5 mg per day with dosage adjustments based on results of INR determinations. " " Step 2. Day that INR is stabilized in the therapeutic range: Check INR daily. Adjust [MEDICATION NAME] dose based on the results of INR determinations. Patients stabilized in the therapeutic range: Intervals between subsequent INR determinations should be based upon the physician ' s judgment of the patient ' s reliability and response to [MEDICATION NAME] in order to maintain the individual within therapeutic range. Acceptable intervals for INR determinations are normally within the range of 1-4 weeks after a stable dosage has been determined. Most patients are satisfactorily maintained on [MEDICATION NAME] at a dose of 2-10 mg daily. " Review of the Admission Minimum Data Set, dated dated [DATE], revealed the resident scored a 15/15 on her Brief Interview for Mental Status indicating no cognitive impairment. No behaviors were coded during the assessment window. The resident required extensive one to two person assistance with all activities of daily living except eating. The resident was coded as continent of bowel and bladder. Review of the admission orders [REDACTED]. There were no orders for a PT/INR upon admission or during her admission to the facility. Review of the facility ' s policy entitled " Anticoagulant Therapy " with a copyright date of 2008 revealed the Purpose of the policy was " To effectively monitor residents receiving anticoagulant therapy and reduce the risk of bleeding by maintaining therapeutic blood levels in accordance with physician orders. " Under Procedure, Item 3. " Confirm with the physician the desired INR/PT testing schedule and therapeutic range at the time of the anticoagulant therapy order. " Item 11 revealed " Document lab results, current dosage and physician orders [REDACTED]. " Review of the Attending Physician ' s " PT/INR Protocol " given to the facility in 2012 revealed: " All new admissions who are on [MEDICATION NAME], you must use the Anticoagulant MAR " (no longer valid with eMAR). " Category A- New admissions- if the resident doesn ' t come with a current PT/INR, you are to write an order to be done the next day. " " Category B -New admissions- if the resident does come with a current (the day of admission) PT/INR result, then you are to write an order for [REDACTED]." " Once you determine what category the resident goes under then. You must write an order for [REDACTED]. Review of the Care Plan dated 11/6/13 revealed a problem area related to bleeding and anticoagulant use with approaches including " labs as ordered, notify MD of lab results out of expected range, check PT/INR prior to administering anticoagulant medication, observe for unusual bleeding, blood in stool or urine ..., encourage, remind and assist to avoid activities that may cause injury and encourage and assist as needed to use soft toothbrush ... " Facility staff however, did not make any attempt to contact the physician for PT/INR orders in accordance with the plan of care. Review of the Narrative Nurses Notes revealed the resident was admitted on [DATE] and was alert and oriented times three and required moderate 1-2 person assistance with her activities of daily living. The facility nurses did not document the resident ' s admitting PT/INR lab on the admission note. The resident reported diarrhea upon admission. Review of the nurses ' note dated 11/22/13 at 3:57 PM revealed, " at approx(imately). 2:30 PM, MD (Medical Doctor) responded to page and instructed to send pt (patient) out to (local hospital) non-emergent for eval(uation) pt has abnormal lab values, c/o (complains of) diarrhea and nausea and blood in stool from hemorrhoids. Pt has yellow tinged skin. Contacted sister to inform of pts condition. Pts skin is warm, dry and intact. Redness to inner buttocks. Pts family members requested to be sent by emergency 911, so 911 was called. Will wait with pt until EMS (Emergency Medical Services) arrives. " Review of the daily Clinical Nursing Assessments revealed between 11/7-11/18/13 there was no documentation of resident reported pain or blood in the resident ' s stool. Her skin was normal in appearance. On 11/19/13 the resident had " hemorrhoids and blood when having BM. " No pain was reported on 11/19/13. On 11/20 the resident did not report any pain and did not have any rectal bleeding. On 11/20 the resident did not report any pain and did not have any rectal bleeding. On 11/21 the resident was assessed with [REDACTED]. On 11/22/13 the resident was assessed at 2:25 PM. Her vital signs were 97.8 degrees (temperature), 99 heart beats per minute, 24 respirations per minute, 110/70 blood pressure, her pulse oximetry was 94% and her pain level was a 7/10. Her pain was noted to be generalized and she was medicated. The resident was alert and oriented times three and was verbally coherent. The resident ' s urine was amber in color. The resident last had a bowel movement on 11/22/13 and was noted to have bright red blood " from hemorrhoids. MD paged. " The resident ' s skin was jaundiced. There was no documented evidence that the nursing staff attempted to contact the attending physician to obtain orders for a PT/INR. Review of the Transfer Form dated 11/22/13 revealed the resident was transferred to the ER for abnormal labs, jaundice, diarrhea and nausea. When an order for [REDACTED]. She was discharged prior to her 11/22/13 dose. The eMAR did not include the lab box for the entry of the INR lab value. The nurses that administered the [MEDICATION NAME] at 5 PM were Employees D, E, F (LPNs). Record review revealed the resident did not have an Anticoagulation Flow sheet. The flow sheet was utilized by the facility for tracking and trending the PT/INR, current [MEDICATION NAME] dose and adjustments and physician and responsible party notification per facility protocol. Review of the physician's order [REDACTED]. On 11/14 the resident had a CMP (Comprehensive Metabolic Panel) and BNP (B-Type Naturetic Peptide, used to measure fluid volume) was ordered. On 11/18/13 the resident had a CMP ordered and her [MEDICATION NAME] was discontinued as well as her [MEDICATION NAME] was increased due to an increase in her liver enzymes and a decrease in her kidney function. On 11/20/13 an order was obtained for a BNP and a CMP, the resident ' s liver and kidney functions were still compromised. On 11/22/13 an order was obtained to send the resident to the ER (emergency room ). There were no orders for a PT/INR. Review of the Physician ' s Progress Notes revealed the resident was " doing ok " on 11/18/13. On 11/21/13 the resident was " doing ok. " There was no documented evidence the physician addressed the resident ' s [MEDICATION NAME] administration or lack of a PT/INR. Review of the laboratory data dated 11/19/13 revealed the resident ' s renal and liver functions were elevated. The lab data dated 11/22/13 and received by the facility at 11:37 AM revealed the resident ' s renal and liver functions were elevated. No PT/INRs were obtained or ordered. A resident with elevated renal and liver function is indicative of kidney and liver failure. Medications are broken down by the liver and excreted through the kidneys, when either of the organs is not functioning appropriately, the medication accumulates in the body causing increased medication levels and potentially harmful side effects. In addition, one of the functions of the liver is the production of blood clotting factors that [MEDICATION NAME] directly inhibits. If the liver functions are compromised and not producing the clotting factors, the [MEDICATION NAME] effects could also intensify (i.e. increased bleeding times.) During an interview on 12/2/13 10:05 AM the Pharmacy Consultant, stated that he completed a 100% audit of all residents currently in house once a month. He stated that he routinely checked for drug interactions, irregularities, unnecessary medications and reviews labs. He also stated that for a resident receiving [MEDICATION NAME], he would check the PT/INRs. He stated that if no labs were in the chart he would request a PT/INR from the physician. He stated that he was last in the facility on 11/14/13. Review of the 11/14/13 Pharmacy Consultant Recommendations revealed Resident #1 was reviewed with no recommendations for a PT/INR were requested. During a follow up interview on 12/2/13 at 11:10 AM, the Pharmacy Consultant stated that he " must have seen the hospital INR " and " it must have been within limits. " He stated that there was no literature that defined how often a PT/INR should be collected and stated that he was not aware of any facility policy regarding anticoagulation therapy. He stated that he was not aware of Resident #1 ' s Attending Physician ' s PT/INR protocol. During an interview on 11/27/13 at 11:30 AM the attending physician stated that he assessed the resident frequently related to her co-morbid conditions. He stated that he was monitoring her for her increased liver enzymes. The physician stated that he thought her elevated liver enzymes were a result of the [MEDICATION NAME] and he discontinued the [MEDICATION NAME]. He stated that on 11/22/13 he was called and it was reported that she was pale. He stated that the resident was sent to the ER due to her abnormal labs. Lab work was completed at the hospital and she was anemic. He also stated that she had blood in her stool. The physician confirmed she was on [MEDICATION NAME] and that she had a high PT at the hospital; " greater than 120 seconds. " He stated again that the resident was in liver failure. He also stated that the elevated liver enzymes could have been a contributing factor to the increased PT/INR. He confirmed that no orders were written or obtained for a PT/INR and no labs were collected for the PT/INR. He also confirmed facility staff did not contact him for lab orders regarding the PT/INR. He stated that he had a written protocol for when to order PT/INRs and the facility staff were supposed to follow his protocol. During an interview on 11/27/13 at 3:05 PM the Medical Director stated he saw the resident in the hospital on 11/22 and she had a GI Bleed, Acute [MEDICAL CONDITION] and [MEDICAL CONDITION]. The " PT/INR was very elevated " and she received FFP (Plasma) and Vitamin K. The Medical Director was asked regarding the facility ' s policy on PT/INR lab draws. He stated that it was up to the attending physician to set his own protocols. He stated that he checked his residents every Monday and Thursday. He also stated that " everyone should be checked when they come in and every three to four days. " He stated that if the PT/INR was stable " it was ok to check every week. " If the resident required a dosage change, then " check the INR every three to four days. " He stated that the nurses would be responsible for contacting the physician for the PT/INR orders. He also stated the nurses should have called the doctor and asked what the plan is for checking the PT/INR for Resident #1. He stated a resident that was newly started on [MEDICATION NAME] should have had PT/INR checked in one week or less from admission. He stated that Resident #1 was a " system failure. " The Medical Director stated that he was the Medical Director of the facility and did not have specific contact with the resident prior to 11/22. He also stated that the facility did not have any specific policy regarding the frequency of PT/INR draws, however he stated again that it should be done at least weekly if stable and more frequently if warranted. During an interview on 11/27/13 at 11:47 AM Employee A (CNA) stated she routinely cared for Resident #1. She stated the resident was continent but would not get up to go to the bathroom. She had diarrhea one day. The resident had bright red blood in the toilet. The resident stated that she had hemorrhoids. Employee A reported the bleeding to the nurse. The nurse (Employee B) came in and looked at the resident. She stated that the resident did not have any pain. The CNA stated that the resident was later sent to the ER. During an interview on 11/27/13 at 12 PM with Employee B (LPN) and Employee G (LPN Unit Manager), Employee B stated that she cared for Resident #1 and had noticed some jaundice, abnormal labs and diarrhea; she paged the doctor and he ordered a non-emergent transfer. However, the family insisted on 911. Called 911 and the resident left via ambulance. She stated the resident hadn ' t left by end of shift, but she left around 3:30 PM with the EMS personnel. The LPN stated that the resident had blood from hemorrhoids, and she could visibly see the hemorrhoids. The resident also complained of her rectum hurting. She did not have any other complaints of pain. The LPN stated that she first paged the doctor around lunch time with the abnormal labs and he said he would come and see her. The unit manager notified the sister. The sister arrived and agreed that she was yellow. The sister called her daughter around 2 PM, and she was coming in the 30 minutes and requested the doctor send her to the ER. She paged the doctor back, assessed the resident again, and her vital signs were stable, the resident was not hurting and was alert and oriented. The physician said to send her out non-emergently. The DON (Director of Nurses) met with the niece around 3 PM and she wanted the resident sent out via 911. The DON notified the unit manager to call the doctor and request to send 911. The LPN called the physician back and he agreed to 911 transport. 911 was called and the resident left via stretcher at approximately 3:30 PM. The nurse stated that the resident was receiving [MEDICATION NAME] at 5 PM daily. She stated that the attending physician specialized his care for each patient. She stated that the other attending physician ' s in the facility would order PT/INRs based on admission and were typically drawn on Mondays and Thursdays. She stated that the resident did not have any PT/INRs drawn or ordered. She stated that if a PT/INR was not ordered, the nurses would notify the doctor that the PT/INR not scheduled and get them scheduled. She stated that Employee C (Desk Nurse on East) takes care of all of the attending physician's order [REDACTED]. She stated that the attending physician preferred to go through one nurse (Employee C) for all of his orders. During an interview on 11/27/13 at 12:15 PM with Employee C (Desk Nurse) and the DON, Employee C stated that she acted as a liaison between the doctors and the staff. She stated that she attempted to group the issues and the labs and make one phone call a day to the physician if possible and get the information together for rounds. She stated that the attending physician was in the facility 3-4 times per week. The attending physician gave his orders to Employee C and she entered the items into the computer. She stated the labs were typically routine with [MEDICATION NAME] and some of the doctors had Monday and Thursday standing orders for labs. However, Resident #1 ' s attending physician ordered his own labs for his residents. If a resident had a PT/INR completed in the hospital then the attending physician decided when the next one would be completed. She stated that it was unknown if anyone asked the physician regarding the INR. The DON stated that attending physician could be difficult and liked to order his own labs. He also stated that the physician " individualized care " to each resident. The DON also stated that the attending physician had a guideline with when to order the PT/INR that was written up " a while back. " During an interview 11/27/13 at 3:36 PM Employee D (LPN) stated that she routinely worked the 3-11 shift and was responsible for administering [MEDICATION NAME] to the residents. She stated Resident #1 was on 3 mg of [MEDICATION NAME] and the medication was given during the evening med pass. The nurse confirmed no PT/INRs were ordered or drawn. She stated that the attending physician ordered his own labs. She stated that this physician was " very strict regarding his patients. " She stated that she didn ' t question him " because he was a stickler. " She also stated that he had a strong personality. The nurse stated again that she didn ' t question the physician regarding the lack of a PT/INR and confirmed that she administered the medication to the resident. The nurse also confirmed that she did not inform the unit manager or the DON of the lack of PT/INRs. During an interview on 11/27/13 at 3:47 PM Employee E (LPN Evening Supervisor) stated that the resident was alert and oriented, diabetic, on [MEDICATION NAME]. The resident had hemorrhoids. Employee E confirmed that she administered [MEDICATION NAME] to Resident #1 at 5 PM. Employee E stated that she didn ' t see any PT/INR ' s on the chart and stated that the attending physician ordered his own labs. She stated that it was " not unusual to not have an order for [REDACTED]. However, confirmed again that the resident did not have a PT/INR and she administered the medication to the resident. She also confirmed that she didn ' t inform anyone (Physician, Unit Manager, Director of Nurses or the Medical Director) of the lack of PT/INRs. She stated that the attending physician only went through one person (Employee C) and he had a certain way he liked things done. Employee E also confirmed she didn ' t speak with Employee C regarding orders for a PT/INR. During an interview on 12/2/13 at 11:45 AM Employee F (LPN) stated that she typically worked the weekend evening shift and was trained to document " see chart " and not the actual lab value on the eMAR. She stated that she did not ever check the PT/INR since she worked the weekends. Surveyor informed DON and he stated he expected the nurses to check the PT/INR prior to [MEDICATION NAME] administration. During an interview on 11/27/13 at 12:50 PM the DON (Director of Nurses), stated that Resident #1 ' s attending physician " was very difficult to deal with and he created an aura of no one to question him. " The DON stated that the attending physician was monitoring her liver enzymes. The resident was jaundiced. The attending physician was informed again of the labs and ordered the resident out to the hospital non-emergently. The resident was stable with no active signs of bleeding. The DON called the unit and got the resident out 911 per the family ' s request. The DON stated that he did not see the resident but had the unit manager go assess her. The resident was admitted to the hospital (he stated he was informed on 11/23 of her admission). The resident was admitted with a possible a GI bleed. The DON was informed on 11/25/13 of the resident ' s hospital course. The DON stated that he " looked into the issue. " Review and discussion of the DON ' s review of the incident revealed: the PT/INR was last done on 11/6 while at the hospital. The resident was receiving [MEDICATION NAME] 3 mg. She was on [MEDICATION NAME] in the hospital and resident didn ' t want to be on [MEDICATION NAME] and she was switched to [MEDICATION NAME] during the most recent admission. No further PT/INRs were drawn. The DON stated that there was " no rhyme or reason for his (the attending physician ' s) orders. " Review of the in-service documentation revealed 14 direct care nursing staff were not in-serviced including one of the three nurses that administered the [MEDICATION NAME] without notifying the physician of the lack of an INR. (Employee E). During an interview on 12/2/13 at 1 PM the ADON, confirmed the 14 staff members who were not educated, including one of the nurses involved in the incident. She stated that she did not have any plans for additional education related to anticoagulant therapy. The facility implemented the following measures which resulted in the removal of the Immediate Jeopardy on 12/3/13 at 5:50 PM. The measures included: All current residents on [MEDICATION NAME] have been sampled with no additional resident identified with any concerns. All residents have orders for [MEDICATION NAME], orders for PT/INRs that were collected routinely, a [MEDICATION NAME] Flow sheet, and an Anticoagulant Care Plan. During an interview on 12/3/13 at 9:30 AM the Director of Nurses stated that 100% current staff members were educated on 12/2/13 per the ADON. Four PRN staff members were terminated due to not working within 3 months. Three have been removed from the schedule until the in-service has been completed. An audit was conducted on 12/2/13 of all residents receiving [MEDICATION NAME]. All residents had a PT/INR collected on 12/2/13 per physician's order [REDACTED]. The PT/INRs and the [MEDICATION NAME] Flow Sheets were validated on 12/3/13 by the survey team. Review of the Lab Data collected on 12/2/13 on all residents receiving [MEDICATION NAME] revealed no resident had a supratherapeutic INR (greater than 3.5). On 12/3/13 all nurses on the first and second shift of all three units were interviewed. The nurses were able to articulate the facility ' s physician order [REDACTED]. They were able to state all residents had orders for PT/INRs to be drawn either on Mondays or Mondays and Thursdays. They also stated that the each resident had a [MEDICATION NAME] Flow Sheet. All of the nurses were able to describe the signs and symptoms of a high PT/INR (i.e. bleeding). The nurses also stated that they were would contact the physician regarding an abnormal lab value. The nurses stated that they would contact the physician for lab orders if no PT/INR was available for review and had not been ordered. The eMAR system has now been revised to include a hard stop on the lab entry prior to initialing the [MEDICATION NAME] as given.

Based on resident record review, interviews with the Consultant Pharmacist and review of the facility ' s policies and procedures related to Anticoagulant Therapy, the facility failed to assure each resident's drug regimen was reviewed by a pharmacist and that the pharmacist reported any irregularities to the attending physician. Based on a review of all current residents receiving Coumadin within the facility and one closed record of a resident receiving Coumadin one of twenty sampled residents (Resident #1) did not have medication irregularities reported to the attending physician. Resident #1 was receiving 3 mg of Coumadin daily without adequate monitoring of the high risk medication. The Pharmacist conducted a Drug Regimen review on 11/14/13 without any recommendations for a PT/INR (Protime/International Normalizing Ratio; a measure of blood clotting time). Resident #1 developed elevated liver enzymes, and then developed an acute Gastrointestinal Bleed related to " Coagulopathy secondary to Coumadin " and severe anemia. Per facility audits, nineteen current residents receiving Coumadin were potentially affected. The actions of the Consultant Pharmacist who failed to report the irregularity to the physician resulted in the findings of Immediate Jeopardy existing in the facility as of 11/6/13. The Immediate Jeopardy was removed on 12/3/13 at 5:50 PM and the scope and severity was reduced to a " D. " The findings included: During an interview on 12/2/13 10:05 AM the Pharmacy Consultant, stated that he completed a 100% audit of all residents currently in house once a month. He stated that he routinely checked for drug interactions, irregularities, unnecessary medications and reviews labs. He also stated that for a resident receiving Coumadin, he would check the PT/INRs. He stated that if no labs were in the chart he would request a PT/INR from the physician. He stated that he was last in the facility on 11/14/13. Review of the 11/14/13 Pharmacy Consultant Recommendations revealed Resident #1 was reviewed with no recommendations for a PT/INR were requested. During a follow up interview on 12/2/13 at 11:10 AM, the Pharmacy Consultant stated that he " must have seen the hospital INR " and " it must have been within limits. " He stated that there was no literature that defined how often an PT/INR should be collected and stated that he was not aware of any facility policy regarding anticoagulation therapy. He stated that he was not aware of Resident #1 ' s Attending Physician ' s PT/INR protocol. Review of Wittkowsky, Ann, The American Society of Health System Pharmacists, Chapter 24 Warfarin, pages 358 revealed: " The intensity of warfarin therapy is monitored by evaluation of the Prothrombin time (PT), expressed as the INR ... " Table 24.7 summarizes the Frequency of INR Monitoring and Patient Assessment. If the initiation of the therapy utilized the flexible initiation method, then after administration of the first dose of Warfarin/Coumadin, monitor the INR daily through day four of administration. If utilizing the Average daily dosing method, monitor the INR every 3-5 days until the INR is greater than the lower limit of the desired therapeutic range then within 1 week. After hospital discharge: if the patient is stable, monitor the INR within 3-5 days, if the patient is unstable monitor the INR within 1-3 days. During the first month of treatment, monitor the INR at least weekly. The routine follow up for an INR of a medically unstable is every 1-2 weeks. Review of the Geriatric Dosage Handbook 12th Edition 2007, pg. 1179, Initiation of Oral Anticoagulation With Warfarin revealed: " Dosing of warfarin (Coumadin) must be individualized according to patient response to the drug as indicated by the INR ... " " Step 1. Obtain baseline INR. Begin therapy with warfarin with a dose of 2-5 mg per day with dosage adjustments based on results of INR determinations. " " Step 2. Day that INR is stabilized in the therapeutic range: Check INR daily. Adjust warfarin dose based on the results of INR determinations. Patients stabilized in the therapeutic range: Intervals between subsequent INR determinations should be based upon the physician ' s judgment of the patient ' s reliability and response to warfarin in order to maintain the individual within therapeutic range. Acceptable intervals for INR determinations are normally within the range of 1-4 weeks after a stable dosage has been determined. Most patients are satisfactorily maintained on warfarin at a dose of 2-10 mg daily. " Review of the facility ' s policy entitled " Anticoagulant Therapy " with a copyright date of 2008 revealed the Purpose of the policy was " To effectively monitor residents receiving anticoagulant therapy and reduce the risk of bleeding by maintaining therapeutic blood levels in accordance with physician orders. " Under Procedure, Item 3 " Confirm with the physician the desired INR/PT testing schedule and therapeutic range at the time of the anticoagulant therapy order. " Item 11 revealed " Document lab results, current dosage and physician orders [REDACTED]. " Review of the Attending Physician ' s " PT/INR Protocol " given to the facility in 2012 revealed: " All new admissions who are on Coumadin, you must use the Anticoagulant MAR " (no longer valid with eMAR). " Category A- New admissions- if the resident doesn ' t come with a current PT/INR, you are to write an order to be done the next day. " " Category B -New admissions- if the resident does come with a current (the day of admission) PT/INR result, then you are to write an order for [REDACTED]." " Once you determine what category the resident goes under then. You must write an order for [REDACTED]. During an interview on 12/5/13 at 11:35 AM, Resident #1 ' s family member stated that Resident #1 was admitted to the facility for rehabilitation services and was supposed to be discharged home. She also stated that the resident did not have any previous history of gastrointestinal bleeding and developed an acute bleed at the facility. The facility admitted Resident #1 on 11/6/13 with [DIAGNOSES REDACTED]. The resident was admitted to the facility for Short Term Subacute Care. The resident was receiving Physical and Occupational Therapy for function and strengthening. Review of the Hospital History and Physical dated 10/29/13 revealed the resident was receiving Aspirin 81 mg daily and Pradaxa 75 mg twice daily for anticoagulation. The resident ' s Aspirin and Pradaxa were discontinued in the hospital and she was started on Coumadin as a new therapy. Review of the hospital laboratory data revealed a PT/INR was collected on 11/5 with a result of 1.8. On 11/6 the PT/INR was 2.4 indicating an upward trend, however still within therapeutic range (between 2.0 and 3.5). Review of the Admission Minimum (MDS) data set [DATE] revealed the resident scored a 15/15 on her Brief Interview for Mental Status indicating no cognitive impairment. No behaviors were coded during the assessment window. The resident required extensive one to two person assistance with all activities of daily living except eating. The resident was coded as continent of bowel and bladder. Review of the admission orders [REDACTED]. There were no orders for a PT/INR upon admission or during her admission to the facility. Review of the Care Plan dated 11/6/13 revealed a problem area related to bleeding and anticoagulant use with approaches including " labs as ordered, notify MD of lab results out of expected range, check PT/INR prior to administering anticoagulant medication, observe for unusual bleeding, blood in stool or urine ..., encourage, remind and assist to avoid activities that may cause injury and encourage and assist as needed to use soft toothbrush ... " Facility staff however, did not make any attempt to contact the physician for PT/INR orders in accordance with the plan of care. Review of the Narrative Nurses Notes revealed the resident was admitted on [DATE] and was alert and oriented times three and required moderate 1-2 person assistance with her activities of daily living. The facility nurses did not document the resident ' s admitting PT/INR lab on the admission note. The resident reported diarrhea upon admission. Review of the nurses ' note dated 11/22/13 at 3:57 PM revealed, " at approx(imately). 2:30 PM, MD (Medical Doctor) responded to page and instructed to send pt (patient) out to (local hospital) non-emergent for eval(uation) pt has abnormal lab values, c/o (complains of) diarrhea and nausea and blood in stool from hemorrhoids. Pt has yellow tinged skin. Contacted sister to inform of pts condition. Pts skin is warm, dry and intact. Redness to inner buttocks. Pts family members requested to be sent by emergency 911, so 911 was called. Will wait with pt until EMS (Emergency Medical Services) arrives. " Review of the daily Clinical Nursing Assessments revealed between 11/7-11/18/13 there was no documentation of resident reported pain or blood in the resident ' s stool. Her skin was normal in appearance. On 11/19/13 the resident had " hemorrhoids and blood when having BM. " No pain was reported on 11/19/13. On 11/20 the resident did not report any pain and did not have any rectal bleeding. On 11/20 the resident did not report any pain and did not have any rectal bleeding. On 11/21 the resident was assessed with [REDACTED]. On 11/22/13 the resident was assessed at 2:25 PM. Her vital signs were 97.8 degrees (temperature), 99 heart beats per minute, 24 respirations per minute, 110/70 blood pressure, her pulse oximetry was 94% and her pain level was a 7/10. Her pain was noted to be generalized and she was medicated. The resident was alert and oriented times three and was verbally coherent. The resident ' s urine was amber in color. The resident last had a bowel movement on 11/22/13 and was noted to have bright red blood " from hemorrhoids. MD paged. " The resident ' s skin was jaundiced. There was no documented evidence that the nursing staff attempted to contact the attending physician to obtain orders for a PT/INR. Review of the Transfer Form dated 11/22/13 revealed the resident was transferred to the ER for abnormal labs, jaundice, diarrhea and nausea. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. She was discharged prior to her 11/22/13 dose. The eMAR did not include a pop up for the entry of the INR lab value. The nurses that administered the Coumadin at 5 PM were Employees D, E, F (LPNs). Per interviews with staff, when an order for [REDACTED]. Record review revealed the resident did not have an Anticoagulation Flow sheet. The flow sheet was utilized by the facility for tracking and trending the PT/INR, current Coumadin dose and adjustments and physician and responsible party notification per facility protocol. Review of the physician's order [REDACTED]. On 11/14 the resident had a CMP (Comprehensive Metabolic Panel) and BNP (B-Type Naturetic Peptide, used to measure fluid volume) was ordered. On 11/18/13 the resident had a CMP ordered and her Lipitor was discontinued as well as her Lasix was increased due to an increase in her liver enzymes and a decrease in her kidney function. On 11/20/13 an order was obtained for a BNP and a CMP, the resident ' s liver and kidney functions were still compromised. On 11/22/13 an order was obtained to send the resident to the ER (emergency room ). There were still no orders for a PT/INR. Review of the Physician ' s Progress Notes revealed the resident was " doing ok " on 11/18/13. On 11/21/13 the resident was " doing ok. " There was no documented evidence the physician addressed the resident ' s Coumadin administration or lack of a PT/INR. Review of the laboratory data dated 11/19/13 revealed the resident ' s renal and liver functions were elevated. The lab data dated 11/22/13 and received by the facility at 11:37 AM revealed the resident ' s renal and liver functions were elevated. No PT/INRs were obtained or ordered. A resident with elevated renal and liver function is indicative of kidney and liver failure. Medications are broken down by the liver and excreted through the kidneys, when either of the organs are not functioning appropriately, the medication accumulates in the body causing increased medication levels and potentially harmful side effects. In addition, one of the functions of the liver is the production of blood clotting factors that Coumadin directly inhibits. If the liver functions are compromised and not producing the clotting factors, the Coumadin effects could also intensify (i.e. increased bleeding times.) Review of the hospital records obtained on 12/2/13 from the hospital revealed the PT on 11/22/13 was >120 seconds and the " INR was not done " due to the lack of clotting. The therapeutic range for the Protime indicated for clot prevention is 9-12.5 seconds and a therapeutic INR is between 2.0 and 3.5. The resident ' s hemoglobin level was 5.3 g/dL, normal range is 11.3-15.6 g/dL. Both lab values (the PT and the hemoglobin) were critical lab values that required immediate intervention. Review of the Hospital History and Physical dated 11/23 revealed the resident was admitted to the hospital for abdominal pain, elevated liver enzymes. While in the ER, the resident was also diagnosed with [REDACTED]. The INR was supratherapeutic. The family gave consent for blood transfusions and blood pressure support. The resident received 10 mg of Vitamin K in the emergency room as an antidote to the Coumadin. Her blood pressure was 85/43. The physician ' s impression was " 1. GI Bleed 2. Coagulopathy secondary to Coumadin 3. Severe Anemia. " The plan was to admit to the ICU and transfuse Fresh Frozen Plasma and 2 units of packed red blood cells. The resident ' s prognosis was poor. Per a family interview on 12/5/13 at 11.35 AM, the resident was transfused with 2 units of Fresh Frozen Plasma and 4 Units of Packed Red Blood Cells. She stated that the resident ' s kidneys ' did not regain function and she was unable to remove the excess fluid from the transfusions (potentially 2 extra liters of fluid). Because the resident could not remove the fluid, the excess fluid caused an exacerbation of her underlying Congestive Heart Failure which in turn caused respiratory distress and then her death. During an interview on 11/27/13 at 11:30 AM the attending physician stated that he assessed the resident frequently related to her co-morbid conditions. He stated that he was monitoring her for her increased liver enzymes. The physician stated that he thought her elevated liver enzymes were a result of the Lipitor and he discontinued the Lipitor. He stated that on 11/22/13 he was called and it was reported that she was pale. He stated that the resident was sent to the ER due to her abnormal labs. Lab work was completed at the hospital and she was anemic. He also stated that she had blood in her stool. The physician confirmed she was on Coumadin and that she had a high PT at the hospital; " greater than 120 seconds. " He stated again that the resident was in liver failure. He also stated that the elevated liver enzymes could have been a contributing factor to the increased PT/INR. He confirmed that no orders were written or obtained for a PT/INR and no labs were collected for the PT/INR. He also confirmed facility staff did not contact him for lab orders regarding the PT/INR. He stated that he had a written protocol for when to order PT/INRs and the facility staff were supposed to follow his protocol. During an interview on 11/27/13 at 3:05 PM the Medical Director stated he saw the resident in the hospital on 11/22 and she had a GI Bleed, Acute Renal Failure and Respiratory failure. The " PT/INR was very elevated " and she received FFP (Plasma) and Vitamin K. The Medical Director was asked regarding the facility ' s policy on PT/INR lab draws. He stated that it was up to the attending physician to set his own protocols. He stated that he checked his residents every Monday and Thursday. He also stated that " everyone should be checked when they come in and every three to four days. " He stated that if the PT/INR was stable " it was ok to check every week. " If the resident required a dosage change, then " check the INR every three to four days. " He stated that the nurses would be responsible for contacting the physician for the PT/INR orders. He also stated the nurses should have called the doctor and asked what the plan is for checking the PT/INR for Resident #1. He stated a resident that was newly started on Coumadin should have had PT/INR checked in one week or less from admission. He stated that Resident #1 was a " system failure. " The Medical Director stated that he was the Medical Director of the facility and did not have specific contact with the resident prior to 11/22. He also stated that the facility did not have any specific policy regarding the frequency of PT/INR draws, however he stated again that it should be done at least weekly if stable and more frequently if warranted. During an interview on 11/27/13 at 11:47 AM Employee A (CNA) stated she routinely cared for Resident #1. She stated the resident was continent but would not get up to go to the bathroom. She had diarrhea one day. The resident had bright red blood in the toilet. The resident stated that she had hemorrhoids. Employee A reported the bleeding to the nurse. The nurse (Employee B) came in and looked at the resident. She stated that the resident did not have any pain. The CNA stated that the resident was later sent to the ER. During an interview on 11/27/13 at 12 PM with Employee B (LPN) and Employee G (LPN Unit Manager), Employee B stated that she cared for Resident #1 and had noticed some jaundice, abnormal labs and diarrhea; she paged the doctor and he ordered a non-emergent transfer. However, the family insisted on 911. Called 911 and the resident left via ambulance. She stated the resident hadn ' t left by end of shift, but she left around 3:30 PM with the EMS personnel. The LPN stated that the resident had blood from hemorrhoids, and she could visibly see the hemorrhoids. The resident also complained of her rectum hurting. She did not have any other complaints of pain. The LPN stated that she first paged the doctor around lunch time with the abnormal labs and he said he would come and see her. The unit manager notified the sister. The sister arrived and agreed that she was yellow. The sister called her daughter around 2 PM, and she was coming in the 30 minutes and requested the doctor send her to the ER. She paged the doctor back, assessed the resident again, and her vital signs were stable, the resident was not hurting and was alert and oriented. The physician said to send her out non-emergently. The DON (Director of Nurses) met with the niece around 3 PM and she wanted the resident sent out via 911. The DON notified the unit manager to call the doctor and request to send 911. The LPN called the physician back and he agreed to 911 transport. 911 was called and the resident left via stretcher at approximately 3:30 PM. The nurse stated that the resident was receiving Coumadin at 5 PM daily. She stated that the attending physician specialized his care for each patient. She stated that the other attending physician ' s in the facility would order PT/INRs based off of the admission and were typically draw on Mondays and Thursdays. She stated that the resident did not have any PT/INRs drawn or ordered. She stated that if an PT/INR was not ordered, the nurses would notify the doctor that the PT/INR not scheduled and get them scheduled. She stated that Employee C (Desk Nurse on East) takes care of all of the attending physician's order [REDACTED]. She stated that the attending physician preferred to go through one nurse (Employee C) for all of his orders. During an interview on 11/27/13 at 12:15 PM with Employee C (Desk Nurse) and the DON, Employee C stated that she acted as a liaison between the doctors and the staff. She stated that she attempted to group the issues and the labs and make one phone call a day to the physician if possible and get the information together for rounds. She stated that the attending physician was in the facility 3-4 times per week. The attending physician gave his orders to Employee C and she entered the items into the computer. She stated the labs were typically routine with Coumadin and some of the doctors had Monday and Thursday standing orders for labs. However, Resident #1 ' s attending physician ordered his own labs for his residents. If a resident had an PT/INR completed in the hospital then the attending physician decided when the next one would be completed. She stated that it was unknown if anyone asked the physician regarding the INR. The DON stated that attending physician could be difficult and liked to order his own labs. He also stated that the physician " individualized care " to each resident. The DON also stated that the attending physician had a guideline with when to order the PT/INR that was written up " a while back. " During an interview 11/27/13 at 3:36 PM Employee D (LPN) stated that she routinely worked the 3-11 shift and was responsible for administering Coumadin to the residents. She stated Resident #1 was on 3 mg of Coumadin and the medication was given during the evening med pass. The nurse confirmed no PT/INRs were ordered or drawn. She stated that the attending physician ordered his own labs. She stated that this physician was " very strict regarding his patients. " She stated that she didn ' t question him " because he was a stickler. " She also stated that he had a strong personality. The nurse stated again that she didn ' t question the physician regarding the lack of an PT/INR and confirmed that she administered the medication to the resident. The nurse also confirmed that she did not inform the unit manager or the DON of the lack of PT/INRs. During an interview on 11/27/13 at 3:47 PM Employee E (LPN Evening Supervisor) stated that the resident was alert and oriented, diabetic, on Coumadin. The resident had hemorrhoids. Employee E confirmed that she administered Coumadin to Resident #1 at 5 PM. Employee E stated that she didn ' t see any PT/INR ' s on the chart and stated that the attending physician ordered his own labs. She stated that it was " not unusual to not have an order for [REDACTED]. However, confirmed again that the resident did not have an PT/INR and she administered the medication to the resident. She also confirmed that she didn ' t inform anyone (Physician, Unit Manager, Director of Nurses or the Medical Director) of the lack of PT/INRs. She stated that the attending physician only went through one person (Employee C) and he had a certain way he liked things done. Employee E also confirmed she didn ' t speak with Employee C regarding orders for an PT/INR. During an interview on 12/2/13 at 11:45 AM Employee F (LPN) stated that she typically worked the weekend evening shift and was trained to document " see chart " and not the actual lab value on the eMAR. She stated that she did not ever check the PT/INR since she worked the weekends. Surveyor informed DON and he stated he expected the nurses to check the PT/INR prior to Coumadin administration. During an interview on 11/27/13 at 12:50 PM the DON (Director of Nurses), stated that Resident #1 ' s attending physician " was very difficult to deal with and he created an aura of no one to question him. " The DON stated that the attending physician was monitoring her liver enzymes. The resident was jaundiced. The attending physician was informed again of the labs and ordered the resident out to the hospital non-emergently. The resident was stable with no active signs of bleeding. The DON called the unit and got the resident out 911 per the family ' s request. The DON stated that he did not see the resident but had the unit manager go assess her. The resident was admitted to the hospital (he stated he was informed on 11/23 of her admission). The resident was admitted with a possible a GI bleed. The DON was informed on 11/25/13 of the resident ' s hospital course. The DON stated that he " looked into the issue. " Review and discussion of the DON ' s review of the incident revealed: the PT/INR was last done on 11/6 while at the hospital. The resident was receiving Coumadin 3 mg. She was on Pradaxa in the hospital and resident didn ' t want to be on Pradaxa and she was switched to Coumadin during the most recent admission. No further PT/INRs were drawn. The DON stated that there was " no rhyme or reason for his (the attending physician ' s) orders. " Review of the in-service documentation revealed 14 direct care nursing staff were not in-serviced including one of the three nurses that administered the Coumadin without notifying the physician of the lack of an INR. (Employee E). During an interview on 12/2/13 at 1 PM the ADON, confirmed the 14 staff members who were not educated, including one of the nurses involved in the incident. She stated that she did not have any plans for additional education related to anticoagulant therapy. The facility implemented the following measures which resulted in the removal of the Immediate Jeopardy on 12/3/13 at 5:50 PM. The measures included: All current residents on Coumadin have been sampled with no additional resident identified with any concerns. All residents have orders for Coumadin, orders for PT/INRs that were collected routinely, a Coumadin Flow sheet, and an Anticoagulant Care Plan. During an interview on 12/3/13 at 9:30 AM the Director of Nurses stated that 100% current staff members were educated on 12/2/13 per the ADON. Four PRN staff members were terminated due to not working within 3 months. Three have been removed from the schedule until the in-service has been completed. An audit was conducted on 12/2/13 of all residents receiving Coumadin. All residents had a PT/INR collected on 12/2/13 per physician's order [REDACTED]. The PT/INRs and the Coumadin Flow Sheets were validated on 12/3/13 by the survey team. Review of the Lab Data collected on 12/2/13 on all residents receiving Coumadin revealed no resident had a supratherapeutic INR (greater than 3.5). On 12/3/13 all nurses on the first and second shift of all three units were interviewed. The nurses were able to articulate the facility ' s physician order [REDACTED]. They were able to state all residents had orders for PT/INRs to be drawn either on Mondays or Mondays and Thursdays. They also stated that the each resident had a Coumadin Flow Sheet. All of the nurses were able to describe the signs and symptoms of a high PT/INR (i.e. bleeding). The nurses also stated that they were would contact the physician regarding an abnormal lab value. The nurses stated that they would contact the physician for lab orders if no PT/INR was available for review and had not been ordered. The eMAR system has now been revised to include a hard stop on the lab entry prior to initialing the Coumadin as given.

Based on review of the facility ' s Administrator Job Description, review of the facility ' s policy and guidelines for Anticoagulant Therapy, resident record review, nursing staff interviews, interviews with the attending physician, the medical director and the facility ' s Administrator the facility failed to provide resource management to meet the needs of one of twenty sampled residents receiving [MEDICATION NAME]. The facility failed to assure their written policies and procedures were implemented related to Anticoagulant Therapy. Resident #1 had received 3 mg of [MEDICATION NAME] daily without adequate monitoring of the high risk medication. Resident #1 developed elevated liver enzymes, and then developed an acute [MEDICAL CONDITION] related to " Coagulopathy secondary to [MEDICATION NAME] " and severe [MEDICAL CONDITION]. Per facility audits, nineteen current residents receiving [MEDICATION NAME] were potentially affected. The failure to adequately monitor a resident on a high risk anticoagulant medication resulted in the findings of Immediate Jeopardy existing in the facility as of 11/6/13. The Immediate Jeopardy was removed on 12/3/13 at 5:50 PM and the scope and severity was reduced to a " D. " The findings included: Review of the Administrator ' s Job Description revealed the Position Overview was described as " Responsible for overall operations and daily management of the facility by planning, developing, directing, monitoring and supporting all operational, administrative, clinical, human resources, customer service and fiscal activities for the facility programs and services. " The Essential Job Duties included " Ensures quality resident care is provided to meet and exceed company expectations and in accordance with state and federal laws, rules and regulations " , " Provides overall supervision and guidance to department managers to ensure compliance in all areas and tracks progress/performance in each area " and " Responsible for the compliance of legal, regulatory, accreditation and reimbursement laws, regulations and expectations. " Review of the facility ' s policy entitled " Anticoagulant Therapy " with a copyright date of 2008 revealed the Purpose of the policy was " To effectively monitor residents receiving anticoagulant therapy and reduce the risk of bleeding by maintaining therapeutic blood levels in accordance with physician orders. " Under Procedure, Item 3 " Confirm with the physician the desired INR/PT testing schedule and therapeutic range at the time of the anticoagulant therapy order. " Item 11 revealed " Document lab results, current dosage and physician orders [REDACTED]. " Review of the Attending Physician ' s " PT/INR Protocol " given to the facility in 2012 revealed: " All new admissions who are on [MEDICATION NAME], you must use the Anticoagulant MAR " (no longer valid with eMAR). " Category A- New admissions- if the resident doesn ' t come with a current PT/INR, you are to write an order to be done the next day. " " Category B -New admissions- if the resident does come with a current (the day of admission) PT/INR result, then you are to write an order for [REDACTED]." " Once you determine what category the resident goes under then. You must write an order for [REDACTED]. During an interview on 11/27/13 at 8:50 AM the Administrator stated that he was aware of one family member who was upset regarding the care their loved one received. He stated that Resident #1 had been a resident at the facility for about 3 weeks and had a critically high PT/INR at the hospital. The hospital was able to get the INR down, however the resident passed away the next day. He also stated that the facility did not draw an INR while she was admitted because her level was therapeutic upon admission and she did not have a dosage change. He also stated that the resident ' s physician was the same physician she had at the hospital prior to her admission and he saw her about twice a week during her admission. The Administrator stated that the facility did not have a specific policy on [MEDICATION NAME] and that the nurses followed the physician's order [REDACTED]. During an interview on 12/2/13 at 12:00 PM the Administrator and Director of Nurses were interviewed regarding QAA and the identification of a concern related to anticoagulant therapy. Review of the in-service documentation revealed 14 direct care nursing staff were not in-serviced including one of the three nurses that administered the [MEDICATION NAME] without notifying the physician of the lack of an INR. (Employee E). During an interview on 12/2/13 at 1 PM the ADON, confirmed the 14 staff members who were not educated, including one of the nurses involved in the incident. She stated that she did not have any plans for additional education related to anticoagulant therapy. At 12/2/13 at 12:10 PM both the Administrator and the DON stated nothing else had been completed for the incident; no reporting, incident reports or Adverse Reports or any further investigation/disciplinary action was/will be completed. During an interview on 12/5/13 at 11:35 AM, Resident #1 ' s family member stated that Resident #1 was admitted to the facility for rehabilitation services and was supposed to be discharged home. She also stated that the resident did not have any previous history of [MEDICAL CONDITION] and developed an acute bleed at the facility. The facility admitted Resident #1 on 11/6/13 with [DIAGNOSES REDACTED]. The resident was admitted to the facility for Short Term Subacute Care. The resident was receiving Physical and Occupational Therapy for function and strengthening. Review of the Hospital History and Physical dated 10/29/13 revealed the resident was receiving Aspirin 81 mg daily and [MEDICATION NAME] 75 mg twice daily for anticoagulation. The resident ' s Aspirin and [MEDICATION NAME] were discontinued in the hospital and she was started on [MEDICATION NAME] as a new therapy. Review of the hospital laboratory data revealed a PT/INR was collected on 11/5 with a result of 1.8. On 11/6 the PT/INR was 2.4 indicating an upward trend, however still within therapeutic range (between 2.0 and 3.5). Review of Wittkowsky, Ann, The American Society of Health System Pharmacists, Chapter 24 [MEDICATION NAME], pages 358 revealed: " The intensity of [MEDICATION NAME] therapy is monitored by evaluation of the [MEDICATION NAME] time (PT), expressed as the INR ... " Table 24.7 summarizes the Frequency of INR Monitoring and Patient Assessment. If the initiation of the therapy utilized the flexible initiation method, then after administration of the first dose of [MEDICATION NAME]/[MEDICATION NAME], monitor the INR daily through day four of administration. If utilizing the Average daily dosing method, monitor the INR every 3-5 days until the INR is greater than the lower limit of the desired therapeutic range then within 1 week. After hospital discharge: if the patient is stable, monitor the INR within 3-5 days, if the patient is unstable monitor the INR within 1-3 days. During the first month of treatment, monitor the INR at least weekly. The routine follow up for an INR of a medically unstable is every 1-2 weeks. Review of the Geriatric Dosage Handbook 12th Edition 2007, pg. 1179, Initiation of Oral Anticoagulation With [MEDICATION NAME] revealed: " Dosing of [MEDICATION NAME] ([MEDICATION NAME]) must be individualized according to patient response to the drug as indicated by the INR ... " " Step 1. Obtain baseline INR. Begin therapy with [MEDICATION NAME] with a dose of 2-5 mg per day with dosage adjustments based on results of INR determinations. " " Step 2. Day that INR is stabilized in the therapeutic range: Check INR daily. Adjust [MEDICATION NAME] dose based on the results of INR determinations. Patients stabilized in the therapeutic range: Intervals between subsequent INR determinations should be based upon the physician ' s judgment of the patient ' s reliability and response to [MEDICATION NAME] in order to maintain the individual within therapeutic range. Acceptable intervals for INR determinations are normally within the range of 1-4 weeks after a stable dosage has been determined. Most patients are satisfactorily maintained on [MEDICATION NAME] at a dose of 2-10 mg daily. " Review of the Admission Minimum (MDS) data set [DATE] revealed the resident scored a 15/15 on her Brief Interview for Mental Status indicating no cognitive impairment. No behaviors were coded during the assessment window. The resident required extensive one to two person assistance with all activities of daily living except eating. The resident was coded as continent of bowel and bladder. Review of the admission orders [REDACTED]. There were no orders for a PT/INR upon admission or during her admission to the facility. Review of the Care Plan dated 11/6/13 revealed a problem area related to bleeding and anticoagulant use with approaches including " labs as ordered, notify MD of lab results out of expected range, check PT/INR prior to administering anticoagulant medication, observe for unusual bleeding, blood in stool or urine ..., encourage, remind and assist to avoid activities that may cause injury and encourage and assist as needed to use soft toothbrush ... " Facility staff however, did not make any attempt to contact the physician for PT/INR orders in accordance with the plan of care. Review of the Narrative Nurses Notes revealed the resident was admitted on [DATE] and was alert and oriented times three and required moderate 1-2 person assistance with her activities of daily living. The facility nurses did not document the resident ' s admitting PT/INR lab on the admission note. The resident reported diarrhea upon admission. Review of the nurses ' note dated 11/22/13 at 3:57 PM revealed, " at approx(imately). 2:30 PM, MD (Medical Doctor) responded to page and instructed to send pt (patient) out to (local hospital) non-emergent for eval(uation) pt has abnormal lab values, c/o (complains of) diarrhea and nausea and blood in stool from hemorrhoids. Pt has yellow tinged skin. Contacted sister to inform of pts condition. Pts skin is warm, dry and intact. Redness to inner buttocks. Pts family members requested to be sent by emergency 911, so 911 was called. Will wait with pt until EMS (Emergency Medical Services) arrives. " Review of the daily Clinical Nursing Assessments revealed between 11/7-11/18/13 there was no documentation of resident reported pain or blood in the resident ' s stool. Her skin was normal in appearance. On 11/19/13 the resident had " hemorrhoids and blood when having BM. " No pain was reported on 11/19/13. On 11/20 the resident did not report any pain and did not have any rectal bleeding. On 11/20 the resident did not report any pain and did not have any rectal bleeding. On 11/21 the resident was assessed with [REDACTED]. On 11/22/13 the resident was assessed at 2:25 PM. Her vital signs were 97.8 degrees (temperature), 99 heart beats per minute, 24 respirations per minute, 110/70 blood pressure, her pulse oximetry was 94% and her pain level was a 7/10. Her pain was generalized and she was medicated. The resident was alert and oriented times three and was verbally coherent. The resident ' s urine was amber in color. The resident last had a bowel movement on 11/22/13 and was noted to have bright red blood " from hemorrhoids. MD paged. " The resident ' s skin was jaundiced. There was no documented evidence that the nursing staff attempted to contact the attending physician to obtain orders for a PT/INR. Review of the Transfer Form dated 11/22/13 revealed the resident was transferred to the ER for abnormal labs, jaundice, diarrhea and nausea. When an order for [REDACTED]. She was discharged prior to her 11/22/13 dose. The eMAR did not include the lab box for the entry of the INR lab value. The nurses that administered the [MEDICATION NAME] at 5 PM were Employees D, E, F (LPNs). Record review revealed the resident did not have an Anticoagulation Flow sheet. The flow sheet was utilized by the facility for tracking and trending the PT/INR, current [MEDICATION NAME] dose and adjustments and physician and responsible party notification per facility protocol. Review of the physician's order [REDACTED]. On 11/14 the resident had a CMP (Comprehensive Metabolic Panel) and BNP (B-Type Naturetic Peptide, used to measure fluid volume) was ordered. On 11/18/13 the resident had a CMP ordered and her [MEDICATION NAME] was discontinued as well as her [MEDICATION NAME] was increased due to an increase in her liver enzymes and a decrease in her kidney function. On 11/20/13 an order was obtained for a BNP and a CMP, the resident ' s liver and kidney functions were still compromised. On 11/22/13 an order was obtained to send the resident to the ER (emergency room ). There were no orders for a PT/INR. Review of the Physician ' s Progress Notes revealed the resident was " doing ok " on 11/18/13. On 11/21/13 the resident was " doing ok. " There was no documented evidence the physician addressed the resident ' s [MEDICATION NAME] administration or lack of a PT/INR. Review of the laboratory data dated 11/19/13 revealed the resident ' s renal and liver functions were elevated. The lab data dated 11/22/13 and received by the facility at 11:37 AM revealed the resident ' s renal and liver functions were elevated. No PT/INRs were obtained or ordered. A resident with elevated renal and liver function is indicative of kidney and liver failure. Medications are broken down by the liver and excreted through the kidneys, when either of the organs are not functioning appropriately, the medication accumulates in the body causing increased medication levels and potentially harmful side effects. In addition, one of the functions of the liver is the production of blood clotting factors that [MEDICATION NAME] directly inhibits. If the liver functions are compromised and not producing the clotting factors, the [MEDICATION NAME] effects could also intensify (i.e. increased bleeding times.) Review of the hospital records obtained on 12/2/13 from the hospital revealed the PT on 11/22/13 was >120 seconds and the " INR was not done " due to the lack of clotting. The therapeutic range for the [MEDICATION NAME] indicated for clot prevention is 9-12.5 seconds and a therapeutic INR is between 2.0 and 3.5. The resident ' s hemoglobin level was 5.3 g/dL, normal range is 11.3-15.6 g/dL. Both lab values (the PT and the hemoglobin) were critical lab values that required immediate intervention. Review of the Hospital History and Physical dated 11/23 revealed the resident was admitted to the hospital for abdominal pain, elevated liver enzymes. While in the ER, the resident was also diagnosed with [REDACTED]. The INR was supratherapeutic. The family gave consent for blood [MEDICAL CONDITION] and blood pressure support. The resident received 10 mg of Vitamin K in the emergency room as an antidote to the [MEDICATION NAME]. Her blood pressure was 85/43. The physician ' s impression was " 1. GI Bleed 2. Coagulopathy secondary to [MEDICATION NAME] 3. Severe [MEDICAL CONDITION]. " The plan was to admit to the ICU and transfuse Fresh Frozen Plasma and 2 units of packed red blood cells. The resident ' s prognosis was poor. Per a family interview on 12/5/13 at 11.35 AM, the resident was transfused with 2 units of Fresh Frozen Plasma and 4 Units of Packed Red Blood Cells. She stated that the resident ' s kidneys ' did not regain function and she was unable to remove the excess fluid from the [MEDICAL CONDITION] (potentially 2 extra liters of fluid). Because the resident could not remove the fluid, the excess fluid caused an exacerbation of her underlying [MEDICAL CONDITION] which in turn caused respiratory distress and then her death. During an interview on 12/2/13 10:05 AM the Pharmacy Consultant, stated that he completed a 100% audit of all residents currently in house once a month. He stated that he routinely checked for drug interactions, irregularities, unnecessary medications and reviews labs. He also stated that for a resident receiving [MEDICATION NAME], he would check the PT/INRs. He stated that if no labs were in the chart he would request a PT/INR from the physician. He stated that he was last in the facility on 11/14/13. Review of the 11/14/13 Pharmacy Consultant Recommendations revealed Resident #1 was reviewed with no recommendations for a PT/INR were requested. During a follow up interview on 12/2/13 at 11:10 AM, the Pharmacy Consultant stated that he " must have seen the hospital INR " and " it must have been within limits. " He stated that there was no literature that defined how often an PT/INR should be collected and stated that he was not aware of any facility policy regarding anticoagulation therapy. He stated that he was not aware of Resident #1 ' s Attending Physician ' s PT/INR protocol. During an interview on 11/27/13 at 11:30 AM the attending physician stated that he assessed the resident frequently related to her co-morbid conditions. He stated that he was monitoring her for her increased liver enzymes. The physician stated that he thought her elevated liver enzymes were a result of the [MEDICATION NAME] and he discontinued the [MEDICATION NAME]. He stated that on 11/22/13 he was called and it was reported that she was pale. He stated that the resident was sent to the ER due to her abnormal labs. Lab work was completed at the hospital and she was anemic. He also stated that she had blood in her stool. The physician confirmed she was on [MEDICATION NAME] and that she had a high PT at the hospital; " greater than 120 seconds. " He stated again that the resident was in liver failure. He also stated that the elevated liver enzymes could have been a contributing factor to the increased PT/INR. He confirmed that no orders were written or obtained for a PT/INR and no labs were collected for the PT/INR. He also confirmed facility staff did not contact him for lab orders regarding the PT/INR. He stated that he had a written protocol for when to order PT/INRs and the facility staff were supposed to follow his protocol. During an interview on 11/27/13 at 11:47 AM Employee A (CNA) stated she routinely cared for Resident #1. She stated the resident was continent but would not get up to go to the bathroom. She had diarrhea one day. The resident had bright red blood in the toilet. The resident stated that she had hemorrhoids. Employee A reported the bleeding to the nurse. The nurse (Employee B) came in and looked at the resident. She stated that the resident did not have any pain. The CNA stated that the resident was later sent to the ER. During an interview on 11/27/13 at 12 PM with Employee B (LPN) and Employee G (LPN Unit Manager), Employee B stated that she cared for Resident #1 and had noticed some jaundice, abnormal labs and diarrhea; she paged the doctor and he ordered a non-emergent transfer. However, the family insisted on 911. Called 911 and the resident left via ambulance. She stated the resident hadn ' t left by end of shift, but she left around 3:30 PM with the EMS personnel. The LPN stated that the resident had blood from hemorrhoids, and she could visibly see the hemorrhoids. The resident also complained of her rectum hurting. She did not have any other complaints of pain. The LPN stated that she first paged the doctor around lunch time with the abnormal labs and he said he would come and see her. The unit manager notified the sister. The sister arrived and agreed that she was yellow. The sister called her daughter around 2 PM, and she was coming in the 30 minutes and requested the doctor send her to the ER. She paged the doctor back, assessed the resident again, and her vital signs were stable, the resident was not hurting and was alert and oriented. The physician said to send her out non-emergently. The DON (Director of Nurses) met with the niece around 3 PM and she wanted the resident sent out via 911. The DON notified the unit manager to call the doctor and request to send 911. The LPN called the physician back and he agreed to 911 transport. 911 was called and the resident left via stretcher at approximately 3:30 PM. The nurse stated that the resident was receiving [MEDICATION NAME] at 5 PM daily. She stated that the attending physician specialized his care for each patient. She stated that the other attending physician ' s in the facility would order PT/INRs based off of the admission and were typically draw on Mondays and Thursdays. She stated that the resident did not have any PT/INRs drawn or ordered. She stated that if an PT/INR was not ordered, the nurses would notify the doctor that the PT/INR not scheduled and get them scheduled. She stated that Employee C (Desk Nurse on East) takes care of all of the attending physician's order [REDACTED]. She stated that the attending physician preferred to go through one nurse (Employee C) for all of his orders. During an interview on 11/27/13 at 12:15 PM with Employee C (Desk Nurse) and the DON, Employee C stated that she acted as a liaison between the doctors and the staff. She stated that she attempted to group the issues and the labs and make one phone call a day to the physician if possible and get the information together for rounds. She stated that the attending physician was in the facility 3-4 times per week. The attending physician gave his orders to Employee C and she entered the items into the computer. She stated the labs were typically routine with [MEDICATION NAME] and some of the doctors had Monday and Thursday standing orders for labs. However, Resident #1 ' s attending physician ordered his own labs for his residents. If a resident had an PT/INR completed in the hospital then the attending physician decided when the next one would be completed. She stated that it was unknown if anyone asked the physician regarding the INR. The DON stated that attending physician could be difficult and liked to order his own labs. He also stated that the physician " individualized care " to each resident. The DON also stated that the attending physician had a guideline with when to order the PT/INR that was written up " a while back. " During an interview 11/27/13 at 3:36 PM Employee D (LPN) stated that she routinely worked the 3-11 shift and was responsible for administering [MEDICATION NAME] to the residents. She stated Resident #1 was on 3 mg of [MEDICATION NAME] and the medication was given during the evening med pass. The nurse confirmed no PT/INRs were ordered or drawn. She stated that the attending physician ordered his own labs. She stated that this physician was " very strict regarding his patients. " She stated that she didn ' t question him " because he was a stickler. " She also stated that he had a strong personality. The nurse stated again that she didn ' t question the physician regarding the lack of an PT/INR and confirmed that she administered the medication to the resident. The nurse also confirmed that she did not inform the unit manager or the DON of the lack of PT/INRs. During an interview on 11/27/13 at 3:47 PM Employee E (LPN Evening Supervisor) stated that the resident was alert and oriented, diabetic, on [MEDICATION NAME]. The resident had hemorrhoids. Employee E confirmed that she administered [MEDICATION NAME] to Resident #1 at 5 PM. Employee E stated that she didn ' t see any PT/INR ' s on the chart and stated that the attending physician ordered his own labs. She stated that it was " not unusual to not have an order for [REDACTED]. However, confirmed again that the resident did not have an PT/INR and she administered the medication to the resident. She also confirmed that she didn ' t inform anyone (Physician, Unit Manager, Director of Nurses or the Medical Director) of the lack of PT/INRs. She stated that the attending physician only went through one person (Employee C) and he had a certain way he liked things done. Employee E also confirmed she didn ' t speak with Employee C regarding orders for an PT/INR. During an interview on 12/2/13 at 11:45 AM Employee F (LPN) stated that she typically worked the weekend evening shift and was trained to document " see chart " and not the actual lab value on the eMAR. She stated that she did not ever check the PT/INR since she worked the weekends. Surveyor informed DON and he stated he expected the nurses to check the PT/INR prior to [MEDICATION NAME] administration. During an interview on 11/27/13 at 12:50 PM the DON (Director of Nurses), stated that Resident #1 ' s attending physician " was very difficult to deal with and he created an aura of no one to question him. " The DON stated that the attending physician was monitoring her liver enzymes. The resident was jaundiced. The attending physician was informed again of the labs and ordered the resident out to the hospital non-emergently. The resident was stable with no active signs of bleeding. The DON called the unit and got the resident out 911 per the family ' s request. The DON stated that he did not see the resident but had the unit manager go assess her. The resident was admitted to the hospital (he stated he was informed on 11/23 of her admission). The resident was admitted with a possible a GI bleed. The DON was informed on 11/25/13 of the resident ' s hospital course. The DON stated that he " looked into the issue. " Review and discussion of the DON ' s review of the incident revealed: the PT/INR was last done on 11/6 while at the hospital. The resident was receiving [MEDICATION NAME] 3 mg. She was on [MEDICATION NAME] in the hospital and resident didn ' t want to be on [MEDICATION NAME] and she was switched to [MEDICATION NAME] during the most recent admission. No further PT/INRs were drawn. The DON stated that there was " no rhyme or reason for his (the attending physician ' s) orders. " During an interview on 11/27/13 at 3:05 PM the Medical Director stated he saw the resident in the hospital on 11/22 and she had a GI Bleed, Acute [MEDICAL CONDITION] and [MEDICAL CONDITION]. The " PT/INR was very elevated " and she received FFP (Plasma) and Vitamin K. The Medical Director was asked regarding the facility ' s policy on PT/INR lab draws. He stated that it was up to the attending physician to set his own protocols. He stated that he checked his residents every Monday and Thursday. He also stated that " everyone should be checked when they come in and every three to four days. " He stated that if the PT/INR was stable " it was ok to check every week. " If the resident required a dosage change, then " check the INR every three to four days. " He stated that the nurses would be responsible for contacting the physician for the PT/INR orders. He also stated the nurses should have called the doctor and asked what the plan is for checking the PT/INR for Resident #1. He stated a resident that was newly started on [MEDICATION NAME] should have had PT/INR checked in one week or less from admission. He stated that Resident #1 was a " system failure. " The Medical Director stated that he was the Medical Director of the facility and did not have specific contact with the resident prior to 11/22. He also stated that the facility did not have any specific policy regarding the frequency of PT/INR draws, however he stated again that it should be done at least weekly if stable and more frequently if warranted. The facility implemented the following measures which resulted in the removal of the Immediate Jeopardy on 12/3/13 at 5:50 PM. The measures included: All current residents on [MEDICATION NAME] have been sampled with no additional resident identified with any concerns. All residents have orders for [MEDICATION NAME], orders for PT/INRs that were collected routinely, a [MEDICATION NAME] Flow sheet, and an Anticoagulant Care Plan. During an interview on 12/3/13 at 9:30 AM the Director of Nurses stated that 100% current staff members were educated on 12/2/13 per the ADON. Four PRN staff members were terminated due to not working within 3 months. Three have been removed from the schedule until the in-service has been completed. An audit was conducted on 12/2/13 of all residents receiving [MEDICATION NAME]. All residents had a PT/INR collected on 12/2/13 per physician's order [REDACTED]. The PT/INRs and the [MEDICATION NAME] Flow Sheets were validated on 12/3/13 by the survey team. Review of the Lab Data collected on 12/2/13 on all residents receiving [MEDICATION NAME] revealed no resident had a supratherapeutic INR (greater than 3.5). On 12/3/13 all nurses on the first and second shift of all three units were interviewed. The nurses were able to articulate the facility ' s physician order [REDACTED]. They were able to state all residents had orders for PT/INRs to be drawn either on Mondays or Mondays and Thursdays. They also stated that the each resident had a [MEDICATION NAME] Flow Sheet. All of the nurses were able to describe the signs and symptoms of a high INR (i.e. bleeding). The nurses also stated that they were would contact the physician regarding an abnormal lab value. The nurses stated that they would contact the physician for lab orders if no PT/INR was available for review and had not been ordered. The eMAR system has now been revised to include a hard stop on the lab entry prior to initialing the [MEDICATION NAME] as given.

Based on resident record review, interviews with facility nursing staff, the Attending Physician, Medical Director, facility Administration and review of the facility ' s policies and procedures related to Anticoagulant Therapy the facility failed to provide the necessary care and services in accordance with acceptable standards of practice. Based on a review of all current residents receiving [MEDICATION NAME] within the facility and one closed record of a resident receiving [MEDICATION NAME] one of twenty sampled residents (Resident #1) did not have adequate monitoring of the PT/INRs ([MEDICATION NAME] time/International Normalizing Ratio; a measure of blood clotting time) that were consistent with recognized monitoring standards for [MEDICATION NAME] Therapy. Facility staff failed to obtain the necessary orders for a PT/INR and administered the medication to Resident #1 without the necessary laboratory reports. Resident #1 was receiving 3 mg of [MEDICATION NAME] daily without adequate monitoring of the high risk medication. Resident #1 developed elevated liver enzymes, and then developed an acute [MEDICAL CONDITION] related to " Coagulopathy secondary to [MEDICATION NAME] " and severe [MEDICAL CONDITION]. Per facility audits, nineteen current residents receiving [MEDICATION NAME] were potentially affected. The actions of the medical and nursing staff who failed to order the necessary laboratory tests to monitor the clotting times and the resident subsequently developed an acute [MEDICAL CONDITION], coagulopathy and severe [MEDICAL CONDITION] resulted in the findings of Immediate Jeopardy existing in the facility as of 11/6/13. The Immediate Jeopardy was removed on 12/3/13 at 5:50 PM and the scope and severity was reduced to a " D. " The findings included: Florida Nurse Practice Act Section 464.003 Definitions Part (3)(a) "Practice of professional nursing" means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: 1. The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others. (b) "Practice of practical nursing" means the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infirm and the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist. Review of Potter and Perry ' s Fundamentals of Nursing 6th Ed. Chapter 15, Nursing Assessment page 292 revealed, " Diagnostic and Laboratory Data. The results of diagnostic and laboratory tests can identify or verify alterations questioned or identified during the nursing health history and physical examination [REDACTED]. In addition, the nurse uses laboratory data to evaluate the success or failure or nursing and medical interventions ...Observation and recording of client (resident) assessment is a legal and professional responsibility ...The American Nurses Association Policy Statement (2003) and Standards of Clinical Nursing Practice (1998) mandate accurate data collection and recording as independent functions essential to the role of the professional nurse. " Review of the Hospital History and Physical dated 11/23 revealed Resident #1 was admitted to the hospital for abdominal pain, elevated liver enzymes. While in the ER, the resident was also diagnosed with [REDACTED]. The INR was supratherapeutic. The family gave consent for blood [MEDICAL CONDITION] and blood pressure support. The resident received 10 mg of Vitamin K in the emergency room as an antidote to the [MEDICATION NAME]. Her blood pressure was 85/43. The physician ' s impression was " 1. GI Bleed 2. Coagulopathy secondary to [MEDICATION NAME] 3. Severe [MEDICAL CONDITION]. " The plan was to admit to the ICU and transfuse Fresh Frozen Plasma and 2 units of packed red blood cells. The resident ' s prognosis was poor. Per a family interview on 12/5/13 at 11.35 AM, the resident was transfused with 2 units of Fresh Frozen Plasma and 4 Units of Packed Red Blood Cells. She stated that the resident ' s kidneys ' did not regain function and she was unable to remove the excess fluid from the [MEDICAL CONDITION] (potentially 2 extra liters of fluid). Because the resident could not remove the fluid, the excess fluid caused an exacerbation of her underlying [MEDICAL CONDITION] which in turn caused respiratory distress and then her death. Review of the hospital records obtained on 12/2/13 from the hospital revealed Resident #1 ' s PT on 11/22/13 was >120 seconds and the " INR was not done " due to the lack of clotting. The therapeutic range for the [MEDICATION NAME] time indicated for clot prevention is 9-12.5 seconds and a therapeutic INR is between 2.0 and 3.5. The resident ' s hemoglobin level was 5.3 g/dL, normal range is 11.3-15.6 g/dL. Both lab values (the PT and the hemoglobin) were critical lab values that required immediate intervention. Review of the facility ' s policy entitled " Anticoagulant Therapy " with a copyright date of 2008 revealed the Purpose of the policy was " To effectively monitor residents receiving anticoagulant therapy and reduce the risk of bleeding by maintaining therapeutic blood levels in accordance with physician orders. " Under Procedure, Item 3. " Confirm with the physician the desired INR/PT testing schedule and therapeutic range at the time of the anticoagulant therapy order. " Item 11 revealed " Document lab results, current dosage and physician orders [REDACTED]. " Review of the Attending Physician ' s " PT/INR Protocol " given to the facility in 2012 revealed: " All new admissions who are on [MEDICATION NAME], you must use the Anticoagulant MAR " (no longer valid with eMAR). " Category A- New admissions- if the resident doesn ' t come with a current PT/INR, you are to write an order to be done the next day. " " Category B -New admissions- if the resident does come with a current (the day of admission) PT/INR result, then you are to write an order for [REDACTED]." " Once you determine what category the resident goes under then. You must write an order for [REDACTED]. Review of Wittkowsky, Ann, The American Society of Health System Pharmacists, Chapter 24 [MEDICATION NAME], page 358 revealed: " The intensity of [MEDICATION NAME] therapy is monitored by evaluation of the [MEDICATION NAME] time (PT), expressed as the INR ... " Table 24.7 summarizes the Frequency of INR Monitoring and Patient Assessment. If the initiation of the therapy utilized the flexible initiation method, then after administration of the first dose of [MEDICATION NAME]/[MEDICATION NAME], monitor the INR daily through day four of administration. If utilizing the average daily dosing method, monitor the INR every 3-5 days until the INR is greater than the lower limit of the desired therapeutic range then within 1 week. After hospital discharge: if the patient is stable, monitor the INR within 3-5 days, if the patient is unstable monitor the INR within 1-3 days. During the first month of treatment, monitor the INR at least weekly. The routine follow up for an INR of a medically unstable is every 1-2 weeks. Review of the Geriatric Dosage Handbook 12th Edition 2007, pg. 1179, Initiation of Oral Anticoagulation With [MEDICATION NAME] revealed: " Dosing of [MEDICATION NAME] ([MEDICATION NAME]) must be individualized according to patient response to the drug as indicated by the INR ... " " Step 1. Obtain baseline INR. Begin therapy with [MEDICATION NAME] with a dose of 2-5 mg per day with dosage adjustments based on results of INR determinations. " " Step 2. Day that INR is stabilized in the therapeutic range: Check INR daily. Adjust [MEDICATION NAME] dose based on the results of INR determinations. Patients stabilized in the therapeutic range: Intervals between subsequent INR determinations should be based upon the physician ' s judgment of the patient ' s reliability and response to [MEDICATION NAME] in order to maintain the individual within therapeutic range. Acceptable intervals for INR determinations are normally within the range of 1-4 weeks after a stable dosage has been determined. Most patients are satisfactorily maintained on [MEDICATION NAME] at a dose of 2-10 mg daily. " During an interview on 12/5/13 at 11:35 AM, Resident #1 ' s family member stated that Resident #1 was admitted to the facility for rehabilitation services and was supposed to be discharged home. She also stated that the resident did not have any previous history of [MEDICAL CONDITION] and developed an acute bleed at the facility. The facility admitted Resident #1 on 11/6/13 with [DIAGNOSES REDACTED]. The resident was admitted to the facility for Short Term Sub Acute Care. The resident was receiving Physical and Occupational Therapy for function and strengthening. Review of the Hospital History and Physical, dated 10/29/13, revealed the resident was receiving Aspirin 81 mg daily and [MEDICATION NAME] 75 mg twice daily for anticoagulation. The resident ' s Aspirin and [MEDICATION NAME] were discontinued in the hospital and she was started on [MEDICATION NAME] as a new therapy. Review of the hospital laboratory data revealed a PT/INR was collected on 11/5 with a result of 1.8. On 11/6 the PT/INR was 2.4 indicating an upward trend, however still within therapeutic range (between 2.0 and 3.5). Review of the Admission Minimum Data Set, dated dated [DATE], revealed the resident scored a 15/15 on her Brief Interview for Mental Status indicating no cognitive impairment. No behaviors were coded during the assessment window. The resident required extensive one to two person assistance with all activities of daily living except eating. The resident was coded as continent of bowel and bladder. Review of the admission orders [REDACTED]. There were no orders for a PT/INR upon admission or during her admission to the facility. Review of the Care Plan dated 11/6/13 revealed a problem area related to bleeding and anticoagulant use with approaches including " labs as ordered, notify MD of lab results out of expected range, check PT/INR prior to administering anticoagulant medication, observe for unusual bleeding, blood in stool or urine ..., encourage, remind and assist to avoid activities that may cause injury and encourage and assist as needed to use soft toothbrush ... " Facility staff however, did not make any attempt to contact the physician for PT/INR orders in accordance with the plan of care. Review of the Narrative Nurses Notes revealed the resident was admitted on [DATE] and was alert and oriented times three and required moderate 1-2 person assistance with her activities of daily living. The facility nurses did not document the resident ' s admitting PT/INR lab on the admission note. The resident reported diarrhea upon admission. Review of the nurses ' note dated 11/22/13 at 3:57 PM revealed, " at approx(imately). 2:30 PM, MD (Medical Doctor) responded to page and instructed to send pt (patient) out to (local hospital) non-emergent for eval(uation) pt has abnormal lab values, c/o (complains of) diarrhea and nausea and blood in stool from hemorrhoids. Pt has yellow tinged skin. Contacted sister to inform of pts condition. Pts skin is warm, dry and intact. Redness to inner buttocks. Pts family members requested to be sent by emergency 911, so 911 was called. Will wait with pt until EMS (Emergency Medical Services) arrives. " Review of the daily Clinical Nursing Assessments revealed between 11/7-11/18/13 there was no documentation of resident reported pain or blood in the resident ' s stool. Her skin was normal in appearance. On 11/19/13 the resident had " hemorrhoids and blood when having BM. " No pain was reported on 11/19/13. On 11/20 the resident did not report any pain and did not have any rectal bleeding. On 11/20 the resident did not report any pain and did not have any rectal bleeding. On 11/21 the resident was assessed with [REDACTED]. On 11/22/13 the resident was assessed at 2:25 PM. Her vital signs were 97.8 degrees (temperature), 99 heart beats per minute, 24 respirations per minute, 110/70 blood pressure, her pulse oximetry was 94% and her pain level was a 7/10. Her pain was noted to be generalized and she was medicated. The resident was alert and oriented times three and was verbally coherent. The resident ' s urine was amber in color. The resident last had a bowel movement on 11/22/13 and was noted to have bright red blood " from hemorrhoids. MD paged. " The resident ' s skin was jaundiced. There was no documented evidence that the nursing staff attempted to contact the attending physician to obtain orders for a PT/INR. Review of the Transfer Form dated 11/22/13 revealed the resident was transferred to the ER for abnormal labs, jaundice, diarrhea and nausea. When an order for [REDACTED]. She was discharged prior to her 11/22/13 dose. The eMAR did not include the lab box for the entry of the INR lab value. The nurses that administered the [MEDICATION NAME] at 5 PM were Employees D, E, F (LPNs). Record review revealed the resident did not have an Anticoagulation Flow sheet. The flow sheet was utilized by the facility for tracking and trending the PT/INR, current [MEDICATION NAME] dose and adjustments and physician and responsible party notification per facility protocol. Review of the physician's order [REDACTED]. On 11/14 the resident had a CMP (Comprehensive Metabolic Panel) and BNP (B-Type Naturetic Peptide, used to measure fluid volume) was ordered. On 11/18/13 the resident had a CMP ordered and her [MEDICATION NAME] was discontinued as well as her [MEDICATION NAME] was increased due to an increase in her liver enzymes and a decrease in her kidney function. On 11/20/13 an order was obtained for a BNP and a CMP, the resident ' s liver and kidney functions were still compromised. On 11/22/13 an order was obtained to send the resident to the ER (emergency room ). There were no orders for a PT/INR. Review of the Physician ' s Progress Notes revealed the resident was " doing ok " on 11/18/13. On 11/21/13 the resident was " doing ok. " There was no documented evidence the physician addressed the resident ' s [MEDICATION NAME] administration or lack of a PT/INR. Review of the laboratory data dated 11/19/13 revealed the resident ' s renal and liver functions were elevated. The lab data dated 11/22/13 and received by the facility at 11:37 AM revealed the resident ' s renal and liver functions were elevated. No PT/INRs were obtained or ordered. A resident with elevated renal and liver function is indicative of kidney and liver failure. Medications are broken down by the liver and excreted through the kidneys, when either of the organs is not functioning appropriately, the medication accumulates in the body causing increased medication levels and potentially harmful side effects. In addition, one of the functions of the liver is the production of blood clotting factors that [MEDICATION NAME] directly inhibits. If the liver functions are compromised and not producing the clotting factors, the [MEDICATION NAME] effects could also intensify (i.e. increased bleeding times.) During an interview on 12/2/13 10:05 AM the Pharmacy Consultant, stated that he completed a 100% audit of all residents currently in house once a month. He stated that he routinely checked for drug interactions, irregularities, unnecessary medications and reviews labs. He also stated that for a resident receiving [MEDICATION NAME], he would check the PT/INRs. He stated that if no labs were in the chart he would request a PT/INR from the physician. He stated that he was last in the facility on 11/14/13. Review of the 11/14/13 Pharmacy Consultant Recommendations revealed Resident #1 was reviewed with no recommendations for a PT/INR were requested. During a follow up interview on 12/2/13 at 11:10 AM, the Pharmacy Consultant stated that he " must have seen the hospital INR " and " it must have been within limits. " He stated that there was no literature that defined how often a PT/INR should be collected and stated that he was not aware of any facility policy regarding anticoagulation therapy. He stated that he was not aware of Resident #1 ' s Attending Physician ' s PT/INR protocol. During an interview on 11/27/13 at 11:30 AM the attending physician stated that he assessed the resident frequently related to her co-morbid conditions. He stated that he was monitoring her for her increased liver enzymes. The physician stated that he thought her elevated liver enzymes were a result of the [MEDICATION NAME] and he discontinued the [MEDICATION NAME]. He stated that on 11/22/13 he was called and it was reported that she was pale. He stated that the resident was sent to the ER due to her abnormal labs. Lab work was completed at the hospital and she was anemic. He also stated that she had blood in her stool. The physician confirmed she was on [MEDICATION NAME] and that she had a high PT at the hospital; " greater than 120 seconds. " He stated again that the resident was in liver failure. He also stated that the elevated liver enzymes could have been a contributing factor to the increased PT/INR. He confirmed that no orders were written or obtained for a PT/INR and no labs were collected for the PT/INR. He also confirmed facility staff did not contact him for lab orders regarding the PT/INR. He stated that he had a written protocol for when to order PT/INRs and the facility staff were supposed to follow his protocol. During an interview on 11/27/13 at 3:05 PM the Medical Director stated he saw the resident in the hospital on 11/22 and she had a GI Bleed, Acute [MEDICAL CONDITION] and [MEDICAL CONDITION]. The " PT/INR was very elevated " and she received FFP (Plasma) and Vitamin K. The Medical Director was asked regarding the facility ' s policy on PT/INR lab draws. He stated that it was up to the attending physician to set his own protocols. He stated that he checked his residents every Monday and Thursday. He also stated that " everyone should be checked when they come in and every three to four days. " He stated that if the PT/INR was stable " it was ok to check every week. " If the resident required a dosage change, then " check the INR every three to four days. " He stated that the nurses would be responsible for contacting the physician for the PT/INR orders. He also stated the nurses should have called the doctor and asked what the plan is for checking the PT/INR for Resident #1. He stated a resident that was newly started on [MEDICATION NAME] should have had PT/INR checked in one week or less from admission. He stated that Resident #1 was a " system failure. " The Medical Director stated that he was the Medical Director of the facility and did not have specific contact with the resident prior to 11/22. He also stated that the facility did not have any specific policy regarding the frequency of PT/INR draws, however he stated again that it should be done at least weekly if stable and more frequently if warranted. During an interview on 11/27/13 at 11:47 AM Employee A (CNA) stated she routinely cared for Resident #1. She stated the resident was continent but would not get up to go to the bathroom. She had diarrhea one day. The resident had bright red blood in the toilet. The resident stated that she had hemorrhoids. Employee A reported the bleeding to the nurse. The nurse (Employee B) came in and looked at the resident. She stated that the resident did not have any pain. The CNA stated that the resident was later sent to the ER. During an interview on 11/27/13 at 12 PM with Employee B (LPN) and Employee G (LPN Unit Manager), Employee B stated that she cared for Resident #1 and had noticed some jaundice, abnormal labs and diarrhea; she paged the doctor and he ordered a non-emergent transfer. However, the family insisted on 911. Called 911 and the resident left via ambulance. She stated the resident hadn ' t left by end of shift, but she left around 3:30 PM with the EMS personnel. The LPN stated that the resident had blood from hemorrhoids, and she could visibly see the hemorrhoids. The resident also complained of her rectum hurting. She did not have any other complaints of pain. The LPN stated that she first paged the doctor around lunch time with the abnormal labs and he said he would come and see her. The unit manager notified the sister. The sister arrived and agreed that she was yellow. The sister called her daughter around 2 PM, and she was coming in the 30 minutes and requested the doctor send her to the ER. She paged the doctor back, assessed the resident again, and her vital signs were stable, the resident was not hurting and was alert and oriented. The physician said to send her out non-emergently. The DON (Director of Nurses) met with the niece around 3 PM and she wanted the resident sent out via 911. The DON notified the unit manager to call the doctor and request to send 911. The LPN called the physician back and he agreed to 911 transport. 911 was called and the resident left via stretcher at approximately 3:30 PM. The nurse stated that the resident was receiving [MEDICATION NAME] at 5 PM daily. She stated that the attending physician specialized his care for each patient. She stated that the other attending physician ' s in the facility would order PT/INRs based on admission and were typically drawn on Mondays and Thursdays. She stated that the resident did not have any PT/INRs drawn or ordered. She stated that if a PT/INR was not ordered, the nurses would notify the doctor that the PT/INR not scheduled and get them scheduled. She stated that Employee C (Desk Nurse on East) takes care of all of the attending physician's order [REDACTED]. She stated that the attending physician preferred to go through one nurse (Employee C) for all of his orders. During an interview on 11/27/13 at 12:15 PM with Employee C (Desk Nurse) and the DON, Employee C stated that she acted as a liaison between the doctors and the staff. She stated that she attempted to group the issues and the labs and make one phone call a day to the physician if possible and get the information together for rounds. She stated that the attending physician was in the facility 3-4 times per week. The attending physician gave his orders to Employee C and she entered the items into the computer. She stated the labs were typically routine with [MEDICATION NAME] and some of the doctors had Monday and Thursday standing orders for labs. However, Resident #1 ' s attending physician ordered his own labs for his residents. If a resident had a PT/INR completed in the hospital then the attending physician decided when the next one would be completed. She stated that it was unknown if anyone asked the physician regarding the INR. The DON stated that attending physician could be difficult and liked to order his own labs. He also stated that the physician " individualized care " to each resident. The DON also stated that the attending physician had a guideline with when to order the PT/INR that was written up " a while back. " During an interview 11/27/13 at 3:36 PM Employee D (LPN) stated that she routinely worked the 3-11 shift and was responsible for administering [MEDICATION NAME] to the residents. She stated Resident #1 was on 3 mg of [MEDICATION NAME] and the medication was given during the evening med pass. The nurse confirmed no PT/INRs were ordered or drawn. She stated that the attending physician ordered his own labs. She stated that this physician was " very strict regarding his patients. " She stated that she didn ' t question him " because he was a stickler. " She also stated that he had a strong personality. The nurse stated again that she didn ' t question the physician regarding the lack of a PT/INR and confirmed that she administered the medication to the resident. The nurse also confirmed that she did not inform the unit manager or the DON of the lack of PT/INRs. During an interview on 11/27/13 at 3:47 PM Employee E (LPN Evening Supervisor) stated that the resident was alert and oriented, diabetic, on [MEDICATION NAME]. The resident had hemorrhoids. Employee E confirmed that she administered [MEDICATION NAME] to Resident #1 at 5 PM. Employee E stated that she didn ' t see any PT/INR ' s on the chart and stated that the attending physician ordered his own labs. She stated that it was " not unusual to not have an order for [REDACTED]. However, confirmed again that the resident did not have a PT/INR and she administered the medication to the resident. She also confirmed that she didn ' t inform anyone (Physician, Unit Manager, Director of Nurses or the Medical Director) of the lack of PT/INRs. She stated that the attending physician only went through one person (Employee C) and he had a certain way he liked things done. Employee E also confirmed she didn ' t speak with Employee C regarding orders for a PT/INR. During an interview on 12/2/13 at 11:45 AM Employee F (LPN) stated that she typically worked the weekend evening shift and was trained to document " see chart " and not the actual lab value on the eMAR. She stated that she did not ever check the PT/INR since she worked the weekends. Surveyor informed DON and he stated he expected the nurses to check the PT/INR prior to [MEDICATION NAME] administration. During an interview on 11/27/13 at 12:50 PM the DON (Director of Nurses), stated that Resident #1 ' s attending physician " was very difficult to deal with and he created an aura of no one to question him. " The DON stated that the attending physician was monitoring her liver enzymes. The resident was jaundiced. The attending physician was informed again of the labs and ordered the resident out to the hospital non-emergently. The resident was stable with no active signs of bleeding. The DON called the unit and got the resident out 911 per the family ' s request. The DON stated that he did not see the resident but had the unit manager go assess her. The resident was admitted to the hospital (he stated he was informed on 11/23 of her admission). The resident was admitted with a possible a GI bleed. The DON was informed on 11/25/13 of the resident ' s hospital course. The DON stated that he " looked into the issue. " Review and discussion of the DON ' s review of the incident revealed: the PT/INR was last done on 11/6 while at the hospital. The resident was receiving [MEDICATION NAME] 3 mg. She was on [MEDICATION NAME] in the hospital and resident didn ' t want to be on [MEDICATION NAME] and she was switched to [MEDICATION NAME] during the most recent admission. No further PT/INRs were drawn. The DON stated that there was " no rhyme or reason for his (the attending physician ' s) orders. " Review of the in-service documentation revealed 14 direct care nursing staff were not in-serviced including one of the three nurses that administered the [MEDICATION NAME] without notifying the physician of the lack of an INR. (Employee E). During an interview on 12/2/13 at 1 PM the ADON, confirmed the 14 staff members who were not educated, including one of the nurses involved in the incident. She stated that she did not have any plans for additional education related to anticoagulant therapy. The facility implemented the following measures which resulted in the removal of the Immediate Jeopardy on 12/3/13 at 5:50 PM. The measures included: All current residents on [MEDICATION NAME] have been sampled with no additional resident identified with any concerns. All residents have orders for [MEDICATION NAME], orders for PT/INRs that were collected routinely, a [MEDICATION NAME] Flow sheet, and an Anticoagulant Care Plan. During an interview on 12/3/13 at 9:30 AM the Director of Nurses stated that 100% current staff members were educated on 12/2/13 per the ADON. Four PRN staff members were terminated due to not working within 3 months. Three have been removed from the schedule until the in-service has been completed. An audit was conducted on 12/2/13 of all residents receiving [MEDICATION NAME]. All residents had a PT/INR collected on 12/2/13 per physician's order [REDACTED]. The PT/INRs and the [MEDICATION NAME] Flow Sheets were validated on 12/3/13 by the survey team. Review of the Lab Data collected on 12/2/13 on all residents receiving [MEDICATION NAME] revealed no resident had a supratherapeutic INR (greater than 3.5). On 12/3/13 all nurses on the first and second shift of all three units were interviewed. The nurses were able to articulate the facility ' s physician order [REDACTED]. They were able to state all residents had orders for PT/INRs to be drawn either on Mondays or Mondays and Thursdays. They also stated that the each resident had a [MEDICATION NAME] Flow Sheet. All of the nurses were able to describe the signs and symptoms of a high PT/INR (i.e. bleeding). The nurses also stated that they were would contact the physician regarding an abnormal lab value. The nurses stated that they would contact the physician for lab orders if no PT/INR was available for review and had not been ordered. The eMAR system has now been revised to include a hard stop on the lab entry prior to initialing the [MEDICATION NAME] as given.

Based on review of the facility ' s policy and guidelines for Anticoagulant Therapy, resident record review, nursing staff interviews, and interviews with the attending physician, and the Medical Director Resident #1 ' s attending physician failed to order required laboratory tests to monitor a resident on [MEDICATION NAME] for one of twenty sampled residents reviewed for [MEDICATION NAME] Therapy. Resident #1 had received 3 mg of [MEDICATION NAME] daily without adequate monitoring of the high risk medication. Facility staff did not contact the attending physician for lab orders due to the attending physician ' s preference of not wanting staff to contact him directly. Resident #1 developed elevated liver enzymes, and then developed an acute [MEDICAL CONDITION] related to " Coagulopathy secondary to [MEDICATION NAME] " and severe [MEDICAL CONDITION]. Per facility audits, nineteen current residents receiving [MEDICATION NAME] were potentially affected. The failure of the attending physician to adequately monitor a resident receiving anticoagulant therapy resulted in the findings of Immediate Jeopardy existing in the facility as of 11/6/13. The Immediate Jeopardy was removed on 12/3/13 at 5:50 PM and the scope and severity was reduced to a " D. " The findings included: During an interview on 11/27/13 at 11:30 AM the attending physician stated that he assessed Resident #1 frequently related to her co-morbid conditions. He stated that he was monitoring her for her increased liver enzymes. The physician stated that he thought her elevated liver enzymes were a result of the [MEDICATION NAME] and he discontinued the [MEDICATION NAME]. He stated that on 11/22/13 he was called and it was reported that she was pale. He stated that the resident was sent to the ER (emergency room ) due to her abnormal labs. Lab work was completed at the hospital and she was anemic. He also stated that she had blood in her stool. The physician confirmed she was on [MEDICATION NAME] and that she had a high PT ([MEDICATION NAME] Time) at the hospital; " greater than 120 seconds. " He stated again that the resident was in liver failure. He also stated that the elevated liver enzymes could have been a contributing factor to the increased PT/INR ([MEDICATION NAME]/International Normalizing Ratio; a measure for blood clotting time). He confirmed that no orders were written or obtained for a PT/INR and no labs were collected for the PT/INR. He also confirmed facility staff did not contact him for lab orders regarding the PT/INR. He stated that he had a written protocol for when to order PT/INRs and the facility staff were supposed to follow his protocol. During an interview on 11/27/13 at 12:50 PM the DON (Director of Nurses), stated that Resident #1 ' s attending physician " was very difficult to deal with and he created an aura of no one to question him. " The DON stated that the attending physician was monitoring her liver enzymes. The resident was jaundiced. The attending physician was informed again of the labs and ordered the resident out to the hospital non-emergently. The resident was stable with no active signs of bleeding. The DON called the unit and got the resident out 911 per the family ' s request. The DON stated that he did not see the resident but had the unit manager go assess her. The resident was admitted to the hospital (he stated he was informed on 11/23 of her admission). The resident was admitted with a possible a GI bleed. The DON was informed on 11/25/13 of the resident ' s hospital course. The DON stated that he " looked into the issue. " Review and discussion of the DON ' s review of the incident revealed: the PT/INR was last done on 11/6 while at the hospital. The resident was receiving [MEDICATION NAME] 3 mg. She was on [MEDICATION NAME] in the hospital and resident didn ' t want to be on [MEDICATION NAME] and she was switched to [MEDICATION NAME] during the most recent admission. No further PT/INRs were drawn. The DON stated that there was " no rhyme or reason for his (the attending physician ' s) orders. " During an interview on 11/27/13 at 3:05 PM the Medical Director stated he saw Resident #1 in the hospital on 11/22 and she had a GI Bleed, Acute [MEDICAL CONDITION] and [MEDICAL CONDITION]. The " PT/INR was very elevated " and she received FFP (Plasma) and Vitamin K. The Medical Director was asked regarding the facility ' s policy on INR lab draws. He stated that it was up to the attending physician to set his own protocols. He stated that he checked his residents every Monday and Thursday. He also stated that " everyone should be checked when they come in and every three to four days. " He stated that if the PT/INR was stable " it was ok to check every week. " If the resident required a dosage change, then " check the INR every three to four days. " He stated that the nurses would be responsible for contacting the physician for the INR orders. He also stated the nurses should have called the doctor and asked what the plan is for checking the PT/INR for Resident #1. He stated a resident that was newly started on [MEDICATION NAME] should have had PT/INR checked in one week or less from admission. He stated that Resident #1 was a " system failure. " The Medical Director stated that he was the Medical Director of the facility and did not have specific contact with the resident prior to 11/22. He also stated that the facility did not have any specific policy regarding the frequency of PT/INR draws, however he stated again that it should be done at least weekly if stable and more frequently if warranted. Review of the facility ' s policy entitled " Anticoagulant Therapy " with a copyright date of 2008 revealed the Purpose of the policy was " To effectively monitor residents receiving anticoagulant therapy and reduce the risk of bleeding by maintaining therapeutic blood levels in accordance with physician orders. " Under Procedure, Item 3 " Confirm with the physician the desired INR/PT testing schedule and therapeutic range at the time of the anticoagulant therapy order. " Item 11 revealed " Document lab results, current dosage and physician orders [REDACTED]. " Review of the Attending Physician ' s " PT/INR Protocol " given to the facility in 2012 revealed: " All new admissions who are on [MEDICATION NAME], you must use the Anticoagulant MAR " (no longer valid with eMAR). " Category A- New admissions- if the resident doesn ' t come with a current PT/INR, you are to write an order to be done the next day. " " Category B -New admissions- if the resident does come with a current (the day of admission) PT/INR result, then you are to write an order for [REDACTED]." " Once you determine what category the resident goes under then. You must write an order for [REDACTED]. Review of Wittkowsky, Ann, The American Society of Health System Pharmacists, Chapter 24 [MEDICATION NAME], pages 358 revealed: " The intensity of [MEDICATION NAME] therapy is monitored by evaluation of the [MEDICATION NAME] time (PT), expressed as the INR ... " Table 24.7 summarizes the Frequency of INR Monitoring and Patient Assessment. If the initiation of the therapy utilized the flexible initiation method, then after administration of the first dose of [MEDICATION NAME]/[MEDICATION NAME], monitor the INR daily through day four of administration. If utilizing the Average daily dosing method, monitor the INR every 3-5 days until the INR is greater than the lower limit of the desired therapeutic range then within 1 week. After hospital discharge: if the patient is stable, monitor the INR within 3-5 days, if the patient is unstable monitor the INR within 1-3 days. During the first month of treatment, monitor the INR at least weekly. The routine follow up for an INR of a medically unstable is every 1-2 weeks. Review of the Geriatric Dosage Handbook 12th Edition 2007, pg. 1179, Initiation of Oral Anticoagulation With [MEDICATION NAME] revealed: " Dosing of [MEDICATION NAME] ([MEDICATION NAME]) must be individualized according to patient response to the drug as indicated by the INR ... " " Step 1. Obtain baseline INR. Begin therapy with [MEDICATION NAME] with a dose of 2-5 mg per day with dosage adjustments based on results of INR determinations. " " Step 2. Day that INR is stabilized in the therapeutic range: Check INR daily. Adjust [MEDICATION NAME] dose based on the results of INR determinations. Patients stabilized in the therapeutic range: Intervals between subsequent INR determinations should be based upon the physician ' s judgment of the patient ' s reliability and response to [MEDICATION NAME] in order to maintain the individual within therapeutic range. Acceptable intervals for INR determinations are normally within the range of 1-4 weeks after a stable dosage has been determined. Most patients are satisfactorily maintained on [MEDICATION NAME] at a dose of 2-10 mg daily. " During an interview on 11/27/13 at 11:47 AM Employee A (CNA) stated she routinely cared for Resident #1. She stated the resident was continent but would not get up to go to the bathroom. She had diarrhea one day. The resident had bright red blood in the toilet. The resident stated that she had hemorrhoids. Employee A reported the bleeding to the nurse. The nurse (Employee B) came in and looked at the resident. She stated that the resident did not have any pain. The CNA stated that the resident was later sent to the ER. During an interview on 11/27/13 at 12 PM with Employee B (LPN) and Employee G (LPN Unit Manager), Employee B stated that she cared for Resident #1 and had noticed some jaundice, abnormal labs and diarrhea; she paged the doctor and he ordered a non-emergent transfer. However, the family insisted on 911. Called 911 and the resident left via ambulance. She stated the resident hadn ' t left by end of shift, but she left around 3:30 PM with the EMS personnel. The LPN stated that the resident had blood from hemorrhoids, and she could visibly see the hemorrhoids. The resident also complained of her rectum hurting. She did not have any other complaints of pain. The LPN stated that she first paged the doctor around lunch time with the abnormal labs and he said he would come and see her. The unit manager notified the sister. The sister arrived and agreed that she was yellow. The sister called her daughter around 2 PM, and she was coming in the 30 minutes and requested the doctor send her to the ER. She paged the doctor back, assessed the resident again, and her vital signs were stable, the resident was not hurting and was alert and oriented. The physician said to send her out non-emergently. The DON (Director of Nurses) met with the niece around 3 PM and she wanted the resident sent out via 911. The DON notified the unit manager to call the doctor and request to send 911. The LPN called the physician back and he agreed to 911 transport. 911 was called and the resident left via stretcher at approximately 3:30 PM. The nurse stated that the resident was receiving [MEDICATION NAME] at 5 PM daily. She stated that the attending physician specialized his care for each patient. She stated that the other attending physician ' s in the facility would order PT/INRs based on admission and were typically drawn on Mondays and Thursdays. She stated that the resident did not have any PT/INRs drawn or ordered. She stated that if an PT/INR was not ordered, the nurses would notify the doctor that the PT/INR not scheduled and get them scheduled. She stated that Employee C (Desk Nurse on East) takes care of all of the attending physician's order [REDACTED]. She stated that the attending physician preferred to go through one nurse (Employee C) for all of his orders. During an interview on 11/27/13 at 12:15 PM with Employee C (Desk Nurse) and the DON, Employee C stated that she acted as a liaison between the doctors and the staff. She stated that she attempted to group the issues and the labs and make one phone call a day to the physician if possible and get the information together for rounds. She stated that the attending physician was in the facility 3-4 times per week. The attending physician gave his orders to Employee C and she entered the items into the computer. She stated the labs were typically routine with [MEDICATION NAME] and some of the doctors had Monday and Thursday standing orders for labs. However, Resident #1 ' s attending physician ordered his own labs for his residents. If a resident had an PT/INR completed in the hospital then the attending physician decided when the next one would be completed. She stated that it was unknown if anyone asked the physician regarding the INR. The DON stated that attending physician could be difficult and liked to order his own labs. He also stated that the physician " individualized care " to each resident. The DON also stated that the attending physician had a guideline with when to order the PT/INR that was written up " a while back. " During an interview 11/27/13 at 3:36 PM Employee D (LPN) stated that she routinely worked the 3-11 shift and was responsible for administering [MEDICATION NAME] to the residents. She stated Resident #1 was on 3 mg of [MEDICATION NAME] and the medication was given during the evening med pass. The nurse confirmed no PT/INRs were ordered or drawn. She stated that the attending physician ordered his own labs. She stated that this physician was " very strict regarding his patients. " She stated that she didn ' t question him " because he was a stickler. " She also stated that he had a strong personality. The nurse stated again that she didn ' t question the physician regarding the lack of an PT/INR and confirmed that she administered the medication to the resident. The nurse also confirmed that she did not inform the unit manager or the DON of the lack of PT/INRs. During an interview on 11/27/13 at 3:47 PM Employee E (LPN Evening Supervisor) stated that the resident was alert and oriented, diabetic, on [MEDICATION NAME]. The resident had hemorrhoids. Employee E confirmed that she administered [MEDICATION NAME] to Resident #1 at 5 PM. Employee E stated that she didn ' t see any PT/INR ' s on the chart and stated that the attending physician ordered his own labs. She stated that it was " not unusual to not have an order for [REDACTED]. However, confirmed again that the resident did not have an PT/INR and she administered the medication to the resident. She also confirmed that she didn ' t inform anyone (Physician, Unit Manager, Director of Nurses or the Medical Director) of the lack of PT/INRs. She stated that the attending physician only went through one person (Employee C) and he had a certain way he liked things done. Employee E also confirmed she didn ' t speak with Employee C regarding orders for an PT/INR. During an interview on 12/2/13 at 11:45 AM Employee F (LPN) stated that she typically worked the weekend evening shift and was trained to document " see chart " and not the actual lab value on the eMAR. She stated that she did not ever check the PT/INR since she worked the weekends. Surveyor informed DON and he stated he expected the nurses to check the PT/INR prior to [MEDICATION NAME] administration. During an interview on 12/2/13 10:05 AM the Pharmacy Consultant, stated that he completed a 100% audit of all residents currently in house once a month. He stated that he routinely checked for drug interactions, irregularities, unnecessary medications and reviews labs. He also stated that for a resident receiving [MEDICATION NAME], he would check the PT/INRs. He stated that if no labs were in the chart he would request a PT/INR from the physician. He stated that he was last in the facility on 11/14/13. Review of the 11/14/13 Pharmacy Consultant Recommendations revealed Resident #1 was reviewed with no recommendations for a PT/INR were requested. During a follow up interview on 12/2/13 at 11:10 AM, the Pharmacy Consultant stated that he " must have seen the hospital INR " and " it must have been within limits. " He stated that there was no literature that defined how often an PT/INR should be collected and stated that he was not aware of any facility policy regarding anticoagulation therapy. He stated that he was not aware of Resident #1 ' s Attending Physician ' s PT/INR protocol. During an interview on 12/5/13 at 11:35 AM, Resident #1 ' s family member stated that Resident #1 was admitted to the facility for rehabilitation services and was supposed to be discharged home. She also stated that the resident did not have any previous history of [MEDICAL CONDITION] and developed an acute bleed at the facility. The facility admitted Resident #1 on 11/6/13 with [DIAGNOSES REDACTED]. The resident was admitted to the facility for Short Term Subacute Care. The resident was receiving Physical and Occupational Therapy for function and strengthening. Review of the Hospital History and Physical dated 10/29/13 revealed the resident was receiving Aspirin 81 mg daily and [MEDICATION NAME] 75 mg twice daily for anticoagulation. The resident ' s Aspirin and [MEDICATION NAME] were discontinued in the hospital and she was started on [MEDICATION NAME] as a new therapy. Review of the hospital laboratory data revealed a PT/INR was collected on 11/5 with a result of 1.8. On 11/6 the PT/INR was 2.4 indicating an upward trend, however still within therapeutic range (between 2.0 and 3.5). Review of the Admission Minimum (MDS) data set [DATE] revealed the resident scored a 15/15 on her Brief Interview for Mental Status indicating no cognitive impairment. No behaviors were coded during the assessment window. The resident required extensive one to two person assistance with all activities of daily living except eating. The resident was coded as continent of bowel and bladder. Review of the admission orders [REDACTED]. There were no orders for a PT/INR upon admission or during her admission to the facility. Review of the Care Plan dated 11/6/13 revealed a problem area related to bleeding and anticoagulant use with approaches including " labs as ordered, notify MD of lab results out of expected range, check PT/INR prior to administering anticoagulant medication, observe for unusual bleeding, blood in stool or urine ..., encourage, remind and assist to avoid activities that may cause injury and encourage and assist as needed to use soft toothbrush ... " Facility staff however, did not make any attempt to contact the physician for PT/INR orders in accordance with the plan of care. Review of the Narrative Nurses Notes revealed the resident was admitted on [DATE] and was alert and oriented times three and required moderate 1-2 person assistance with her activities of daily living. The facility nurses did not document the resident ' s admitting PT/INR lab on the admission note. The resident reported diarrhea upon admission. Review of the nurses ' note dated 11/22/13 at 3:57 PM revealed, " at approx(imately). 2:30 PM, MD (Medical Doctor) responded to page and instructed to send pt (patient) out to (local hospital) non-emergent for eval(uation) pt has abnormal lab values, c/o (complains of) diarrhea and nausea and blood in stool from hemorrhoids. Pt has yellow tinged skin. Contacted sister to inform of pts condition. Pts skin is warm, dry and intact. Redness to inner buttocks. Pts family members requested to be sent by emergency 911, so 911 was called. Will wait with pt until EMS (Emergency Medical Services) arrives. " Review of the daily Clinical Nursing Assessments revealed between 11/7-11/18/13 there was no documentation of resident reported pain or blood in the resident ' s stool. Her skin was normal in appearance. On 11/19/13 the resident had " hemorrhoids and blood when having BM. " No pain was reported on 11/19/13. On 11/20 the resident did not report any pain and did not have any rectal bleeding. On 11/20 the resident did not report any pain and did not have any rectal bleeding. On 11/21 the resident was assessed with [REDACTED]. On 11/22/13 the resident was assessed at 2:25 PM. Her vital signs were 97.8 degrees (temperature), 99 heart beats per minute, 24 respirations per minute, 110/70 blood pressure, her pulse oximetry was 94% and her pain level was a 7/10. Her pain was generalized and she was medicated. The resident was alert and oriented times three and was verbally coherent. The resident ' s urine was amber in color. The resident last had a bowel movement on 11/22/13 and was noted to have bright red blood " from hemorrhoids. MD paged. " The resident ' s skin was jaundiced. There was no documented evidence that the nursing staff attempted to contact the attending physician to obtain orders for a PT/INR. Review of the Transfer Form dated 11/22/13 revealed the resident was transferred to the ER for abnormal labs, jaundice, diarrhea and nausea. When an order for [REDACTED]. She was discharged prior to her 11/22/13 dose. The eMAR did not include the lab box for the entry of the INR lab value. The nurses that administered the [MEDICATION NAME] at 5 PM were Employees D, E, F (LPNs). Record review revealed the resident did not have an Anticoagulation Flow sheet. The flow sheet was utilized by the facility for tracking and trending the PT/INR, current [MEDICATION NAME] dose and adjustments and physician and responsible party notification per facility protocol. Review of the physician's order [REDACTED]. On 11/14 the resident had a CMP (Comprehensive Metabolic Panel) and BNP (B-Type Naturetic Peptide, used to measure fluid volume) was ordered. On 11/18/13 the resident had a CMP ordered and her [MEDICATION NAME] was discontinued as well as her [MEDICATION NAME] was increased due to an increase in her liver enzymes and a decrease in her kidney function. On 11/20/13 an order was obtained for a BNP and a CMP, the resident ' s liver and kidney functions were still compromised. On 11/22/13 an order was obtained to send the resident to the ER (emergency room ). There were no orders for a PT/INR. Review of the Physician ' s Progress Notes revealed the resident was " doing ok " on 11/18/13. On 11/21/13 the resident was " doing ok. " There was no documented evidence the physician addressed the resident ' s [MEDICATION NAME] administration or lack of a PT/INR. Review of the laboratory data dated 11/19/13 revealed the resident ' s renal and liver functions were elevated. The lab data dated 11/22/13 and received by the facility at 11:37 AM revealed the resident ' s renal and liver functions were elevated. No PT/INRs were obtained or ordered. A resident with elevated renal and liver function is indicative of kidney and liver failure. Medications are broken down by the liver and excreted through the kidneys, when either of the organs are not functioning appropriately, the medication accumulates in the body causing increased medication levels and potentially harmful side effects. In addition, one of the functions of the liver is the production of blood clotting factors that [MEDICATION NAME] directly inhibits. If the liver functions are compromised and not producing the clotting factors, the [MEDICATION NAME] effects could also intensify (i.e. increased bleeding times.) Review of the hospital records obtained on 12/2/13 from the hospital revealed the PT on 11/22/13 was >120 seconds and the " INR was not done " due to the lack of clotting. The therapeutic range for the [MEDICATION NAME] indicated for clot prevention is 9-12.5 seconds and a therapeutic INR is between 2.0 and 3.5. The resident ' s hemoglobin level was 5.3 g/dL, normal range is 11.3-15.6 g/dL. Both lab values (the PT and the hemoglobin) were critical lab values that required immediate intervention. Review of the Hospital History and Physical dated 11/23 revealed the resident was admitted to the hospital for abdominal pain, elevated liver enzymes. While in the ER, the resident was also diagnosed with [REDACTED]. The INR was supratherapeutic. The family gave consent for blood [MEDICAL CONDITION] and blood pressure support. The resident received 10 mg of Vitamin K in the emergency room as an antidote to the [MEDICATION NAME]. Her blood pressure was 85/43. The physician ' s impression was " 1. GI Bleed 2. Coagulopathy secondary to [MEDICATION NAME] 3. Severe [MEDICAL CONDITION]. " The plan was to admit to the ICU and transfuse Fresh Frozen Plasma and 2 units of packed red blood cells. The resident ' s prognosis was poor. Per a family interview on 12/5/13 at 11.35 AM, the resident was transfused with 2 units of Fresh Frozen Plasma and 4 Units of Packed Red Blood Cells. She stated that the resident ' s kidneys ' did not regain function and she was unable to remove the excess fluid from the [MEDICAL CONDITION] (potentially 2 extra liters of fluid). Because the resident could not remove the fluid, the excess fluid caused an exacerbation of her underlying [MEDICAL CONDITION] which in turn caused respiratory distress and then her death. Review of the in-service documentation revealed 14 direct care nursing staff were not in-serviced including one of the three nurses that administered the [MEDICATION NAME] without notifying the physician of the lack of an INR. (Employee E). During an interview on 12/2/13 at 1 PM the ADON, confirmed the 14 staff members who were not educated, including one of the nurses involved in the incident. She stated that she did not have any plans for additional education related to anticoagulant therapy. The facility implemented the following measures which resulted in the removal of the Immediate Jeopardy on 12/3/13 at 5:50 PM. The measures included: All current residents on [MEDICATION NAME] have been sampled with no additional resident identified with any concerns. All residents have orders for [MEDICATION NAME], orders for PT/INRs that were collected routinely, a [MEDICATION NAME] Flow sheet, and an Anticoagulant Care Plan. During an interview on 12/3/13 at 9:30 AM the Director of Nurses stated that 100% current staff members were educated on 12/2/13 per the ADON. Four PRN staff members were terminated due to not working within 3 months. Three have been removed from the schedule until the in-service has been completed. An audit was conducted on 12/2/13 of all residents receiving [MEDICATION NAME]. All residents had a PT/INR collected on 12/2/13 per physician's order [REDACTED]. The PT/INRs and the [MEDICATION NAME] Flow Sheets were validated on 12/3/13 by the survey team. Review of the Lab Data collected on 12/2/13 on all residents receiving [MEDICATION NAME] revealed no resident had a supratherapeutic INR (greater than 3.5). On 12/3/13 all nurses on the first and second shift of all three units were interviewed. The nurses were able to articulate the facility ' s physician order [REDACTED]. They were able to state all residents had orders for PT/INRs to be drawn either on Mondays or Mondays and Thursdays. They also stated that the each resident had a [MEDICATION NAME] Flow Sheet. All of the nurses were able to describe the signs and symptoms of a high INR (i.e. bleeding). The nurses also stated that they were would contact the physician regarding an abnormal lab value. The nurses stated that they would contact the physician for lab orders if no PT/INR was available for review and had not been ordered. The eMAR system has now been revised to include a hard stop on the lab entry prior to initialing the [MEDICATION NAME] as given.

Based on clinical record review, Pressure ulcer policies and procedures review, and staff interview, the facility failed to provide accurate assessments, and intervention to residents identified at increased risks for developing pressure ulcers, which resulted in an avoidable, in-house acquired, unstageable pressure ulcer for one (#2) of three sampled residents for pressure ulcers. Findings include: Review of the clinical record for resident #2 revealed the resident was admitted to the nursing center on 12/30/10 for rehabilitation after a right hip replacement. The resident was discharged back to the hospital on [DATE] due to a foul smelling, unstageable pressure ulcer on her sacrum, at the family's request. Review of the initial Minimum Data Set assessment reference date was 01/06/2011 and was signed as completed by the RN Assessment Coordinator on 01/10/2011. The resident was coded as having no mood or behavior concerns. Under Section G, Functional Status, she was coded as requiring extensive assistance of one personal physical assist for bed mobility, transfers, locomotion on unit, lomcomotion off unit, dressing, toilet use, personal hygiene; and for bathing she was coded as requiring physical help in part of bathing activity with one person assistance. Under Section M, Skin Conditions, she was coded as having no pressure ulcers, but having a surgical wound. Under Section H for continence, she was coded as being continent of bowel and bladder. Weekly and p.r.n. (as necessary) skin check dated on the day of admission, 12/30/10 noted that the resident had a right hip surgical wound. On 01/06/11 on the same weekly and p.r.n. skin check document noted that there were no changes, and there was a checkmark indicating there were no new areas of skin impairment. On the same document, on 01/13/11 it noted the resident had an open area on the sacrum. On 01/09/11 a weekly skin grid for resident #2 noted the resident had a pressure ulcer in the sacrum, partial thickness, measuring 4.0 cm. x 3.5 cm. x 0.2 cm. (length x width x depth). with a small amount of blood drainage. Color pink, necrotic/slough (dead tissue), mild odor, periwound pink, no tunneling or undermining. The next measurement was taken on 01/13/11 and the nurse documented the ulcer was unstageable measuring 3.9 cm. x 4.0 cm. x 0.1/0.2 cm. There was serous drainage, the periwound area was excoriated, and the color of the wound bed was black, foul odor. Review of the resident's care plan revealed a care plan dated 12/30/10 noting that the resident has a disruption in skin integrity not related to pressure, right hip surgical site, and that the resident has a potential for skin breakdown. The same care plan was updated on 01/10/11 noting that the resident had an open area to the sacrum, and that the resident was non-compliant with turning and repositioning. The care plan included multiple approaches, which included to inspect skin during bathing and during dressing changes, especially over bony prominences. Notify nurse immediately of any new areas of skin breakdown, redness, blisters, bruises, discoloration noted during bathing or daily care. To assist with positioning p.r.n./shift weight to relieve pressure. Monitor for signs and symptoms of infection or delayed healing and report to MD p.r.n. On 02/04/11, several staff interviews were conducted as follows: At 3:30 p.m., an interview with the staff nurse caring for the resident when she was in the nursing center, revealed that the resident had been admitted with a hip surgical wound, and no other wounds or pressure ulcers on admission. He stated that the wound on the sacrum was found by the Certified Nursing Assistant (CNA) on 01/09/11, and the weekend wound nurse was notified. When he found out about the pressure ulcer he measured the wound and contacted the physician and received an order to treat. He stated that the weekend nurse had measured the wound, and had already requested a low air loss specialty mattress. At 3:50 pm. an interview with CNA, who cared for the resident on the 7 to 3 shift on 12/31/10 and 01/03/11 revealed the resident refused showers, so she was getting bed baths daily. She stated that the resident would only let her wash her front, and not wash her back. She reported this to the nurse. She stated that the unit manager keeps shower sheets. She stated that the resident used the bed pan, and she provided care after each use, cleansed resident front to back. She checked resident for changes in the skin when giving care. Review of the seven resident bath and skin reports, which had been kept at the nurses station brought for surveyors to review, revealed that on 12/31/10, 01/03/11, 01/05/11, 01/07/11, the resident had refused to let the care giver wash her back. On 01/10/11, 01/12/11 and on 01/14/11 there was no refusal. At 3:56 p.m. an interview with the restorative aide and who works 9:00 to 5:30 p.m., she only worked with this resident on 01/07/11. She washed, dressed and got her up. She does not recall resident having any issues with the skin. At 4:05 p.m., an interview with Staff/Supervisor RN, Supervisor/Staff Nurse stated she completed a skin assessment on the resident on 01/06/11 and did not see any open areas. At 4:15 p.m. and interview Staff/Supervisor RN on the 3 to 11 shift on 01/16/11 when the resident was discharged back to the hospital at the family's request revealed, that a friend of the family, who is an RN, had and who had come to visit the resident with a male visitor, did not know who he was, had requested to look at the resident's wound. They contacted the resident's family up north, and the family gave permission for the RN to look at the wound. The supervisor stated, the CNA was giving care to the resident, who had had a bowel movement. The 3 to 11 staff nurse on 01/16/11 was planning to change the dressing after the resident was cared for. This nurse had identified that the wound had a foul odor and had taken a specimen from the wound to send to the laboratory. The RN family friend stated when she went into the resident's room on 01/16/11 that there was a foul odor coming from the wound and she was afraid that the resident might be septic (blood infection), and requested the resident be sent out to the hospital. Family agreed, and so did the physician. Further record review of resident #2 clinical record revealed a telephone phyisician order was obtained on 01/15/11 for Culture and Sensitivity of the Wound. Laboratory culture reported on 01/18/11, after the resident had been discharged to the hospital revealed heavy growth of two organisms. A review of the facility's Clinical Guidelines Manual, Weekly and PRN Skin check, policy # CCHC 0609 Purpose to document skin condition throughout the resident's stay in the facility....If a new area of impairment is identified between the scheduled checks, it should be documented on the weekly and p.r.n. skin check and the appropriate weekly skin grid initiated depending on the cause. The Procedure has multiple items. Item 4. Identify any changes in the week. These additional risk factors may increase the risk for skin impairment and need to be communicated to the IDT (interdisciplinary team) - it includes new degress in functional ability; new right or left lower extremity [MEDICAL CONDITION]; new right or left lower extremity skin discoloration; refuses some care or treatments; new short term memory loss; new incontinence of bowel or bladder; weight loss this week; recent illness or acute condition; started on steroids; admitted to hospice. The Clinical Guidelines Manual, Weekly Skin Grid, policy # CCHC 01/09 Purpose to track all identified skin alterations and to assess and document weekly size, stage (if applicable), treatment and other pertinent date. The procedure included to notify the physician and family. .