Every finding on record at Temple Manor Nursing Home

Based on observation and interview, the facility failed to ensure storage and maintenance closets containing insulin syringes and hazardous chemicals remained locked in order to protect residents. The administrator reported 37 residents resided in the facility. Findings: A Storage Areas, Maintenance policy, dated December 2009, read in part, Maintenance storage areas shall be maintained in a clean and safe manner. A Hazardous Areas, Devices and Equipment policy, dated July 2017, read in parts, A hazard is defined as anything in the environment that has the potential to cause injury or illness .Sharp objects that are accessible to vulnerable residents .Open areas or items that should be locked when not in use .Access to toxic chemicals .Disabled locks. On 01/22/25 at 10:41 a.m., during initial tour a medical supply closet was observed to be unlocked. Insulin syringes were observed to be stored inside the unlocked closet. On 01/22/25 at 10:53 a.m., a maintenance closet was observed to be unlocked. The closet was observed to contain liquid hand soap, disinfectant spray, and a bottle of granite/stone cleaner without a spray pump or any type of lid on the container. Two cans of AX-IT spray baseboard stripper were observed. A rusted container, without a clear label, was observed with a liquid substance which was noted to have a chemical like smell. On 01/22/25 at 1:00 p.m., the storage/maintenance closets were observed to remain unlocked. On 01/22/25 at 10:45 a.m. to 2:00 p.m., observations of residents were made throughout the facility. No residents were observed to wander into rooms, open doors, or show interest in the supply closets. During this time period several staff members including CNAs, CMAs, and housekeeping staff were interviewed regarding residents with wandering behaviors. Staff reported no knowledge of any resident who would open closed doors or get into the storage and/or maintenance closets. On 01/22/25 at 2:14 p.m., the administrator reported the storage and maintenance closets should have been locked. The administrator reported sometime over the weekend a staff member had combined all of the keys to the storage closets on one key holder. The administrator reported maintenance staff was going to change and install all new locks on each of the supply closets immediately.

Based on observation, record review, and interview, the facility failed to ensure oxygen tubing was labeled and dated, per the facility policy and professional standards of care, for two (#9 and #19) of three residents reviewed for respiratory services. Findings: The facility's Oxygen Administration policy, dated 10/2020, read in part, .After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record .The date and time that the procedure was performed .The name and title of the individual who performed the procedure .The rate of oxygen flow, route and rationale .The frequency and duration of the treatment . 1. Resident #9 was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease. A physician order, with start date of 12/03/21, documented, Change and date O2 tubing every week on Sunday, and prn in the evening every Sun. On 12/21/23, the resident's oxygen tubing was observed to be dated 12/11/23. The resident's December TAR documented the oxygen tubing had been changed on 12/17/23. 2. Resident #19 was admitted on [DATE] with a diagnosis of heart failure. A physician's order, dated 12/03/21, documented, Change O2 tubing every week on Sunday and PRN every night shift every Sun for Infection control protocol. On 12/21/23, the resident's oxygen tubing was observed to be dated 12/11/23. The resident's December TAR documented the oxygen tubing had been changed on 12/17/23. On 12/21/23 at 2:45 p.m., LPN #1 observed the O2 tubing for resident #9 and #19, and noted the date of 12/11/23. The LPN reported the tubing should have been changed the previous Sunday night on 12/17/23. On 12/21/23 at 3:00 p.m., the administrator was informed of the above findings and reported the O2 tubing should have been changed as ordered.

Based on observation, interview, and record review, the facility failed to refer a resident, with a newly diagnosed mental disorder, to the Oklahoma Health Care Authority (OHCA)/Level of Care Evaluation Unit (LOCEU) for a level II resident assessment for one (#33) of three sampled residents who were reviewed for PASRR screening. The Resident Census and Conditions of Residents report documented 21 residents who received antidepressant medications. Findings: The OHCA policy and rules for PASRR screening process, dated 09/01/17, read in parts, .a new condition of intellectual disabilities or mental illness must be referred to LOCEU by the nursing facility for determination of the need for the level II assessment .The facility's failure to refer such individuals for a level II assessment may result in recoupment of funds and/or penalties from CMS. Resident #33 was admitted to the facility on [DATE], with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's PASRR level I, dated 01/08/21, documented the resident did not have a medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's clinical record, dated 05/19/21, documented a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's clinical record did not contain documentation the OHCA/LOCEU was notified of the resident's new diagnosis. On 01/05/22 at 10:00 a.m., the Administrator reported the facility did not have a policy and procedure for the PASRR screening process. The Administrator reported they utilized the OHCA policy and rules for PASRR screening process. On 01/05/22 at 11:47 a.m., the MDS Nurse reported she did the PASRR level I assessment on each resident before admission or within 10 days of admission. She reported if a resident was given a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS nurse reported being told by the OHCA in the past that a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She reported she did not contact the OHCA/LOCEU after this resident received a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on interview and record review, the facility failed to put the proper diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The level I PASRR screening conducted by the facility did not include the resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The Resident Census and Conditions of Residents report, dated 01/05/22, identified 21 residents who received antidepressant medications. The administrator identified 34 residents resided in the facility. Findings: Resident #12 was admitted to the facility on [DATE] with admission diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The level I PASRR Screen, dated 03/03/21, read in parts, .Question 2 (with a Yes or No response) diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .depressive disorder .) The question documented an answer of, No. On 01/05/22 at 2:15 p.m., the MDS coordinator reported, I didn't know question #2 was supposed to be answered yes if they had dementia. She reported, I was told if they had dementia the other diangosis don't matter. On 01/05/22 at 4:30 p.m., the administrator was informed of the above findings.

Based on observation, interview, and record review, it was determined the facility failed to maintain an infection control program and implement measures to properly prevent and/or contain COVID-19 in quarantined residents for two (#1 and #2) of two residents reviewed for quarantine precautions. The facility failed to wear appropriate PPE with quarantined residents. The facility reported two residents were quarantined for possible exposure to COVID-19 and 38 residents resided in the facility. The Center for Disease Control guidance titled, Preparing for COVID-19 in Nursing Homes documented, .Managing New Admissions and Readmissions Whose COVID-19 Status is Unknown .HCP (Health Care Provider) should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown when caring for these residents . The facility reported no confirmed positive cases of COVID-19 in residents or staff. The ADM reported resident #1 was admitted on [DATE] and was quarantined as a new admission, in addition to requiring quarantine related to [MEDICAL TREATMENT] treatments. The ADM reported resident #2 was readmitted on [DATE] following a hospital stay. On 06/24/20 at 12:50 p.m., the ADM and IP staff were interviewed regarding PPE use with quarantined residents. They reported staff members were using masks and gloves only with quarantined residents. When asked about availability of PPE supplies, they reported the facility had a good supply of gowns, face shields, and N95 masks which had been fit-tested to employees. The ADM reported they were not aware the use of full PPE was required when providing care for quarantined residents. On 06/24/20 at 1:30 p.m., a tour of the facility was conducted. Quarantined residents were not identified with signage. PPE was observed to be stored in a storage closet in the hallway and not readily available to staff.

Based on interview and record review, it was determined the facility failed to ensure the written notice of involuntary discharge met the federal regulations for two (#1, #2) of three residents whose records were reviewed for discharges. This had the potential to affect 33 residents. Findings: Resident #1 had [DIAGNOSES REDACTED]. On 06/30/19 resident #1 was sent a Notice of Transfer/Discharge from the facility. The family filed an appeal. According to the Administrative Law Judge the reason for discharge was not sufficient. The clinical record was reviewed and there was no documentation by the resident's physician pertaining to a discharge. Resident #2 had [DIAGNOSES REDACTED]. On 06/30/19 resident #2 was sent a Notice of Transfer/Discharge from the facility. The family filed an appeal. According to the Administrative Law Judge the reason for discharge was not sufficient. The clinical record was reviewed and there was no documentation by the resident's physician pertaining to a discharge. On 08/01/19 the assistant administrator was in agreement the discharges should have been more detailed as to the reason why they had been sent. She agreed they did not meet federal regulations.

Based on record review and interview, it was determined the facility failed to ensure a care plan was accurate for one (#8) of eight residents whose care plans were reviewed. This had the potential to affect all 30 residents. Findings: Resident #8 had diagnoses which included depression and cognitive deficit. The resident's care plan, dated 02/18/19, documented the resident had depression and took an antidepressant medication. The Medication Administration Record [REDACTED]. There was no documentation of the resident having taken an antidepressant. The resident's care plan documented the resident had a [DIAGNOSES REDACTED]. On 04/30/19 at 10:15 a.m. the assessment coordinator was asked about the resident's care plan documenting she had dementia and took an antidepressant. She reviewed the resident's clinical record and stated, Those were both errors. At 10:26 a.m. the director of nursing was shown the above information and was in agreement both care plans were in error.

Based on observation, record review, and interview, it was determined the facility failed to ensure one (#1) of three residents reviewed were free from use of physical restraints. This had the potential to affect 35 residents. Findings: Resident #1 was admitted with [DIAGNOSES REDACTED]. The resident's quarterly assessment, dated 05/05/18, documented the resident was cognitively intact and required extensive assistance for transfers, dressing, hygiene, and utilized a wheelchair for mobility. The assessment had not documented the use of restraints. The resident's care plan, dated 04/10/18, documented the resident had poor safety awareness and needed to be monitored closely by staff. No documentation of use of a restraint was found in the care plan. The resident's clinical record was reviewed and had not documented when or why the lap belt was put into use. There was no physician's order for the use of [REDACTED] On 07/05/18 at 11:20 a.m., the resident was observed to be up in a wheelchair with a lap belt secured around his waist and the wheelchair. The resident stated the staff put the lap belt in place. Six direct care staff members were asked when and why the lap belt was to be used for the resident. All denied any knowledge of justification for use or when the lap belt was put into use. On 07/05/18 at 2:10 p.m. the administrator was informed of the above findings. She agreed there had been no documentation or justification for the use of a restraint.

Based on interview and record review, it was determined the facility failed to develop a care plan in regard to residents with a [DIAGNOSES REDACTED].#8 and #19) of five residents reviewed for unnecessary use of medications. This had the potential to effect 11 residents receiving an anti-depressant medication according to the Resident Census and Conditions of Residents form. Findings: 1. Resident #8 was admitted with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. The resident's care plan, dated 01/01/16, had not documented the resident had a [DIAGNOSES REDACTED]. On 03/20/17 at 10:07 a.m., an interview with the director of nurses (DON) was conducted. She agreed the resident's depression and antidepressant medication should have been on the care plan. 2. Resident #19 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 12/05/16, documented the resident's cognition was severely impaired. She was independent with most of her activities of daily living. She was totally dependent with personal hygiene and bathing. On 03/16/17 the resident was asked if this surveyor could interview her. She started weeping and had not responded back. She was asked if she wanted me to leave the room. She continued to cry and had not responded back. The surveyor left the resident's room. The clinical record had documented the resident cried a lot. The resident's Medication Administration Record [REDACTED]. She had received [MEDICATION NAME] (antidepressant) 150 mg 1 PO for [MEDICAL CONDITION]. She had received [MEDICATION NAME] (antidepressant) 60 mg 1 PO daily for [MEDICAL CONDITION]. She had received [MEDICATION NAME] 125 mg 2 tablets PO at 1:00 p.m. and 4:00 p.m. for major [MEDICAL CONDITION]. The resident had no careplan for depression or [MEDICAL CONDITION]. On 03/16/17 at 12:55 p.m., the DON was asked if the resident had a careplan for depression or [MEDICAL CONDITION]. She was in agreement there was no careplan for the [DIAGNOSES REDACTED].

Based on record review, interview and observation, it was determined the facility failed to ensure peri-care had been done in a manner to prevent infections. This had the potential to affect 25 residents who were occasionally or frequently incontinent of bladder as identified by the Resident Census and Conditions of Residents form. Findings: On 03/16/17 the infection control tracking and trending log was reviewed. It had documented for January 2017, the facility had six urinary track infections (UTI's). For the month of February 2017 the facility had five UTI's. For the first week of March 2017 there were two UTI's The facility's policy and procedure for perineal care documented, .the resident's knees are to be bent and feet flat on the mattress .Thoroughly rinse perineal area .Wash and rinse the rectal area thoroughly, including the area under .the anus, and the buttocks . On 03/20/17 at 11:04 a.m., certified nurse aide (CNA) #1 was observed to perform peri-care. She had not separated the resident's legs to thoroughly rinse the perineal area and she had not washed and rinsed the rectal area at all. On 03/20/17 at 2:29 p.m., CNA #2 was observed to perform peri-care. She had not separated the resident's legs to thoroughly rinse the perineal area and she had not washed and rinsed the rectal area at all. At 3:00 p.m the director of nursing was asked about the 14 urinary tract infections since January 2017. She stated, I had recognized it and had an inservice on 03/06/17. She stated, I educated staff over the number of UTI's and went over peri-care and infection control. She was informed of the observations made with the two CNA's performing peri-care. She stated, They are both new CNA's, one started in January and one started in February. That is when we started having problems with UTI's. She stated she would re-train the CNA's on proper peri-care.

Based on record review and interview, it was determined the facility failed to ensure assessment accuracy for two (#8 and #10) residents of 10 residents whose records were reviewed for assessment accuracy. This had the potential to effect all 29 residents living in the facility as identified by the Resident Census and Conditions of Residents form. Findings: 1. Resident #8 was admitted with [DIAGNOSES REDACTED]. The resident's care plan, dated 12/01/16, documented the resident was receiving hospice services. A quarterly assessment, dated 02/10/17, had not documented the resident had a life expectancy of six months or less to live. The resident's clinical record documented the resident was admitted to hospice services on 07/08/16. On 03/20/17 at 10:43 a.m., an interview with the minimum data set (MDS) coordinator was conducted. She reviewed the above findings and agreed it was not correct. 2. Resident #10 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 10/11/16, documented the resident was independent with bed mobility, required limited assistance with transfers, and eating. An annual assessment, dated 12/27/16, documented the resident required total dependence for bed mobility, assistance with transfers, and eating. On 03/15/17 at 1:32 p.m., the resident was observed wheeling herself up and down the hall in her wheel chair. She would turn the wheels with her hands and move her feet along with the wheelchair in a walking manner. At 2:09 p.m., the director of nursing was interviewed and asked about the resident's decline during the period from her quarterly assessment to her annual assessment. She stated, The resident did not have a decline from 10/11/17 to 12/27/17, that was an assessment error. On 03/20/17 the assessment coordinator was interviewed and asked about the resident's documented decline. She stated, II'll check on it. She returned and stated, I corrected it.

Based on interview and record review, it was determined the facility failed to follow physician's orders for one (#1) of three sampled residents. This had the potential to affect all 25 residents residing in the facility. Findings: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's order, dated 03/31/15, documented the resident was to be ambulated with assistance twice a day and for physical therapy (PT) to evaluate the resident. A chart review revealed no PT evaluation had been done for this resident. On 04/15/15 at 1:22 p.m., licensed practical nurse (LPN) #1 was asked if the order for PT to evaluate and to ambulate the resident twice a day had been placed. She stated the order had been overlooked and had not been placed. On 04/15/15 at 1:24 p.m., the director of nursing was asked if physical therapy had evaluated resident #1. She stated if the nurse had not placed the order then physical therapy would not have evaluated the resident.

Based on record review and interview, it was determined the facility failed to have liability and appeal notices for three (#10, #13 and #36) of three sampled residents who were reviewed for liability and appeal notices. The facility identified three residents discharged from skilled services in the last seven months. Findings: Resident #10 was admitted to the facility on [DATE] for skilled nursing services and discharged from skilled services on 08/24/14. There was no documentation to show the resident or responsible party had received a liability and appeal notice. Resident #13 was admitted to the facility on [DATE] for skilled nursing services and discharged from skilled services on 08/24/14. There was no documentation to show the resident or responsible party had received a liability and appeal notice. Resident #26 was admitted to the facility on [DATE] for skilled nursing services and discharged from skilled services on 06/15/14. There was no documentation to show the resident or responsible party had received a liability and appeal notice. On 12/17/14 at 3:50 p.m., the administrator stated the liability and appeal notices had not been provided to the residents.

Based on interview and record review, it was determined the facility failed to complete an accurate assessment for two (#15 and #27) of 24 sampled residents. This had the potential to affect all 27 residents residing in the facility. 1. Resident #15 had [DIAGNOSES REDACTED]. The annual assessment, dated 04/16/14, documented the resident was independent with transfers, she required limited assistance with ambulating, dressing and personal hygiene. She required extensive assistance with bathing. She was always continent of bowel and bladder. The resident had not received an antibiotic or an anti-anxiety medication in the past seven days. The quarterly assessment, dated 10/14/14, documented resident the resident had not received an antibiotic or an anti-anxiety medication for the last seven days. The December 2014 physician's orders documented the resident had orders for [MEDICATION NAME] (antibiotic) 100 milligrams (mg) every day at bedtime for "urgency of urination prevention. The original date of this order was 09/06/13. The December 2014 physician's orders documented the resident had orders for [MEDICATION NAME] (anti-anxiety) 0.125 mg. The original date of this order was 11/21/14. The resident had been on [MEDICATION NAME] 0.25 mg prior to 11/21/14. The original order for the 0.25 mg was 02/05/14. On 12/18/14 at 3:00 p.m., the minimum data set (MDS) coordinator was in agreement the assessments had not been correct. The resident had received an antibiotic and an anti-anxiety medication every day. 2. Resident #27 had [DIAGNOSES REDACTED]. The quarterly assessment, dated 06/25/14, documented his cognition was severely impaired. He did not ambulate and was totally dependent with transfers, dressing and eating. He was continent of urine and always incontinent of bowel. The pressure ulcer section of the quarterly assessment documented the resident had a pressure ulcer. The resident's clinical record was reviewed. There was no physician's order for wound treatment and the treatment administration record had no documentation to show a wound was being treated. On 12/17/14 at 11:40 a.m. the MDS stated, "The resident did not have a pressure ulcer, it was an error on my part."

Based on record review and interview, it was determined the facility failed to develop a comprehensive care plan for one (#15) of 24 sampled residents. The facility had 27 residents residing in the facility. Findings: Resident #15 had [DIAGNOSES REDACTED]. The quarterly assessment, dated 10/14/14, documented the resident was independent with transfers, she required limited assistance with ambulating, dressing and personal hygiene. She required extensive assistance with bathing. She was always continent of bowel and bladder. The care plan with an original date of 04/18/14, updated 10/14/14, contained no documentation the resident had received a maintenance antibiotic daily for her urinary system with goals or interventions to include but not limited to outcomes and potential side effects of receiving the medication. The care plan contained no documentation to show the resident had received an anti-anxiety medication with goals or interventions for anxiety. The December 2014 physician's orders [REDACTED]. The original date of this order was 09/06/13. The December 2014 physician's orders [REDACTED]. The original date of this order was 11/21/14. The resident had been on [MEDICATION NAME] 0.25 mg prior to 11/21/14. The original order for the 0.25 mg was 02/05/14. The December 2014 Medication Record documented the resident had received [MEDICATION NAME] and [MEDICATION NAME] every day as ordered. On 12/18/14 at 3:00 p.m., the minimum data set (MDS) coordinator was in agreement the antibiotic and the anti-anxiety medication had not been care planned.

Based on interview and record review, it was determined the facility failed to issue quarterly statements for 8 (#23, #19, #1, #22, #10, #8, #6 and #32) of 8 sampled residents with individual financial accounts. The facility documented 8 residents who held financial accounts. Findings: The financial accounts of 8 sampled residents whose monies were held in a trust account were reviewed. The records documented no quarterly statements were provided to the residents or the residents legal representative as required. On 12/17/14 at 2:02 p.m. the administrator stated, "Quarterly statements have not been sent out. I did not know I was suppose to do that, I will start sending out quarterly statements."

Based on observation, record review and interview, it was determined the facility failed to adhere to the resident's General Durable Power of Attorney and Advance Directive for Health Care for 1 (#1) of 3 sampled residents. This had the potential to affect all residents with a POA or an Advanced Directive. Findings: Resident #1 had [DIAGNOSES REDACTED]. A General Durable Power of Attorney form, dated 05/15/08 was signed by resident #1, appointing his spouse and son to act on his behalf. A State of Oklahoma Advance Directive For Health Care form, dated 11/08/09 by resident #1, appointing his son first and his spouse second as his health care proxy. A care plan meeting was held at the facility on 05/22/14 at 9:30 a.m. The facility had a small piece of paper, dated 05/22/14 at 9:37 a.m., that documented, " I want her Power of Attorney (POA) revoked." (indicating the resident's spouse's POA was to be revoked ). It was signed by the resident and witnessed by four facility staff members and three hospice staff members. The resident's spouse's signature was not on the form. A nurse's note, dated 05/22/14 at 10:35 p.m., documented the resident had spoken with his wife on the phone earlier in the shift. He called the nurse to his room and stated his wife told him that she was told in the care plan meeting today if she was not his POA she couldn't come and see him or have anything to do with him. He was upset and emotional and stated he wanted to make his wife his POA again. The resident's significant change assessment, dated 05/26/14, documented the resident's cognitive status was moderately impaired. He required extensive assistance with most activities of daily living. The resident was interviewed on 06/05/14 at 11:00 a.m. He was awake and alert and sitting in a recliner in his room. He did not know what day it was but knew what month it was. He stated he could see outlines of people but not make out their faces. He stated he was almost blind in the right eye and couldn't see much out of the left eye. He was asked, "Who is your doctor?" He stated, "I don't think we have one here." He was asked,"Who makes your decisions about your care? Is it you or your spouse?" He stated, "The nursing home does." He stated he loved his wife and wanted to see her and she hadn't been to the facility in about two weeks. He stated his spouse and the facility's owner had some problems. His wife had told him the facility wouldn't let her come back. He stated he wanted her involved in his care. "She wants to move me to another facility and they won't let her." He stated, "I wouldn't ever tell them I didn't want her not to be in charge of my care. I have [MEDICAL CONDITION] and I can't always remember what I tell people." He was asked what problems his wife and the facility's owner had. He didn't remember having said that at the beginning of the conversation. The care plan dated 05/28/14, documented, "Cognitive loss alteration in thought process related to dementia. Resident is very oriented and knows what is going on. Sometimes he needs assistance with everything and reminding of everything that is going on." On 06/05/14 at 6:05 p.m., the administrator was asked if the spouse was present for the care plan meeting. She stated the resident's spouse arrived at about 9:45 a.m. after the resident had signed to revoke her POA. The administrator stated resident #1 had a good day on the day he signed to revoke his POA.

Based on record review and interview, it was determined the facility failed to release medical records for 1 (#1) of 3 sampled residents. This had the potential to affect 33 other residents residing in the facility. Findings: Resident #1 had [DIAGNOSES REDACTED]. The resident's significant change assessment, dated 05/26/14, documented the resident's cognitive status was moderately impaired. He required extensive assistance with most activities of daily living. The facility had a copy of a request for medical records, dated 05/29/14, from another facility. The request form was signed by the named resident's power of attorney. On 06/05/14 at 5:00 p.m., the administrator was asked if a copy of resident #1's medical records had been sent to the other facility. She stated, "No." She stated she had faxed the forms to the facility's attorney.

Based on record review and interview it was determined the facility failed to promptly address grievances for 1 (#1) of 3 sampled residents. This had the potential to affect 33 other residents residing in the facility. Findings: A nurse's note, dated 05/22/14 at 10:35 p.m., documented the resident had spoken with his wife on the phone earlier in the shift. He called the nurse to his room and stated his wife had told him that she was told by the facility in the care plan meeting that day if she was not his power of attorney (POA) she couldn't come and see him or have anything to do with him. He was upset and emotional and stated he wanted to make his wife his POA again. On 06/05/14 at 5:00 p.m., the administrator was asked if she had seen the above nurse's note. She stated she had seen it on 06/04/14. She was asked if she had spoken to the resident's spouse since the 05/22/14 care plan meeting. She stated the resident's spouse had called her and asked how the resident could revoke his POA and she had told her she could not discuss it with her because they had turned everything over to the facility's lawyer. She was asked if she had spoken to the resident's son, his other appointed POA. She stated he had called and left a message yesterday, but she hadn't called him back.

Based on record review and interview, it was determined the facility failed to notify the physician for a change in condition for one (#1) of four sampled residents. This had the potential to affect 39 residents residing in the facility. Findings: Resident #1 had [DIAGNOSES REDACTED]. A nurse's note, dated 01/17/14 at 12:27 p.m., documented, "Back from Dr. (name withheld) office today. He has made her a appt. (appointment) with DR.(name withheld) in (nearby town), which is a GI (gastrointestinal) specialist... Since her return from Dr. appt. she is weak, won't eat, alert but not very talkative. After assessment and conference with other nursing staff, Dr. (name withheld) (GI specialist's) office called and notified that she really needed to be seen earlier than January 23 rd. They said they could see her next Tuesday but if she was really feeling that bad, go ahead and send her to emergency room ER (emergency room ) at (nearby hospital) for evaluation and treatment. I notified her dtr (daughter) and discussed her mothers care and she was agreeable to sending her mom to (nearby hospital). I called report to (nearby hospital) ER nurse and notified EMS (emergency medical services) for transport to (nearby hospital)." A nurse's note, dated 01/17/14 at 4:09 p.m., documented, "ER Dr.(name withheld) called...states that he sees no need to do workup at this time to follow with Dr. (name withheld) (GI specialist) in office next week..." A nurse's note, dated 01/17/14 at 10:21 p.m., documented, "Resident returned from (nearby hospital)ER earlier without any orders at this time..." There was no documentation that the primary care physician was notified of the resident being transferred to the emergency room . The quarterly assessment, dated 01/28/14, documented the resident's cognition was moderately impaired. She was independent with most all activities of daily living. She required supervision with hygiene and dressing and extensive assistance with bathing. On 03/05/14 at 4:00 p.m., the primary care physician was interviewed. He stated he was not called after the resident left his office on 01/17/14. He was called by the facility after the resident returned for readmission orders [REDACTED] At 5:40 p.m., the assistant director of nurses (ADON) was asked if the resident's primary care physician was notified before the resident was transferred to the ER. She stated, "No, I didn't. I see now I should have done that." At 5:45 p.m., the director of nurses (DON) was informed the resident's primary care physician was not contacted for orders to send the resident to the ER. She stated, "I can see where that should have been done."