Every finding on record at The Villages at Southern Hills

Surveyor: [NAME], [NAME] Based on observation, record review, and interview, the facility failed to ensure a resident with MASD received necessary treatment and services that were consistent with the standards of practice for one (#256) of two residents reviewed for skin conditions. The DON identified 20 residents with MASD resided in the facility. Findings: The Non-Pressure Wounds: Moisture Associated Dermatitis Clinical Operations policy, dated July 2018, read in parts, .Review and investigate the type and frequency in which the areas managed for prevention and treatments .Briefs used and frequency of changing briefs .Review orders and treatments and gather supplies .Report abnormalities to supervisor . Resident #256 had diagnoses which included acute infarction of the spinal cord and neuromuscular dysfunction of the bladder. The care plan, dated 10/31/23, documented to inspect skin daily with care and bathing and report any changes to charge nurse. The late entry nurse note, dated 11/01/23, documented the resident had MASD and scarring to the sacrum and the skin was intact. The late entry nurse note, dated 11/06/23 at 2:15 p.m., documented the resident had a scabbed area to the sacrum that was currently intact. The note further documented the brief was soiled with stool and the nurse changed the residents brief and performed catheter care. On 11/07/23 at 1:40 p.m., LPN #1 was observed removing the resident's brief. The resident's brief was soiled with stool and the wound on the sacrum was observed to be open. The nurse contacted the physician and obtained wound care orders for the resident. On 11/07/23 at 2:15 p.m., CNA #2 stated they had performed incontinent care on the resident on 11/06/23 and they were unsure if the wound was open or not at that time. On 11/07/23 at 3:00 p.m., CNA #3 stated they had provided incontinent care for the resident around 10:30 a.m. on 11/07/23 and they noted the wound on the resident's sacrum was open. They stated they forgot to tell the nurse the wound had opened. On 11/08/23 at 2:00 p.m., Resident #246 stated they were unable to tell if they had been incontinent. They also stated that the aides do not check very often to see if the resident's brief is soiled. They stated this has been an ongoing issue and today they complained to the charge nurse. On 11/08/23 at 3:00 p.m., LPN #3 stated Resident #246 had spoken to him about the aides not providing care and he spoke to the CNA working that hall regarding the importance of providing care in a timely manner. On 11/08/23 at 4:45 p.m., the DON stated CNAs were required to report changes in a residents condition to the charge nurse and appropriate incontinent care is part of the treatment protocol for residents with MASD.

Based on record review, observation, and interview, the facility failed to ensure a [MEDICATION(S)] injection (an anticoagulant medication) was available for one (#158) of 12 residents observed during medication pass. The DON identified five residents who were prescribed [MEDICATION(S)]. Findings: A facility policy titled, Disposal of Medications, Syringes and Needles, dated December 2012, read in parts, .Discontinued medications and/or medications left in the nursing care center after a resident's discharge, which do not qualify for return to the pharmacy, are identified and removed from current medication supply in a timely manner for disposition . A facility policy titled, Medication Administration General Guidelines, dated September 2018, read in parts, .Medications supplied for one resident are never administered to another resident . Resident #158 had diagnoses which included fracture of the left femur. A Physician's Order, dated 08/16/22, documented to administer [MEDICATION(S)] 40 mg/0.4 mL subcutaneous one time a day for 24 days. A delivery manifest, dated 08/16/22, documented six [MEDICATION(S)] 40 mg/0.4 mL syringes were delivered to the facility. This provided the medication for six days. Resident #158 would not have a dose for 08/23/22, unless reordered. Resident #158's MAR, dated August 2022, documented the resident had received a [MEDICATION(S)] injection everyday from 08/17/22 to 08/23/22. A delivery manifest, dated 08/24/22, documented six [MEDICATION(S)] 40 mg/0.4 mL syringes were delivered to the facility. On 08/24/22 at 8:50 a.m., LPN #3 was observed to prepare/administer medications to Resident #158. The resident was scheduled to receive a [MEDICATION(S)] 40 mg injection. The nurse obtained a [MEDICATION(S)] 40 mg syringe from the medication cart and prepared supplies to administer the injection. The label of the injection's packaging identified a different resident's name. When this surveyor requested to review the label, the nurse stated, Oh that's not who is getting the medication. The nurse identified the name on the label was a discharged resident. LPN #3 was asked if Resident #158 had their own [MEDICATION(S)] on the cart. The LPN searched the cart and stated no and it appeared as the medication had not been reordered. The nurse was asked if the resident had received the [MEDICATION(S)] as ordered by the physician. The LPN stated Resident #158 had been at the facility since the 08/16/22 and had received [MEDICATION(S)] since 08/17/22. LPN #3 was asked what the protocol was for medications when a resident discharged from the facility. The nurse stated when a resident was discharged , medications should be put in the dispose box in the medication room. LPN #3 was asked why the discharged resident's [MEDICATION(S)] was not removed from the cart. They stated they did not know. The LPN was asked if other medications for the discharged resident were on the cart. They stated the one [MEDICATION(S)] injection was the only medication of the discharged resident on the cart. On 08/26/22 at 2:26 p.m., the DON was asked if it was acceptable to utilize a discharged resident's medication for a current resident. They stated no. They were asked why a discharged resident's medication was still available and on the medication cart. They stated they did not know and it may have been over looked. The DON was asked how Resident #158 had received the medication if it were not available in the facility on 08/23/22. They stated the resident may have received a different resident's medication or did not receive the [MEDICATION(S)] injection on that day.

Based on record review, observation, and interview, the facility failed to ensure medications and treatments were properly stored/secured for one (100 hall) of six medication carts observed and two of two treatment carts observed. The DON identified the facility had seven medication carts and two treatment carts. Findings: A facility policy titled, Medication Administration General Guidelines, dated September 2018, read in parts, .During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse .The cart must be clearly visible to the personnel administering medications when unlocked . On 08/23/22 at 10:30 a.m., a medication cart was observed to be unlocked/unsecured on the 100 hall. LPN #2 was sitting at the nurses desk with their back to the cart. On 08/23/22 at 10:32 a.m., LPN #2 approached the medication cart, obtained medication, and locked the cart. On 08/24/22 at 8:43 a.m., a medication cart was observed to be unlocked/unsecured on the 100 hall. On 08/24/22 at 8:46 a.m., LPN #1 was asked who the medication cart belonged to. They stated it was their cart. They were asked why the medication cart was not locked/secured. They stated they had been called into a room but the cart was supposed to be locked. On 08/26/22 at 9:44 a.m., two unlocked/unsecured treatment carts were observed in the wound nurse's office by the door. The door was open and staff were not observed in the office. On 08/26/22 at 9:52 a.m., CNA #1 was observed to enter the office for the wound nurse. CNA #1 was asked who the treatment carts belonged to. They stated the wound nurse. On 08/26/22 at 9:59 a.m., the wound nurse approached the office and was asked who was responsible for the two treatment carts. The wound nurse stated the treatment carts belonged to them. They were asked what the treatment carts contained. They stated treatment supplies which included wound cleanser and medicated ointments. The wound nurse was asked how treatments were secured. They stated the carts were stored in the office when not in use. They were asked why the carts were not secured/locked. They stated because the carts were in the office where CNA #1 was located. The wound nurse was informed of the surveyor's observation of the unattended, unlocked/unsecured treatment carts. The wound nurse stated the treatments carts should have been locked. On 08/26/22 at 11:02 a.m., the 100 hall medication cart was observed to be unlocked/unsecured and unattended. On 08/26/22 at 11:06 a.m., LPN #1 was observed to approach the medication cart. They were asked who was responsible for the medication cart. They stated they were responsible for the medication cart. They were asked how they ensured medications were properly stored/secured. They stated they usually locked the cart. LPN #1 was asked why the medication cart was unlocked/unsecured. They stated they had just placed medications in the cart and went to a resident room. On 08/26/22 at 2:18 p.m., the DON was asked how they ensured medications and treatments were properly stored/secured. They stated medications were stored in medication rooms and treatment/medication carts. They stated they were kept secure by locks. The DON was told of the surveyors' observations and was asked why the treatment and medication carts were observed to be unlocked/unsecured. The DON stated they thought the staff probably had interruptions but the expectation was to keep them locked.

Based on observation, interview, and record review, it was determined the facility failed to: a. ensure staff wore face masks according to the Centers for Medicare & Medicaid Services (CMS) guidelines to prevent the development and transmission of COVID-19; and b. ensure COVID-19 screening was completed upon entry and exit to the facility per policy. The administrator identified 107 residents who resided in the facility. Findings: CDC (Centers for Disease Control) guidance, updated on 04/06/21, titled Improve the Fit and Filtration of Your Mask to Reduce the Spread of COVID-19, .Correct and consistent mask use is a critical step everyone can take to reduce their risk of getting and spreading COVID-19 .Masks should a) Completely cover the nose and mouth. b) Fit snugly against the sides of the face and should not have any gaps. c) Be handled only by the ear loops, cords, or head straps (not by the surface of the mask) . A facility policy for Coronavirus Management documented for a negative/clean unit the staff must wear a surgical mask, gown, eye protection, and gloves for standard precaution. The policy documented the office staff was to wear a surgical mask on the negative/clean unit. The policy documented if the office staff were alone in the office they could remove their mask, but if anyone entered the office and would be within six feet a mask must be reapplied. The policy further documented the staff were to utilize the visitor screening tool and maintain a visitor screening log. The policy documented staff were to ensure screening of everyone who entered the building. The policy documented staff would be screened by a screener who had been trained in the screening process and self-screening should not be done. The policy documented if the staff leave the facility grounds and return, they must be re-screened. 1. Resident #6 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly assessment, dated 06/26/21, documented the resident was cognitively alert in daily decision making skills and required extensive assistance from staff with most activities of daily living (ADLs). On 07/19/21 at 12:15 p.m., licensed practical nurse (LPN) #1 was observed at a medication chart preparing medications. Her face mask was positioned below her chin. The LPN was interviewed. The LPN continued the interview with her face mask below her chin. The LPN walked down the hall and entered the room of resident #6 to administer medication. The LPN continued to wear her face mask below her chin after entering the resident's room. 2. On 07/19/21 at 11:43 a.m., a resident was observed sitting in a wheelchair in the business office. The discharge planner was standing beside the resident talking with her face mask below her chin. Two staff members sitting across the desk from the resident were not wearing face masks. At 12:05 p.m., certified nurse aide (CNA) #1 was observed walking in the hallway, was in and out of resident rooms, and was delivering meal trays. The CNA's face mask was positioned below her nose. At 12:14 p.m., CNA #2 was observed walking down the resident hall with her face mask positioned below her nose. At 12:47 p.m., LPN #1 was sitting at a desk in the resident hall talking on a cell phone with her mask below her chin. At 12:48 p.m., LPN #1 was interviewed regarding wearing her face mask below her chin. The LPN stated she was told she could pull her mask down when sitting at her desk in the hall if no one was around within six feet. The LPN stated she should have positioned her face mask covering her mouth and nose during the interview at 12:15 p.m. At 1:05 p.m., CNA #1 was interviewed regarding her face mask positioned below her nose. The CNA stated her mask falls down sometimes and pulled her mask up and down to demonstrate. On 07/20/21 at 8:35 a.m., the door screener staff #1 was sitting at the desk with his face mask below his chin. The screener screened three visitors with his mask below his chin. At 12:10 p.m., the administrator stated non-compliance with infection control practices, such as staff use of personal protective equipment (PPE), would be handled in the same manner as any resident care concern. The administrator stated staff would be given a verbal and/or written warning, would be re-education, and possibly terminated. The administrator stated the infection preventionist was responsible for monitoring compliance, but all administrative staff monitor. On 07/21/21 at 10:15 a.m., the discharge planner was interviewed. During the interview the discharge planner answered the telephone pulling her face mask down to talk. The discharge planner continued the interview with her face mask hanging from one ear. 3. On 07/19/21 at 4:00 p.m., no staff was observed at the COVID-19 door screener desk. At 4:05 p.m., the receptionist was interviewed regarding the absence of staff at the screening desk. The receptionist said, I don't know anything about that. At 4:05 p.m., the director of nurses (DON) stated the concierge staff working the door screener desk left around 3:00 p.m. The DON stated the receptionist was to cover the screening desk when screening staff were not available. At 4:06 p.m., CNA #3 was observed entering the facility without being screened. The CNA was asked if she had just entered the building. The CNA stated yes as she continued walking. The Manager on Duty standing at the desk stated she was just going to clock in first. At 4:20 p.m., the DON stated staff entering the facility should be screened at the desk before entering the facility. On 07/20/21 at 11:31 a.m., the infection preventionist (IP) stated visitors would be screened upon entry to the facility. The IP stated if a visitor left the building/property and re-entered the same day a temperature should be obtained upon re-entry. The IP reviewed the screening logs she had provided and stated the log for the previous day did not document a date or time for the screenings completed. On 07/21/21 at 8:35 a.m., the assistant administrator stated the two concierge staff working as the COVID-19 door screeners on 07/19/21 had not completed their competency for screener at that time. The assistant administrator stated the staff should have been supervised. At 10:20 a.m., a visitor was observed entering the building and walked passed the screener without being screened. The screener was observed attending to her cell phone. The visitor stated he visited his wife daily. The visitor stated he sometimes would leave the facility and return the same day. The visitor stated he was never re-screened upon re-entry. At 11:15 a.m., the DON reviewed the 07/19/21 COVID-19 screening log for the facility. She stated the identified staff members with time clock stamps entering or exiting the building from 3:00 p.m. to 4:00 p.m. were not documented on the screening log.

Based on observation, interview, and record review, it was determined the facility failed to provide supervision and assistive devices to prevent accidents for one (#12) of five sampled residents reviewed for accidents. The facility failed to ensure staff used correct technique and equipment to transfer the resident. The facility census and condition report documented 79 residents required assistance with transfers. Findings: Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly assessment, dated 05/29/19, documented the resident was moderately impaired for daily decision making and required total assistance with the activities of daily living (ADLs). The assessment documented the resident required extensive assistance with two persons for transfers. The care plan, dated 05/30/19, documented the resident had impaired mobility and staff were to provide the required level of assistance. The physician orders [REDACTED]. On 07/22/19 at 2:30 PM, the resident was observed on his bed and unable to state his needs. Certified nurse aide (CNA) #1 and certified medication aide (CMA) #1 entered the room. The resident stated he was getting out of bed. The staff lifted the resident under his arms and by the back of his pants to transfer the resident to his wheelchair. The resident did not straighten his legs or bear weight during the transfer. A gait belt was on the table and was not used. On 07/29/19 at 10:12 AM, CNA #1 stated the resident was to be transferred by two staff persons using the gait belt. She was able to state the correct technique for using the gait belt. The CNA stated she was nervous and did not use the gait belt. She stated the resident did not always assist with transfers and staff would use the sit to stand device. The CNA stated residents were not to be lifted under the arms and staff were not to use the back of the resident's pants to assist with transfers.

Based on observation, interview, and record review, it was determined the facility failed to complete a thorough investigation to determine the underlying cause of falls for two (#2 and #6) of three residents reviewed for falls. The facility identified 12 residents fell in the last three months. Findings: The facility policy and procedures for the fall prevention program did not document how falls were to be analyzed in order to determine the underlying cause of falls. 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The initial admission nursing assessment, dated 03/19/18, documented the resident was alert, oriented, severely impaired for decision making, had delusions of grand children and pets, required total assistance with activities of daily living (ADLs), was not steady on her feet, required assistance with transfers, and could walk with a walker or with assistance. The admission baseline care plan, dated 03/20/19, did not document the resident was a high risk for falls. The incident reports between 03/30/19 and 04/19/19, documented the resident had three falls without injury. The facility was not able to provide fall investigations which determined the underlying cause of the falls. The admission assessment, dated 03/26/19, documented the resident was independent for daily decision-making and required extensive assistance of two persons with the activities of daily living (ADLs) including mobility and transferred. The assessment documented the resident needed staff to stabilize and used a wheelchair or walker for mobility. The assessment documented the resident received antipsychotic, antibiotic, and diuretic medications. The care plan, dated 03/26/19, documented the resident was at risk for falls. The care plan documented multiple interventions for fall prevention. On 06/04/19 at 1:30 PM, the resident was not in facility for observation. 2. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The baseline care plan, dated 05/22/19, documented the resident's functional abilities and was a high risk for falls. The five day assessment, dated 05/29/19, documented the resident was moderately impaired for daily decision making and required extensive assistance with activities of daily living. The assessment documented the resident had two falls. The incident reports documented the resident had one fall on 05/28/19 and three falls on 05/29/19. The reports documented the resident did not have a major injury. The facility was not able to provide fall investigations which determined the underlying cause of the falls. On 06/04/19 at 2:45 PM, the resident was in her wheelchair and she wore tennis shoes. The resident was propelling herself toward the door. Her bed was in low position. The resident stated all her needs were met. The resident stated the staff did not want her to get up on her own due to her falls. On 06/05/19 at 2:53 PM, CNA #1 and CNA #2 were interviewed regarding fall prevention. The CNAs stated residents were provided with a low beds, fall mats, a call light within reach, and were checked every hour for needs. The aides stated if the resident was confused the resident was checked more frequently and charting was completed in the hall outside the resident's room for increased monitoring. On 05/06/19 at 4:19 PM, the director of nurses (DON) was interviewed regarding fall investigations. The DON stated she was not able to provide additional information related to fall investigations. The DON stated the fall incident report was used as the fall investigation.

Based on observation, interview, and record review, it was determined the facility failed to ensure controlled drug records were complete and accurate for three (#3, #10, and #11) of six residents reviewed for accurate records. The facility identified 49 resident received as needed narcotic pain medications. Findings: 1. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician orders [REDACTED]. A nurse note, dated 01/18/19 documented a clarification order for the resident's pain medication. The note documented the resident was to receive [MEDICATION NAME] 10 mg one tablet every 4 for pain rating 1-5 and two tabs for pain rated 5-10. A rating of one was minimal pain and a rating of 10 was severe pain. The admission assessment, dated 01/24/19, documented the resident was moderately impaired for daily decision making and had pain rating 5 on a scale of 1-10. The assessment documented the resident received opioid pain medication for 5 of 7 days. The care plan, dated 02/05/19, documented the resident received opioid pain medication and the staff were to monitor for sedation, confusion, hallucinations, and respiratory depression. The narcotic count sheet for 01/18/19 to 01/28/19 documented 35 entries for drug withdrawal. Each entry documented two tablets were withdrawn. The nurse notes for 01/17/19 to 01/28/19 documented the resident was administered two tablets of pain medication 11 times. 24 of 35 medication opportunities were not documented on the medication administration record (MAR) or the nurse notes. On 02/19/19 at 3:11 p.m., residents were involved in various activities, therapies, or resisting in their rooms. The residents did not show signs of sedation or respiratory distress. Staff were attentive to the residents. On 02/21/19 at 3:44 p.m., licensed practical nurse (LPN) #5 stated she administered pain medication according to the resident's rating on the pain scale. The LPN stated she signed for the pain medication on the count sheet each time she administered narcotic medication. The nurse stated she believed it was adequate documentation. The nurse stated she did not always document administration of pain medication in the nurse notes/MAR. On 02/21/19 at 4:46 p.m., LPN #1 was interviewed and stated she did not document all doses of pain medication administered in the electronic record since the times would not match with the count sheet. 2. Resident #11 was admitted on [DATE] with [DIAGNOSES REDACTED]. The assessment, dated 02/17/19, documented the resident was moderately impaired for daily decision making, had pain, and received opioid medication. The care plan, dated 02/12/19, documented the resident had pain and received pain medication. The physician orders [REDACTED]. The narcotic count sheet for 02/12/19 to 02/19/19 documented 12 two tablet doses of [MEDICATION NAME] were signed out for the resident. The nurse notes/MAR for (MONTH) 2019 documented eight doses of [MEDICATION NAME] were administered to the resident. Four of 12 doses were not documented as administered. 3. Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The assessment, dated 01/09/19, documented the resident was independent for daily decision making, and had issues with pain. The care plan, dated 01/14/19, documented the resident had pain and received pain medication. The physician orders [REDACTED]. The narcotic count sheet, dated 02/08/19 to 02/21/19, documented the medication was sign out 55 times. The nurse notes/MAR, dated 02/08/19 to 02/21/19, documented the resident received [MEDICATION NAME] 38 times. 17 of 55 medication opportunities were not documented as administered.

Based on observation, interview, and record review, it was determined the facility failed to ensure administration of pain medication was thoroughly documented in the clinical record for three (#3, #10 and #11) of six residents reviewed for accurate records. The facility identified 49 resident received as needed narcotic pain medications. Findings: 1. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician orders [REDACTED]. A nurse note, dated 01/18/19 documented a clarification order for the resident's pain medication. The note documented the resident was to receive [MEDICATION NAME] 10 mg one tablet every 4 for pain rating 1-5 and two tabs for pain rated 5-10. A rating of one was minimal pain and a rating of 10 was severe pain. The admission assessment, dated 01/24/19, documented the resident was moderately impaired for daily decision making and had pain rating 5 on a scale of 1-10. The assessment documented the resident received opioid pain medication for 5 of 7 days. The care plan, dated 02/05/19, documented the resident received opioid pain medication and the staff were to monitor for sedation, confusion, hallucinations, and respiratory depression. The narcotic count sheet for 01/18/19 to 01/28/19 documented 35 entries for drug withdrawal. Each entry documented two tablets were withdrawn. The nurse notes for 01/17/19 to 01/28/19 documented the resident was administered two tablets of pain medication 11 times. 24 of 35 medication opportunities were not documented on the medication administration record (MAR) or the nurse notes. On 02/19/19 at 3:11 p.m., residents were involved in various activities, therapies, or resisting in their rooms. The residents did not show signs of sedation or respiratory distress. Staff were attentive to the residents. On 02/21/19 at 3:44 p.m., licensed practical nurse (LPN) #5 stated she administered pain medication according to the resident's rating on the pain scale. The LPN stated she signed for the pain medication on the count sheet each time she administered narcotic medication. The nurse stated she believed it was adequate documentation. The nurse stated she did not always document administration of pain medication in the nurse notes/MAR. On 02/21/19 at 4:46 p.m., LPN #1 was interviewed and stated she did not document all doses of pain medication administered in the electronic record since the times would not match with the count sheet. 2. Resident #11 was admitted on [DATE] with [DIAGNOSES REDACTED]. The assessment, dated 02/17/19, documented the resident was moderately impaired for daily decision making, had pain, and received opioid medication. The care plan, dated 02/12/19, documented the resident had pain and received pain medication. The physician orders [REDACTED]. The narcotic count sheet for 02/12/19 to 02/19/19 documented 12 two tablet doses of [MEDICATION NAME] were signed out for the resident. The nurse notes/MAR for (MONTH) 2019 documented eight doses of [MEDICATION NAME] were administered to the resident. Four of 12 doses were not documented as administered. 3. Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The assessment, dated 01/09/19, documented the resident was independent for daily decision making, and had issues with pain. The care plan, dated 01/14/19, documented the resident had pain and received pain medication. The physician orders [REDACTED]. The narcotic count sheet, dated 02/08/19 to 02/21/19, documented the medication was sign out 55 times. The nurse notes/MAR, dated 02/08/19 to 02/21/19, documented the resident received [MEDICATION NAME] 38 times. 17 of 55 medication opportunities were not documented as administered.

Based on observation, interview, and record review, it was determined the facility failed to thoroughly document information in the clinical record for one (#3) of three sampled residents whose records were reviewed. The facility failed to document the percentage of meal intake or meals refused. The census and condition report documented 107 residents ate meals prepared in the kitchen. Findings: The facility did not have a policy regarding documentation of the residents' meal intake or refusal. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan, dated 02/07/17, documented the resident was to be encouraged to eat and not skip meals. The care plan documented the resident preferred meals twice a day. A quarterly assessment, dated 07/02/17, documented the resident was independent for daily decision making and required moderate assistance with activities of daily living. The resident required assistance with set up for meals. The meal and fluid intake record did not document the amount food intake or fluid intake for the resident from 09/05/17 through 09/11/17. The nurse note, dated 09/09/17, documented the resident was offered breakfast but refused her breakfast. On 09/14/17 at 2:43 p.m., certified nurse aide (CNA) #3 was interviewed regarding the documentation of the amount of food the resident had eaten. The CNA stated they were to document on the food and fluid intake record the amount of food the resident had eaten and if the resident had refused a meal. On 09/14/17 at 3:10 p.m., the licensed practical nurse (LPN) #1 was interviewed regarding the documentation of amount of food the residents had eaten. The LPN stated the CNAs were to document on the food and fluid intake record the amount of food the resident had eaten. The LPN sthe tated the CNAs were to report to the nurse if the resident had refused a meal. On 09/18/17 at 12:25 p.m., the resident was observed. The resident was in her room and sat in her wheelchair. A CNA placed a meal tray on the bedside table and assisted the resident with meal set up. On 09/18/17 at 2:00 p.m., the director of nurses (DON) was interviewed regarding the documentation of the resident's food intake. The DON stated the amount of food the resident had eaten was to be documented at every meal. The DON stated the CNAs were to document the amount of food the resident had eaten and if the resident had refused a meal. The DON was asked how she ensured that the meals were documented. The DON stated she reviewed the records weekly. The DON stated in services regarding documentation were completed. The DON stated documentation had improved bur required continual monitoring.

Based on observation, interview, and record review, it was determined the facility failed to notify the resident's legal representative for a change in condition for one (#1) of four sampled residents reviewed for a change in condition. The facility failed to notify the family when the resident had injured his hand. The facility identified 98 residents resided in the facility. Findings: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The comprehensive assessment, dated 02/07/17, documented the resident was severely impaired for daily decision-making, was inattentive, and had disorganized thoughts. The assessment documented the resident required extensive assistance with the activities of daily living (ADLs) and used a wheelchair or walker for mobility. The care plan, dated 02/02/17, documented the resident had a cognitive deficit and impaired mobility. The care plan documented the resident received therapy services and used a wheelchair for mobility. The nurse notes, dated 02/06/17, documented the resident was propelling through the doorway and hit his hand on the door. The note documented the resident sustained [REDACTED]. The note did not document the family was notified. The incident reports for February 2017 did not document a report regarding the injury. On 02/21/17 at 12:00 p.m., a tour of the facility was conducted. The staff were up and down the halls providing care for the residents. Some residents propelled up and down the halls in their wheelchairs. Some resident had chair alarms. Other resident had walkers, low beds, assistive devices, and fall mats. The staff answered the call lights timely and were responsive to the residents. On 02/22/17 at 11:45 a.m., registered nurse (RN) #1 was interviewed regarding the resident. The nurse stated it was the policy for staff to call and notify the responsibility party for injuries the resident sustained [REDACTED]. The nurse stated she thought she notified the family but could not remember. On 02/22/17 at 121:45 p.m., the director of nurses (DON) was interviewed regarding family notification. The DON stated the documentation regarding the resident's injury did not document the notification of the responsible party.

Based on observation, interview, and record review, it was determined the facility failed to assess, monitor, and intervene for the presence of a pressure ulcer for one (#2) of three sampled residents reviewed for pressure ulcers. The facility wound report identified four residents who resided in the facility with a pressure ucler. Findings: The facility's policy for pressure ulcers documented the physician and staff were to examine the skin of a new resident admission for ulcerated areas. The policy documented the staff was to document a full assessment and current treatments of a pressure sore. The facility's policy for pressure ulcer treatment documented the treatment was to focus on assessing the resident and the pressure ucler, managing tissue loads, pressure ulcer care, manage infections, and education. A hospital wound care record, dated 3/31/16, documented the resident had a left buttock wound. The record documented a periwound with small abrasions. The record documented the area was red, fragile, clean, and [MEDICATION NAME] (a wound treatment) gel was applied and covered with a [MEDICATION NAME] dressing. The record documented a cluster of wounds to the right buttock. The record documented the area was red, fragile, and moist. The record documented [MEDICATION NAME] gel and a [MEDICATION NAME] dressing was applied. The record documented a third wound to the left heel. The record documented the wound was brown with closed edges. The record documented a [MEDICATION NAME] dressing was applied. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan, dated 04/01/16, documented the resident was at risk for/actual skin breakdown as evidenced by a pressure, diabetic, or stasis wound. An intervention was for staff to inspect the resident's skin daily and to report any changes. The admission nursing skin assessment, dated 04/01/16, documented a pressure, diabetic, or stasis, wound to the left buttock. The assessment documented the wound was to be cleansed with normal saline, patted dry, and Santyl (a debridement cream) moist gauze applied and secured with a secondary dry dressing. The assessment documented a fluid filled blister to the left heel. The physician's orders for April 2016 documented the resident had a catheter for retention of urine. The physician's orders did not document an order for [REDACTED]. A physician's history and physical examination [REDACTED]. A daily skilled note, dated 04/03/16, documented the resident had no blisters or wounds. The daily skilled note for 04/04/16 was not available. The daily skilled note, dated 04/05/16, documented a stage II pressure blister to the left heel and a wound to the buttock, right knee, left knee, and left heel. The daily skilled note, dated 04/06/16, documented a blister to the left heel and a wound to the buttock. The daily skilled note, dated 04/07/16, documented a blister to the left foot and a wound to the buttock. The daily skilled note for 04/08/16 and 04/09/16 were not available. The admission five day assessment, dated 04/08/16, documented the resident was independent for daily decision making and required extensive assistance with activities of daily living (ADLs). The assessment documented the resident had no pressure ulcers. The emergency room (ER) documentation, dated 04/09/16, documented no [MEDICAL CONDITION] and no rash noted. The hospital progress note, dated 04/11/16 at 4:00 p.m., documented a pressure ulcer to the right buttock witch was purple in color and had superficial skin loss. The note documented a pressure ulcer which was assessed to the left heel on 04/09/16. The note documented the site was boggy and purple. The hospital progress note, dated 04/11/16 at 5:05 p.m., documented a pressure ulcer to the left heel which was purple, boggy, and first assessed on 04/09/16 at 8:25 p.m. The note documented a pressure ulcer on the left side of the gluteal fold witch was linear and purple. The area was first assessed on 04/09/16 at 8: 25 p.m. On 05/10/16 at 3:53 p.m., the wound nurse was interviewed regarding assessments and wound care for the resident. The wound nurse stated a skin assessment was completed for the resident on 04/04/16, but was not documented in the resident's clinical record. The wound nurse stated a wound care order was not obtained because the resident did not have wounds. On 05/10/16 at 4:45 p.m., the director of nurses (DON) was interviewed regarding assessments, monitoring, and treatment of [REDACTED]. The DON stated she was not aware the resident had pressure ulcers. The DON stated assessments were completed daily. The DON stated if a wound was observed the wound nurse would assess the wound and obtain an order from the physician for wound care. The DON reviewed the resident's clinical record. The DON stated the admission assessment documented the resident had a pressure ulcer and a treatment for [REDACTED]. The DON stated the nurse was not available to clarify the assessment documentation. The DON stated the resident's clinical record had some missing documentation, missing assessments, and was unclear pertaining to the resident's pressure ulcers. On 05/25/16 at 12:53 p.m., the physician was interviewed regarding pressure ulcers for the resident. The physician was asked if the resident had pressure ulcers. The physician stated the resident did not have pressure ulcers. The physician was asked how it was determined the resident did not have pressure ulcers. The physician stated through assessments and communication with the nurses. The physician did not recall notification of a pressure ulcer or providing orders for the treatment of [REDACTED]. The physician was asked about the documentation regarding pressure ulcers on the physician's history and physical record. The physician stated the documentation was a cut a paste of all the resident's [DIAGNOSES REDACTED]. On 05/25/16 at 1:40 p.m., licensed practical nurse (LPN) #1 was interviewed regarding pressure ulcers for the resident. The LPN stated she was present when the wound nurse performed a skin assessment. The LPN stated the wound nurse removed a dressing from the resident's buttock and heel and verbalized no wounds were present. The LPN was asked about two resident assessments documenting pressure ulcers. The LPN stated she never removed the dressing and viewed the areas. The LPN stated documentation was repeated from previous assessment documentation. On 05/25/16 at 1:55 p.m., LPN #2 was interviewed regarding documentation of a pressure ucler for the resident. The LPN stated she did not recall the resident. The LPN stated if a dressing was in place she would not have removed the dressing to view the area. The LPN stated documented what previous assessment documented. On 05/25/16 at 4:00 p.m., the DON was interviewed regarding pressure ulcers for the resident. The DON stated the resident did not have pressure uclers. The DON stated the resident was assessed by the wound nurse and determined not to have pressure uclers. The DON stated due to no pressure ulcers present, no orders or treatments were received or provided.

Based on interview and record review, it was determined the facility failed to complete and accurately document assessments for the clinical record for one (#2) of three sampled residents whose clinical records were reviewed. The facility failed to document daily assessments and accurately document skin assessments for the resident. The facility identified 74 who resided in the facility. Findings: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan, dated 04/01/16, documented the resident was at risk for/actual skin breakdown as evidenced by a pressure, diabetic, or stasis wound. An intervention was for staff to inspect the resident's skin daily and to report any changes. The admission five day assessment, dated 04/08/16, documented the resident was independent for daily decision making and required extensive assistance with activities of daily living (ADLs). The assessment documented the resident had no pressure ulcers. A daily skilled note, dated 04/03/16, documented the resident had no blisters or wounds. The daily skilled note for 04/04/16 was not available. The daily skilled note, dated 04/05/16, documented a stage II pressure blister to the left heel and a wound to the buttock, right knee, left knee, and left heel. The daily skilled note, dated 04/06/16, documented a blister to the left heel and a wound to the buttock. The daily skilled note, dated 04/07/16, documented a blister to the left foot and a wound to the buttock. The daily skilled note for 04/08/16 and 04/09/16 were not available. On 05/10/16 at 4:45 p.m., the director of nurses (DON) was interviewed regarding assessments, monitoring, and treatment of [REDACTED]. The DON stated she was not aware the resident had pressure ulcers. The DON stated assessments were completed daily. The DON stated if a wound was observed the wound nurse would assess the wound and obtain an order from the physician for wound care. The DON reviewed the resident's clinical record. The DON stated the admission assessment documented the resident had a pressure ulcer and a treatment for [REDACTED]. The DON stated the nurse was not available to clarify the assessment documentation. The DON stated the resident's clinical record had some missing documentation, missing assessments, and was unclear pertaining to the resident's pressure ulcers. On 05/25/16 at 1:40 p.m., licensed practical nurse (LPN) #1 was interviewed regarding pressure ulcers for the resident. The LPN stated she was present when the wound nurse performed a skin assessment. The LPN stated the wound nurse removed a dressing from the resident's buttock and heel and verbalized no wounds were present. The LPN was asked about two resident assessments documenting pressure ulcers. The LPN stated she never removed the dressing and viewed the areas. The LPN stated documentation was repeated from previous assessment documentation. On 05/25/16 at 1:55 p.m., LPN #2 was interviewed regarding documentation of a pressure ucler for the resident. The LPN stated she did not recall the resident. The LPN stated if a dressing was in place she would not have removed the dressing to view the area. The LPN stated documented what previous assessment documented.

Based on observation, interview, and record review, it was determined the facility failed to maintain complete and accurate clinical records for three (#1, #3, and #4) of four residents whose clinical records were reviewed. The facility failed to thoroughly document wound assessments for resident #3 and complete bath records for residents #1, #3, and #4. The facility identified 102 residents lived in the facility. Findings: 1. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission comprehensive assessment, dated 12/25/15, documented the resident was independent for daily decision-making and required minimal to moderate assistance with the activities of daily living (ADLs). The assessment documented the resident had no surgical wounds. The care plan, dated 12/18/15, documented the resident required assistance with the activities of daily living and had a surgical wound. The admission data, dated 12/18/15, documented the resident had a surgical wound. The admission data did not document regarding the condition of the wound, did not document the status of the sutures, the presence of drainage, what type of dressing was applied, or if a brace was used. The skilled nurse's notes, dated 12/21/15, 12/22/15, 12/25/15, 12/28/15, and 12/29/15 documented the resident did not have a surgical wound. The narrative nurse's notes, dated 12/29/15, documented the resident's left knee incision was red, swollen, and warm. The notes documented the physician was notified and new orders for antibiotics were received by the nurse. The ADL record for December 2015 had no documentation regarding baths provided for the resident. On 02/02/16 at 4:40 p.m., the director of nurses (DON) was interviewed regarding documentation. The DON stated the the occupational therapy notes documented three of the four baths the resident received as a part of her therapy. The DON reviewed the record regarding the documentation of the resident's wound. The DON stated she had not identified the inaccurate documentation in the medical record. 2. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The comprehensive assessment, dated, 01/24/16, documented the resident was independent with daily decision-making and required extensive assistance with bathing. The care plan, dated 01/18/16, documented the resident had a self care deficit, had a fracture, and had a surgical wound. The ADL record for January 2016 and February 2016 documented the resident was offered one bath. The record documented the resident was offered the bath on 02/02/16. On 02/02/16 at 11:30 a.m., the resident was lying in her bed. The resident had a splint on her left foot. The resident was not dressed, groomed, and her eye makeup was old. The resident stated she was to have a bath the day before but did not get a bath. On 02/02/16 at 4:40 p.m., the director of nurses (DON) was interviewed regarding documentation. The DON reviewed the ADL records for the residents. The DON stated a plan of correction for the missed baths had been implemented. The DON stated she had not identified the inaccurate documentation in the medical record. 3. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The assessment, dated 01/26/16, documented the resident was independent for daily decision-making and required extensive assistance with the activities of daily living. The care plan, dated 01/28/16, documented the resident had a self care deficit. On 02/02/16 at 10:20 a.m., the resident sat in her wheelchair, in her room, and visited with family. The resident right leg had a leg brace applied and the leg was elevated. The resident received heat treatment to her back. The resident was clean, groomed, and had no odors. The resident stated she had not been offered the two scheduled baths per week but had a bed bath the day before. The resident stated she was at the facility due to a fracture of her right leg. The resident stated she did not have to have surgery to her leg. On 02/02/16 at 4:40 p.m., the director of nurses (DON) was interviewed regarding documentation. The DON reviewed the ADL records for the residents. The DON stated a plan of correction for the missed baths had been implemented. The DON stated she had not identified the inaccurate documentation in the medical record.

Based on observation and interview, it was determined the facility failed to maintain a hazard free environment regarding medications on the floor for one (west wing) of two wings in the facility. The facility identified five residents who were confused and could pick up a medication from the floor. Findings: On 03/12/15 at 10:45 a.m., a white pill was observed on the floor approximately five feet from the nurses' station and four feet from the round table in the common area located in the west wing. Four residents were observed in the common area in broda and geriatric chairs in front of the television asleep. Residents #23, #24, and #25 were observed at a round table with CMA #1. Resident #23 was observed awake and residents #24 and #25 were asleep. CMA #1 left the table. The pill remained on the floor. At 10:46 a.m., CNA #3 sat at the table, placed a newspaper in front of resident #24 stated, "There you go, " and left the table. The pill remained on the floor. At 10:47 a.m., resident #14 was observed in her wheelchair sitting close to the nurses' station. At 10:45 through 10:49 a.m., LPN #4 was observed as he walked passed the pill three times. CMA #1 was observed as she walked past the pill three times. The pill remained on the floor. At 10:49 a.m., resident #14 had propelled herself in her wheelchair to be close to the white pill on the floor. RN #2 was observed as she left the nurses' station and talked to resident #14. The white pill remained on the floor. At 11:02 a.m., resident #14 gave the surveyor a pink pill she had in her hand. RN #2 was informed and she stated, "I will find out what it was." At 11:09 a.m., CNA #4 walked by the pill on the floor. The pill remained on the floor. The pharmacist was asked what the pink pill was. He stated he was not positive but it looked like a baby aspirin. The pharmacist and RN #2 were informed of the white pill on the floor. The RN picked up the white pill and stated she had given the resident her medications and then gave her a piece of chocolate. As the pharmacist, RN #2, and surveyor walked down the 300 hall towards the medication cart, one white pill and a pink pill broken in half were observed on the floor in the hallway. The pharmacist stated he was not sure what the medications were. On 03/12/14 at 12:20 p.m., the DON was asked if the facility had a policy regarding pills on the floor of the facility. She stated, "No." She was asked what would you expect your staff to do if a pill was on the floor. She stated, "Pick it up, give it to a nurse, and find out what it was." She stated, "I talked with the nurse who gave (resident #14) her medications. She stated she gave them one at time and saw her swallow after each one and then gave her a pieced of candy. She did not think those pills were (resident #14's). We do not know whose pills those were."

Based on observation and interview, it was determined the facility failed to ensure gastrostomy tube placement was checked and the gastrostomy tube was flushed with water prior to the administration of medication for one (#15) of two sampled residents who were observed to receive medication and bolus feedings through a gastrostomy tube. The facility's Census and Conditions report documented the facility had two residents with gastrostomy tubes. Findings: A facility policy, dated April 2007, and titled, "Administering Medications through an Enteral Tube, documented, "...Steps in the procedure...For nasogastric...gastrostomy tubes, check placement and gastric contents:..Return gastric contents to the stomach. Flush tubing with 15 to 30 ml warm water (or prescribed amount)...Administer medication by gravity flow..." Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The current monthly physician's orders [REDACTED]. On 03/10/15 at 12:30 p.m., LPN #2 was observed to administer a medication, dissolved in approximately 15 ml of water, and a bolus feeding to resident #15 through the resident's gastrostomy tube. The LPN entered the room with the medication dissolved in water and opened a new 60 ml syringe. The LPN donned gloves and connected the syringe with plunger into the open end of the resident's gastrostomy tube. The LPN aspirated the gastrostomy tube for stomach residual by pulling back on the plunger. There was no stomach residual visible in the syringe. The LPN disconnected the syringe from the resident's gastrostomy tube, placed the gastrostomy tube onto the resident's chest, turned away from the resident and obtained the resident's medication. The LPN did not plug or clamp the gastrostomy tube. The resident's gastrostomy tube leaked stomach content onto the resident's blanket and clothing. The LPN clamped the gastrostomy tube with her fingers, connected the syringe without the plunger into the end of the gastrostomy tube, and poured the medication into the syringe. The LPN flushed the syringe/gastrostomy tube with water and then poured 250 ml of nutritional formula into the syringe. She followed the formula with approximately 240 ml of water and plugged the gastrostomy tube with a plastic object. The LPN did not auscultate the stomach to confirm tube placement prior to administering medication and did not flush the gastrostomy tube with water prior to the administration of medication into the gastrostomy tube. On 03/10/15 at 12:45 p.m., LPN #2 was asked what the plastic object was she used to plug the resident's gastrostomy tube. The LPN stated it was the cap from a prefilled saline syringe. On 03/10/15 at 3:30 p.m., the ADON was asked what the facility's procedure was for administering medication through a gastrostomy tube. The ADON stated the nurse was to listen to the stomach with a stethoscope while pushing 10 ml of air through the gastrostomy tube to confirm placement. The ADON stated the nurse would pull back on the syringe to check the amount of stomach content, return the stomach content, and then flush the gastrostomy tube with 30 ml of water prior to administering medication. On 03/12/15 at 4:30 p.m., LPN #2 was asked what the facility's procedure was prior to administering medication through a gastrostomy tube. The LPN stated she checked placement of the gastrostomy tube by auscultating the stomach with her stethoscope and pushing 10 ml of air into the stomach through the gastrostomy tube each morning and then would generally not check placement again that day. She stated she would flush the gastrostomy tube with water before administering medications or giving a bolus tube feeding. The LPN was asked why she had not flushed the gastrostomy tube with water prior to administering the medication. The LPN stated she was nervous during the observation.

Based on observation, interview, and record review, it was determined the facility failed to ensure a medication error rate of less than 5% for two (#12, #15) of 16 residents who were observed during medication administration. Two errors were observed during the 29 medication administration opportunities. This resulted in a medication error rate of 6.9%. This had the potential to affect 92 residents who received medications. Findings: 1. A facility policy, dated April 2007, and titled, "Insulin Administration, documented, "...The type of insulin, dosage requirements, strength, and method of administration must be verified before administration, to assure that it corresponds with the order on the medication sheet and the physician's orders [REDACTED]. The monthly physician's orders [REDACTED].= 0 UNITS * MD Call 151-200 = 2 UNITS 201-250 = 4 UNITS 251-300 = 6 UNITS 301-350 = 8 UNITS 351-400 = 10 UNITS Greater than 401 then 0 UNITS * MD Call..." On 03/10/15 at 11:12 a.m., LPN #1 was observed to check the finger stick blood sugar of resident #12. The finger stick blood sugar reading was 298 and the LPN administered 13 units of [MEDICATION NAME]via [MEDICATION NAME] to resident #12. On 03/10/15 at 11:20 a.m., LPN #1 approached the surveyor and stated he had made a mistake and given resident #12 too much sliding scale insulin. The LPN stated he was in the process of contacting the doctor and would monitor the resident for any adverse reaction. The resident's sliding scale documented the resident was to be administered six units when a fingerstick blood sugar was 298. Resident #12 was administered 13 units of insulin. 2. A facility policy, dated April 2007, and titled, "Administering Medications through an Enteral Tube, documented, "...Steps in the procedure...For nasogastric, esophagostromy, or gastrostomy tubes, check placement and gastric contents:..Return gastric contents to the stomach. Flush tubing with 15 to 30 ml warm water (or prescribed amount)...Administer medication by gravity flow..." The monthly physician's orders [REDACTED]. The active monthly physician's orders [REDACTED]. On 03/10/15 at 12:30 p.m., LPN #2 was observed to administer [MEDICATION NAME]-[MEDICATION NAME] 25mg-100mg, one and a half tablets, crushed and dissolved in approximately 15 ml of water to resident #15 through the resident's gastrostomy tube. The LPN aspirated the gastrostomy tube for stomach residual, removed the plunger from the syringe, re-attached the syringe to the gastrostomy tube, and poured the 15 ml of water with the crushed [MEDICATION NAME]-[MEDICATION NAME] medication solution into the syringe. The LPN did not flush the gastrostomy tube with water prior to the administration of medication into the gastrostomy tube. On 03/10/15 at 3:30 p.m., the ADON was asked what the procedure was for administering a medication through a gastrostomy tube. The ADON stated the nurse was to flush the gastrostomy tube with 30 ml of water prior to medication administration or bolus feedings.

Based on observation and interview, it was determined the facility failed to ensure staff sanitized or washed their hands between resident contact during one (the noon meal on 03/10/15) of two meal services this had the potential to affect 90 residents who were served meals. Findings: A policy titled, Handwashing/Hand Hygiene, dated December 2007, documented, "...preferred method of hand hygiene is with an alcohol-based hand rub...after contact with objects...in the immediate vicinity of the resident..." On 3/10/15, at 12:00 p.m., the noon meal was observed. The CNAs were observed to have not sanitized hands between serving residents the prepared plates. They were observed with their thumbs and fingers on the inside rims of the residents' plates. On 3/12/15, at 11:57 a.m. CNA #4 was observed to deliver a salad to a resident in the dining room and obtained a second plate and delivered to another resident without hands being washed or sanitized. At 12:01 p.m., CNAs #1, and #7, were observed two consecutive times to deliver and return to tray line without hands sanitized between residents. At 12:30 p.m., the dietary manager was asked what kind of in-services or instructions are provided to the staff regarding passing meals in the dining room. He stated it is covered in orientation. The dietary manager was asked if the CNAs had the same orientation. He stated, "Not sure." At 12:35 p.m., CNA #4, was asked what she had been instructed regarding hand hygiene during the meal pass. She stated to sanitize hands between residents. CNA #4, was asked if she was aware she had not sanitized her hands while she delivered plates to different residents. She stated, "No."

Based on observation, interview, and record review, it was determined the facility failed to acquire and administer a medication order by the physician for one (#3) of three sampled residents whose medications were reviewed. The facility identified 98 residents as receiving medications. Findings: Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's admission assessment, dated 01/23/15, documented the resident was cognitively intact. It was documented it was very important to the resident to choose her bedtime. A physician's order, dated 01/26/15, documented the resident was to receive oxazepam, an anti-anxiety medication, 10 mg at bedtime for the [DIAGNOSES REDACTED]. The resident's care plan, updated 01/28/15, documented a problem of using an anti-anxiety used to treat insomnia. The goal was the resident would be free of any discomfort or adverse side effects within the next 90 days. Interventions included to administer the medication as ordered. Review of medication administration records, dated 02/06/15 through 02/16/15, showed no documentation the resident had received oxazepam as ordered by the physician. There was no physician's order to discontinue or hold the medication. On 02/17/15 at 3:10 p.m., LPN #1 was asked to show the surveyor all the resident's medications. There was no oxazepam in the medication cart for the resident. He was asked to review the resident's medication orders. He was shown the physician's order for the oxazepam and was asked where the medication was. He stated, "I don't know." LPN #1 stated it had not been reported to him the resident was not taking the medication. LPN #1 was asked why the resident had not received the medication from 02/06/15 until present. He stated he did not know. He stated the resident had transferred from a different hall on 02/14/15 for skilled nursing services. LPN #1 was asked if there was an order to discontinue or hold the medication. He stated, "I don't see any note of why it hasn't been given." On 02/17/15 at 3:18 p.m., LPN #2, the nurse on the resident's former hall, was asked to check the medication cart for the resident's oxazepam. He searched the cart and stated, "I do not have anything for her." On 02/17/15 at 3:39 p.m., the DON was asked what the process was for ordering medications for residents receiving skilled services. She stated the medication was ordered for ten days, and when the supply was down to three days worth, a request for a refill was entered into the computer. She stated the request was automatically sent to the pharmacy for refill. The DON was asked who was responsible for requesting the refill. She stated the charge nurses were. The DON was asked why resident #3 did not receive her oxazepam as ordered by the physician from 02/06/15 through 02/16/15. She stated, "I can't answer that. I don't know." She stated an audit of the medication carts had been completed during the previous week, and it did not show up the medication was missing. The DON stated she would find out why the resident did not receive the medication. On 02/17/15 at approximately 4:00 p.m., the DON reported the original prescription had been written for ten days, and when the supply reached three days worth, the nurse did not contact the physician or the physician's agent for another prescription. She stated the resident was without the medication for eleven days. She stated someone had requested a refill but did not follow through with getting a written prescription for the medicine.

Based on observation, interview, and record review, it was determined the facility failed to report, investigate, and protect the resident after an allegation of verbal and physical abuse for one (#4) of 11 sampled residents. This had the potential to affect 88 residents who resided at the facility. Findings: The facility's undated policy and procedure titled, Abuse Prohibition Management Program Identification, Investigation and Reporting Policy, documented, "...Policy: All personnel...Are encouraged to report actual or suspected incidents of Resident Abuse...Investigating: Should an incident or suspected incident of resident abuse, neglect or injury of an unknown source be reported, the Abuse Coordinator or his/her designee will investigate the alleged incident...Reporting: Any person observing an incident of resident abuse or suspecting resident abuse must immediately report such incidents to the Charge Nurse, regardless of the time lapse since the incident occurred... The Abuse Coordinator will immediately report to the Oklahoma State Department of Health utilizing the Incident Report Form, appropriate licensing board, if applicable and other appropriate authorities, incidents of resident abuse as required under applicable regulations and regulatory guidance...Protection of Residents During Abuse Investigations...Policy Statement...Our facility will protect residents from harm during investigations of abuse allegations..." Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nurses' note, dated 07/06/14 at 7:47 p.m., documented, " ...son yelled at this nurse and demanded that I assess skin for any problems...Requested another nurse to come with (sic) while assessing skin...Upon entering room, son approached both us (sic) nurses and stated that he is further angered that his mother reports that this nurse has gone in and shaken (patient) and forced (patient) to get out of bed..." The note was signed by LPN #2. A nurses' note, dated 07/06/14 at 7:50 p.m., documented, "...This nurse attests to the truth of all event (sic) in the nursing notes of 7/6/2014 created and written by (LPN #2)..." The note was signed by LPN #1. An admission assessment, dated 08/23/14, documented the resident was cognitively intact, required extensive assistance with bed mobility, transfer, and toilet use. The assessment documented the resident required a wheelchair for mobility. On 09/08/14 at 9:50 a.m., resident #4 was asked if any of the staff had ever been rude to her or been rough when providing care. She stated she had a male nurse shake her by her shoulders once. She stated she refused to get out of bed for physical therapy because she was having trouble breathing. She stated she thought the nurse was going to hit her so she raised her arm, but he grabbed her by the shoulders and started shaking her. She stated he told her she was going to get up and go to physical therapy. She stated another nurse stepped in and stopped the situation. She was asked when the incident happened. She stated in July 2014. She stated the nurse did not work at the facility for a period of time, but then came back. She was asked if the nurse had resumed providing her care. She stated, "Yes." She was asked if she was afraid. She stated, "At first I was, but things have been okay." She was asked if anyone from administration had spoken to her regarding the incident. She stated, "No I wouldn't want to get anyone in trouble." No incident report was found in the facility regarding the incident. At 3:45 p.m., the DON was asked what the facility's protocol was when an allegation of abuse was reported. She stated the allegation is taken to the administrator, who is the abuse coordinator. She asked what procedure was when the resident's son alleged his mother had been shaken. She stated, "The nurse should have reported it." At 3:47 p.m., the administrator was asked if he was aware of an allegation of abuse for resident #4. He stated, "No." He was asked what the facility's protocol was when there was an allegation of abuse. He stated it is reported to him and if it involved staff, that staff member is suspended until an investigation is completed. He was informed of the allegation and asked if the staff members involved had followed the facility protocol. He stated, "No." At 4:15 p.m., the ADON was asked if any staff members had informed her of an allegation of abuse regarding resident #4. She stated LPN #2 had called her and informed her of an altercation with the resident's son, but had not informed her that the resident had allegedly been shook. She stated the resident can get confused at times. She was asked if the staff members had followed the facility's protocol regarding the allegation of abuse. She stated, "I think so." She was asked what the meaning of abuse was. She stated, "If the resident said she was shook, I see what you're asking." She stated the staff members had not followed the facility protocol regarding abuse. At 4:24 p.m., LPN #1 was asked to provide a synopsis of the incident that had occurred in July 2014 with LPN #2 and the resident ' s son. She stated there had been an argument between LPN #2 and the resident ' s son. She stated she stepped in to calm the situation. She stated the resident's son had later approached the nurses' station and told her that he did not believe anyone had shaken his mother. She was asked where that was documented. She stated she had not documented it. She denied she had heard the resident's son confront LPN #2 regarding the allegation that his mother had been shaken by a staff member. At 5:08 p.m., LPN #2 was asked what had transpired between him and the resident ' s son in July 2014. He stated the resident's son had stated the resident had skin breakdown. He stated he had asked another nurse to accompany him during a skin assessment per the son's request. He stated when he and the other nurse had entered the resident's room the resident's son, "Said something about us shaking her." He stated he did not know who the alleged perpetrator was or when the incident had occurred. He was asked what the facility's protocol was regarding an allegation of abuse. He stated, "Report to immediate supervisor." He stated he had called and informed the ADON and she was to inform the DON. He stated later the resident's son had stated the resident was confused and he did not believe anyone had shaken her. He was asked, regardless of the son's comment about his mother's confusion, what would be the course of action to take per the facility's protocol regarding an abuse allegation. He stated, "Report it." He was asked if the resident's son had alleged he was the staff member who had shaken the resident. He stated, "The son said me, but when we were in the room again she said it wasn't me. He was asked about his documentation in the nurses' notes, dated 07/06/14, regarding the occurrence between him and the resident's son. He stated, "I haven't seen that note in so long I don't remember what is in it."

Based on observation, interview, and record review, it was determined the facility failed to implement their policies and procedures in regards to reporting, keeping the resident safe, and completing a thorough investigation for an allegation of verbal and physical abuse for one (#4) of 11 sampled residents. This had the potential to affect 88 residents who resided at the facility. Findings: The facility's undated policy and procedure titled, Abuse Prohibition Management Program Identification, Investigation and Reporting Policy, documented, "...Policy: All personnel...Are encouraged to report actual or suspected incidents of Resident Abuse...Investigating: Should an incident or suspected incident of resident abuse, neglect or injury of an unknown source be reported, the Abuse Coordinator or his/her designee will investigate the alleged incident...Reporting: Any person observing an incident of resident abuse or suspecting resident abuse must immediately report such incidents to the Charge Nurse, regardless of the time lapse since the incident occurred... The Abuse Coordinator will immediately report to the Oklahoma State Department of Health utilizing the Incident Report Form, appropriate licensing board, if applicable and other appropriate authorities, incidents of resident abuse as required under applicable regulations and regulatory guidance...Protection of Residents During Abuse Investigations...Policy Statement...Our facility will protect residents from harm during investigations of abuse allegations..." Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nurses' note, dated 07/06/14 at 7:47 p.m., documented, " ...son yelled at this nurse and demanded that I assess skin for any problems...Requested another nurse to come with (sic) while assessing skin...Upon entering room, son approached both us (sic) nurses and stated that he is further angered that his mother reports that this nurse has gone in and shaken (patient) and forced (patient) to get out of bed..." The note was signed by LPN #2. A nurses' note, dated 07/06/14 at 7:50 p.m., documented, "...This nurse attests to the truth of all event (sic) in the nursing notes of 7/6/2014 created and written by (LPN #2)..." The note was signed by LPN #1. An admission assessment, dated 08/23/14, documented the resident was cognitively intact, required extensive assistance with bed mobility, transfer, and toilet use. The assessment documented the resident required a wheelchair for mobility. On 09/08/14 at 9:50 a.m., resident #4 was asked if any of the staff had ever been rude to her or been rough when providing care. She stated she had a male nurse shake her by her shoulders once. She stated she refused to get out of bed for physical therapy because she was having trouble breathing. She stated she thought the nurse was going to hit her so she raised her arm, but he grabbed her by the shoulders and started shaking her. She stated he told her she was going to get up and go to physical therapy. She stated another nurse stepped in and stopped the situation. She was asked when the incident happened. She stated in July 2014. She stated the nurse did not work at the facility for a period of time, but then came back. She was asked if the nurse had resumed providing her care. She stated, "Yes." She was asked if she was afraid. She stated, "At first I was, but things have been okay." She was asked if anyone from administration had spoken to her regarding the incident. She stated, "No I wouldn't want to get anyone in trouble." No incident report was found in the facility regarding the incident. At 3:45 p.m., the DON was asked what the facility's protocol was when an allegation of abuse was reported. She stated the allegation is taken to the administrator, who is the abuse coordinator. She asked what procedure was when the resident's son alleged his mother had been shaken. She stated, "The nurse should have reported it." At 3:47 p.m., the administrator was asked if he was aware of an allegation of abuse for resident #4. He stated, "No." He was asked what the facility's protocol was when there was an allegation of abuse. He stated it is reported to him and if it involved staff, that staff member is suspended until an investigation is completed. He was informed of the allegation and asked if the staff members involved had followed the facility protocol. He stated, "No." At 4:15 p.m., the ADON was asked if any staff members had informed her of an allegation of abuse regarding resident #4. She stated LPN #2 had called her and informed her of an altercation with the resident's son, but had not informed her that the resident had allegedly been shook. She stated the resident can get confused at times. She was asked if the staff members had followed the facility's protocol regarding the allegation of abuse. She stated, "I think so." She was asked what the meaning of abuse was. She stated, "If the resident said she was shook, I see what you're asking." She stated the staff members had not followed the facility protocol regarding abuse. At 4:24 p.m., LPN #1 was asked to provide a synopsis of the incident that had occurred in July 2014 with LPN #2 and the resident ' s son. She stated there had been an argument between LPN #2 and the resident ' s son. She stated she stepped in to calm the situation. She stated the resident's son had later approached the nurses' station and told her that he did not believe anyone had shaken his mother. She was asked where that was documented. She stated she had not documented it. She denied she had heard the resident's son confront LPN #2 regarding the allegation that his mother had been shaken by a staff member. At 5:08 p.m., LPN #2 was asked what had transpired between him and the resident ' s son in July 2014. He stated the resident's son had stated the resident had skin breakdown. He stated he had asked another nurse to accompany him during a skin assessment per the son's request. He stated when he and the other nurse had entered the resident's room the resident's son, "Said something about us shaking her." He stated he did not know who the alleged perpetrator was or when the incident had occurred. He was asked what the facility's protocol was regarding an allegation of abuse. He stated, "Report to immediate supervisor." He stated he had called and informed the ADON and she was to inform the DON. He stated later the resident's son had stated the resident was confused and he did not believe anyone had shaken her. He was asked, regardless of the son's comment about his mother's confusion, what would be the course of action to take per the facility's protocol regarding an abuse allegation. He stated, "Report it." He was asked if the resident's son had alleged he was the staff member who had shaken the resident. He stated, "The son said me, but when we were in the room again she said it wasn't me. He was asked about his documentation in the nurses' notes, dated 07/06/14, regarding the occurrence between him and the resident's son. He stated, "I haven't seen that note in so long I don't remember what is in it."

On 05/09/12, an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to ensure care and services were provided for resident #2, who had critically low potassium levels. The facility failed to administer medications as prescribed, provide laboratory services as required and ordered by the physician, and failed to notify the physician of laboratory results including abnormal values and critical levels On 05/09/12, at 1:34 p.m., the Oklahoma State Department of Health (OSDH) verified the existence of the IJ related to the facility's failure to ensure medications were provided, laboratory services were provided and/or provided in a timely manner and physicians were informed of laboratory results, including abnormal values and critical values. At 1:35 p.m., the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), and Corporate Nurse Consultant were informed of the IJ situation related to the facility's failure to provide medications, laboratory services, and failure to inform physicians of abnormal lab values. At 7:30 p.m., the facility submitted an acceptable plan of removal. The plan of removal documented: "Identification of Others - -- 100% Audit of Charts for potassium has been conducted by the nurse management and nurse consultants on 5/9/12. All residents with potassium will be checked that appropriate labs had been completed as ordered and physician notified of results, and ordered potassium was administered. -- Lab will be conducting a 100% audit of all Labs/Results on 5/10/12. -- Pharmacy will be conducting a 100% audit of MARS/Med Carts for medication availability and administration on 5/10/12. -- Effective immediately nurse management and nurse consultants will conduct 100% audit of all physician orders for current residents. This will continue daily in clinical weekday stand-up, weekly in Standards of Care, and monthly with QA meeting. This will continue indefinitely. -- Lab representative is scheduled to meet with facility by 10 am on 5/10/12, to discuss and review the procedure. The lab will have a representative available to complete 100% audit of lab orders and results. -- On 5/9/12 at 5pm the pharmacy Vice President of national accounts was notified and is sending a (sic) specialty trained nurse for 100% audit of MAR/medication cart/medication administration/transcription and time line to improve the efficiency of ordering, delivering, transcription, and administering of medications. -- The Medical Director was notified on 5/9/12 at 6pm and will be here on 5/10/12 to discuss the above stated procedures and to discuss the communication between facility and acting physicians. The Medical Director will be an active liaison to ensure this communication/education is effective with all disciplines in the facility including acting physicians, lab, and pharmacy. Staff in-services- licensed nursing staff and certified medication aides will be in serviced on policy and procedure for lab protocol and communication with physician regarding lab results and the administration of medications ordered. On 5/9/12 at 3:00 pm (sic) 27 of 31 licensed nursing staff were in serviced. One licensed staff was in serviced at 5pm, and one was contacted by phone for the in-service. Two licensed staff were not reached, but will receive in servicing before returning to work. Systemic Changes - -- The DON or designee will review the lab logs daily at the morning meeting and on Mondays following the weekend. -- Starting immediately all residents that take potassium will have their labs reviewed daily and any order changes reviewed by the DON or the designee. any problems related to lab will be corrected immediately. -- On 5/9/12 at 3pm, the lab representative was contacted by the DON via telephone regarding critical lab procedures. At 5pm on 5/9/12, an email confirmation was received verifying the phone conversation and the changes made in the lab database regarding the procedure of calling all critical labs. All critical labs will be call to the DON, ADON, or QC nurse by the lab. The nursing administration team will call the critical lab values to the charge nurse, who will immediately call the doctor the critical lab values. If no response within one hour, the charge nurse will page the Medical Director. If no response within 30 minutes, the DON or designee will be contacted for further directions. The charge (nurse) will document communication attempts in the nurse's notes. Lab logs are to be utilized on all labs. Monitoring- The facility will monitor this critical system daily at the morning meeting, weekly at the Standards of Care meeting, and review and monitor the outcomes and processes at the Quality Assurance Meeting. This monitoring will be conducted by the Director of Nursing and Assistant Director of Nursing." The IJ was removed on 5/11/12 at 6:30 p.m., when all components of the plan of removal had been completed. The deficiency remained at a pattern level with a potential for more than minimal harm. Based on observations, interviews and record reviews, it was determined the facility failed to ensure care and services were provided to maintain the resident's highest practical well-being for one (resident #2) of one sampled resident, who had critically low potassium levels, by failing to: ~ administer medications as prescribed; ~ provide laboratory services as required and ordered by the physician; and ~ notify the physician of laboratory results including abnormal values and critical levels. The facility failed to assess and monitor the resident's condition by failing to obtain laboratory testing in a timely manner or not at all and failing to intervene when the resident had critically abnormal lab values, by failing to notify the physician. This resulted in an Immediate Jeopardy situation. The facility roster documented 78 residents, who resided at the facility. Findings: The facility's Policy and Procedure for the Documentation of Medication Administration documented: "Policy Statement: The facility shall maintain a Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] Policy Interpretation and Implementation: 1. A Nurse or Certified Medication Aide (where applicable) shall document all medications administered to each resident on the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] 2. Administration of medication must be documented immediately after (never before) it is given. 3. Documentation must include, as a minimum: a. Name and strength of the drug; b. Dosage; c. Method of administration (e.g., oral, injection (and site), etc.); d. Date and time of administration; e. Reason(s) why a medication was withheld, not administered, or refused (as applicable); and f. Signature and title of the person administering the medication." The contracted pharmacy's delivery information documented: -- Hours of operation 9am to 9pm weekdays and 9am-1pm Saturday. Delivery orders needed to be faxed to the pharmacy before 5 pm when possible. -- New orders will be delivered the same day if faxed to the pharmacy before 5 pm weekday and by noon on Saturday. New orders faxed after normal delivery hours but before the pharmacy closes will be delivered the same day if you write "Need Today" clearly on the faxed order form. -- Refills faxed before the pharmacy closes will be delivered the next business day. Order when a 4 day supply remains. Check supply of medications at least 3 times per week. -- For refills needed the same day, please write "Need Today". -- STAT order are for emergencies. Please write "STAT" next to the specific order that needs to be delivered immediately. The pharmacist may call the facility for clarification of the STAT request. The facility protocol for Laboratory and Diagnostic Test results documented: "- The physician will identify and order diagnostic and lab testing based on diagnostic and monitoring needs. - The staff will process test requisitions and arrange for tests. - The laboratory, . . . ., will report test results to the facility. - If the staff who first receive or review lab . . . results cannot follow the remainder of this procedure for reporting and documenting the results and their implications, another nurse in the facility (Supervisor, Charge Nurse, etc.) should follow or coordinate the procedure. - The person who is to communicate results to a physician will review and be prepared to discuss the following . . . : a. The individual's current condition and any recent changes in status, including vital signs and mental status. b. Major diagnoses, allergies [REDACTED]. c. Why the tests were obtained. d. How test results might relate to the individual's current status, treatments, or medications. e. Any concerns or issues the physician will be expected to address upon receiving the results. - Before contacting the physician, the nurse will gather and organize the information listed above and coordinate any telephone communications with others who may also need to speak with the physician. - A nurse will identify the urgency of communicating with the attending physician based on physician request, the seriousness of any abnormality, and the individual's current condition. - A nurse will try to determine whether the test was done: a. As a routine screen or follow-up. b. To assess a condition change or recent onset of signs and symptoms. c. To monitor a drug level. The reason for getting a test often affects the urgency of acting upon the results. If the reason for performing the test cannot be identified, the nurse should proceed as though the tests were ordered to assess a condition change or recent onset of signs and symptoms. Nursing staff will consider the following factors to help identify situations requiring prompt physician notification concerning lab . . . results: - The physician has requested to be notified as soon as result is received. -The result is something that should be conveyed to a physician regardless of other circumstances . . .(abnormal results . . . ) - High or toxic drug levels. . . The following may constitute exceptions to situations . . . . - . . . . . . terminally ill, or is receiving palliative care or comfort measures only. - The results are similar to (or better than) known chronic abnormally results . . . . . - The physician previously left specific guidance or orders . . . . . - The results are the same as or better than previous ones, treatment has already been instituted for an acute condition change, and the individual is stable or improving. However, nursing staff may sometimes determine that an individual's condition warrants immediate reporting of lab results despite these exceptions. If the results do not meet the preceding criteria for immediate notification, then the nursing staff will review why the test was obtained, as well as the resident's current clinical status including the presence of any signs and symptoms. a. If the resident has signs and symptoms of acute illness or condition change and he/she is not stable or improving, or there are no previous results for comparison, the the nurse will notify the physician promptly to discuss the situation, including a description of relevant clinical findings as well as the test results. b. If the individual is stable or improving and the results do not warrant immediate notification, then the nursing staff may notify the physician routinely, . . . . A physician can be notified by phone, fax, voicemail, e-mail, mail, pager, or telephone message to another person acting as the physician's agent (for example, office staff). a. Facility staff should document information about, when, how, and to whom the information was provided and the response. This should be done in the progress notes section of the medical record and not on the lab results report, because test results should be correlated with other relevant information such as the individual's overall situation, current symptoms, advance directives, prognosis, etc. b. Direct voice communication with the physician is the preferred means for presenting any results requiring immediate notification, especially when the resident's clinical status is unstable or current treatment needs review or clarification. c. For information that does not need immediate physician response, staff may use alternatives such as faxing, voice mail, or a clipboard in the facility. Alternatively, the staff and physician may also establish designated times during the day when they will review test results with the physician by phone. Physician Responses. 1. Time frames. A physician will respond within an appropriate time frame, based on the request from nursing staff and the clinical significance of the information. a. A physician should respond within one hour regarding a lab test result requiring immediate notification, and by the end of the next office day to a non-emergency message regarding non-immediate lab test notification with a request for response. . . . b. If the attending or covering physician does not respond to immediate notification within an hour, the nursing staff should contact the Medical Director for assistance. 2. Physician decisions. When responding to notification of test results, the physician and staff will discuss the implications of the test results for the resident, as well as subsequent actions. . . . Physicians or nurses who have concerns about how test results have been handled or reported should communicate such concerns to the DON (director of nurses) and/ or Medical Director. Such concerns or disagreement should not prevent timely, clinically appropriate management of a current result or clinical situation." Resident # 2 was re-admitted to the facility on [DATE] with gastro-intestinal hemorrhage, [MEDICAL CONDITION], lack of coordination, muscle weakness, muscle disuse atrophy, and abnormality of gait. The careplan, dated 12/23/11, documented: Problem -- Lab: Resident is at risk for abnormal lab values R/T (related to) [MEDICAL CONDITION] Goals -- Resident's lab will be within normal range for resident thru the next 90 days. Interventions -- 1. Diet as ordered 2. Investigate and report any changes in resident's condition promptly to MD. 3. Monitor lab and report abnormal readings to MD. The admission assessment, dated 01/25/12, documented the resident was independent in decision making and required limited to extensive assistance in activities of daily living. The resident had full range of motion in all extremities and was occasionally incontinent of bowel and bladder. The assessment documented the resident had two stage II pressure ulcers present on admission, along with surgical incisions, and open [MEDICAL CONDITION] on the foot. Medications On 01/18/12, the admission orders [REDACTED]. The January 2012 MAR indicated [REDACTED]. On 01/22/12, a physician's order was received for potassium chloride, 40 mEq, now. The order was written on the MAR. The date to administer the medication was outlined, but no initials were present to denote the medication was given. On the January 2012 MAR, the dose of potassium for 01/24/12, was initialed and circled as not given. There was no rationale documented for the missed dose. The potassium chloride was not documented as given on 01/25/12. The 40 mEq of potassium chloride was documented as given on 01/26/12. After 01/26/12, the dedicated row for potassium chloride 40 mEq daily, was then marked through with a line and N.O. (new order) and D/C (discontinue) were documented on the line. There was no physician's order to discontinue the daily dose of potassium chloride 40 mEq. On 01/26/12, a physician's order was received for potassium chloride, 40 mEq, every 6 hours x 2 doses. Two doses were documented as given on 01/26/12, on the MAR. The MAR indicated [REDACTED]. An arrow was drawn to indicate it was to start on 01/27/12. Written to the right of the arrow was, "D/C 1/27/12." No potassium chloride was documented as given for this entry. There was no physician's order to discontinue the daily dose of potassium chloride 40 mEq. A physician's order, dated 01/31/12, documented, "[MEDICATION NAME] 20mg PO QD Potassium 10 mEq PO QD." The January 2012 MAR indicated Potassium 10 mEq PO QD 1/31/12." There was no documentation on the MAR indicated [REDACTED]. There was no documentation to show any potassium chloride was administered from 01/27/12 through 01/31/12. The January MAR indicated There was no documentation to show the [MEDICATION NAME] was administered on 01/31/12. The February 2012 monthly physician's orders, dated 02/01/12, documented, "...Potassium Chlor (Chloride) 40 mEq PO QD..." The February 2012 MAR indicated [REDACTED]." The MAR indicated [REDACTED]. The February 2012 MAR indicated [REDACTED]." A line was drawn through 02/01/12 through 02/07/12. The MAR indicated [REDACTED]. There was no physician's order, dated after the February monthly orders (02/01/12), to change the potassium chloride to 10 mEq. The February 2012 MAR indicated [REDACTED]." A line was drawn through 02/01/12 through 02/07/12. The MAR indicated [REDACTED]. There was no [MEDICATION NAME] administered from 02/01/12 through 02/07/12. A physician's order, dated 02/23/12, documented: "KCL 40 mEq PO q 6 hrs x 3 doses - STAT (Increase) KCL to 20 mEq PO Q Day..." The February 2012 MAR indicated [REDACTED]." The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The February 2012 MAR indicated [REDACTED]." An arrow was drawn to indicate the medication should be started on 02/24/12. The arrow was then extended (with a line drawn through the 24th and 25th) to indicate the medication should be started on 02/26/12. There was no potassium chloride documented as given to the resident on 02/24/12. The MAR indicated [REDACTED]. On 05/09/12 at 11:00 a.m., LPN #9 was interviewed about the discontinuation of the routine order for potassium chloride 40 mEq in January 2012.. The LPN stated the order of potassium chloride, 40 mEq daily, was written on the MAR indicated [REDACTED]'d (discontinued), and dated and initialed the row. The LPN stated he/she was unsure why the other entry was also marked through with N.O. (new order) and d/c'd. Laboratory Services and Physician notification of laboratory reports A physician's order, dated 01/19/12, documented, "CBC (Complete Blood Count) Chem 8 (Chemistry or Basic Metabolic Panel)..." A laboratory report, dated 01/21/12, documented the specimen was collected on 01/20/12 at 8:00 p.m. The results were faxed to the facility on [DATE] at 2:03 a.m. The results documented the resident's potassium was 2.9, which was low with a reference range of 3.5 - 5.1. A nurse's note, dated 01/22/12 at 3:30 p.m., documented, "pt K (potassium) level low Dr. notified order to give 40 meq now and recheck K level tomorrow 1/23/12." A physician's order, dated 01/22/12, documented, "give 40 MEQ K potassium chloride now recheck K level tomorrow 1/23." The potassium level, ordered for 01/23/12, was not requested or performed by the lab. A physician's order, dated 01/23/12, documented, "CBC & CMP (complete metabolic panel) to draw 1/24." A lab report for the CMP, collected on 01/24/12 and reported on 01/24/12, documented the following abnormal results: Results Range BUN 47 (H) 10 - 26 MG/DL (milligrams per deciliter) Creatinine 2.3 (H) 0.4-1.5 MG/DL Potassium 3.0 (L) 3.5-5.0 MMOL/L (millimoles per liter) Calcium 8.1 (L) 8.5 - 10.5 MG/DL Total Protein 5.5 (L) 6.0 - 8.5 GM/DL (gram per deciliter) [MEDICATION NAME] 2.7 (L) 3.0 - 5.5 GM/DL A notation at the bottom of the laboratory results documented, "serum hemolyzed - potassium may be falsely increased." There was no documentation to show the physician was notified of the abnormal results. A physician's progress note, dated 01/26/12, documented the results of the CBC and CMP drawn 01/24/12. A physician's order, dated 01/30/12, documented, "CBC, Chem - 8, PT/INR ([MEDICATION NAME] Time/International Normalized Ratio) on 2/1/12..." This lab was requested but not performed by the laboratory. A Specimen Unobtained Form documented two attempted venipunctures were performed but no specimen was obtained. The form documented a follow-up attempt at obtaining the lab would be performed on the next scheduled draw date. A physician's order, dated 02/16/12, documented, "...CBC, Chem 8." This order was entered into the computer for laboratory and an unsuccessful attempt was performed on 02/17/12 to obtain the specimens by lab. A specimen unobtained form was presented to the charge nurse and a follow-up attempt scheduled for the next draw date. The specimen was collected on 02/20/12. Handwritten on the bottom of the laboratory report was, "Faxed to (physician) 2/21/12." The abnormal results of the Chem 8, dated 02/20/12, were as follows: Results Range BUN 39 (H) 10 - 26 MG/DL Creatinine 2.2 (H) 0.4-1.5 MG/DL Potassium 2.7 (L) 3.5-5.0 MMOL/L (Critical Value Detected) Chloride 113 (H) 98 - 107 MMOL/L Carbon [MEDICATION NAME] 17 (L) 21 - 32 MMOL/L A physician's progress note, dated 02/23/12, documented, "Chart reviewed I noted K+ level on 2/20/12 was 2.7-> results called to nurse but was not addressed or called to physician. Noted labs faxed 1/21/12 to our office but none received in my office." On 05/09/12 at 10:30 a.m., the Assistant Director of Nursing (ADON) was asked what the Specimen Unobtained Form meant by "Will attempt re-draw on next scheduled draw date?" The ADON stated it meant the lab would attempt to re-draw the specimen on the next visit to the facility. The ADON was asked when the lab was regularly scheduled and the ADON stated the lab was in the facility daily. On 05/09/12 at 11:30 a.m., the primary care physician for resident #2 was interviewed. The physician stated there was often a delay in receiving critical lab values. The physician was informed of the missed potassium chloride doses and the delay in administering the STAT doses and initiating the dosage changes as ordered. The physician stated he/she was unaware of the missed potassium chloride doses and would have sent the resident out immediately to the hospital for evaluation had he/she been made aware. The physician stated, had the potassium chloride been administered as ordered and laboratory results had been called in a timely manner, the resident's potassium level would never have dropped to the critical level of 2.7 or below.

On 05/09/12, an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to administer medications as prescribed for resident #2, who had critically low potassium levels. The resident had three delayed doses of potassium, which were ordered STAT (immediately), and nine missed doses of potassium between 01/18/12 and 02/27/12. This resulted in significant medication errors for resident #2. On 05/09/12, at 1:34 p.m., the Oklahoma State Department of Health (OSDH) verified the existence of the IJ related to the facility's failure to ensure residents were free of significant medication errors. At 1:35 p.m., the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), and Corporate Nurse Consultant were informed of the IJ related to the facility's failure to ensure residents were free of significant medication errors. At 7:30 p.m., the facility submitted an acceptable plan of removal. The plan of removal documented: "Identification of Others - -- 100% Audit of Charts for potassium has been conducted by the nurse management and nurse consultants on 5/9/12. All residents with potassium will be checked that appropriate labs had been completed as ordered and physician notified of results, and ordered potassium was administered. -- Lab will be conducting a 100% audit of all Labs/Results on 5/10/12. -- Pharmacy will be conducting a 100% audit of MARS/Med Carts for medication availability and administration on 5/10/12. -- Effective immediately nurse management and nurse consultants will conduct 100% audit of all physician orders for current residents. This will continue daily in clinical weekday stand-up, weekly in Standards of Care, and monthly with QA meeting. This will continue indefinitely. -- Lab representative is scheduled to meet with facility by 10 am on 5/10/12, to discuss and review the procedure. The lab will have a representative available to complete 100% audit of lab orders and results. -- On 5/9/12 at 5pm the pharmacy Vice President of national accounts was notified and is sending a (sic) specialty trained nurse for 100% audit of MAR/medication cart/medication administration/transcription and time line to improve the efficiency of ordering, delivering, transcription, and administering of medications. -- The Medical Director was notified on 5/9/12 at 6pm and will be here on 5/10/12 to discuss the above stated procedures and to discuss the communication between facility and acting physicians. The Medical Director will be an active liaison to ensure this communication/education is effective with all disciplines in the facility including acting physicians, lab, and pharmacy. Staff in-services- licensed nursing staff and certified medication aides will be in serviced on policy and procedure for lab protocol and communication with physician regarding lab results and the administration of medications ordered. On 5/9/12 at 3:00 pm (sic) 27 of 31 licensed nursing staff were in serviced. One licensed staff was in serviced at 5pm, and one was contacted by phone for the in-service. Two licensed staff were not reached, but will receive in servicing before returning to work. Systemic Changes - -- The DON or designee will review the lab logs daily at the morning meeting and on Mondays following the weekend. -- Starting immediately all residents that take potassium will have their labs reviewed daily and any order changes reviewed by the DON or the designee. any problems related to lab will be corrected immediately. -- On 5/9/12 at 3pm, the lab representative was contacted by the DON via telephone regarding critical lab procedures. At 5pm on 5/9/12, an email confirmation was received verifying the phone conversation and the changes made in the lab database regarding the procedure of calling all critical labs. All critical labs will be call to the DON, ADON, or QC nurse by the lab. The nursing administration team will call the critical lab values to the charge nurse, who will immediately call the doctor the critical lab values. If no response within one hour, the charge nurse will page the Medical Director. If no response within 30 minutes, the DON or designee will be contacted for further directions. The charge (nurse) will document communication attempts in the nurse's notes. Lab logs are to be utilized on all labs. Monitoring- The facility will monitor this critical system daily at the morning meeting, weekly at the Standards of Care meeting, and review and monitor the outcomes and processes at the Quality Assurance Meeting. This monitoring will be conducted by the Director of Nursing and Assistant Director of Nursing." The IJ was removed on 5/11/12 at 6:30 p.m., when all components of the plan of removal had been completed. The deficiency remained at a pattern level with a potential for more than minimal harm. Based on observations, interviews and record reviews, it was determined the facility failed to ensure one (#2) of six sampled residents, whose medications were reviewed, were free of significant medication errors. This resulted in an Immediate Jeopardy Situation. The facility roster documented 78 residents resided at the facility. Findings: The facility's Policy and Procedure for the Documentation of Medication Administration documented: "Policy Statement: The facility shall maintain a Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] Policy Interpretation and Implementation: 1. A Nurse or Certified Medication Aide (where applicable) shall document all medications administered to each resident on the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] 2. Administration of medication must be documented immediately after (never before) it is given. 3. Documentation must include, as a minimum: a. Name and strength of the drug; b. Dosage; c. Method of administration (e.g., oral, injection (and site), etc.); d. Date and time of administration; e. Reason(s) why a medication was withheld, not administered, or refused (as applicable); and f. Signature and title of the person administering the medication." The contracted pharmacy's delivery information documented: -- Hours of operation 9am to 9pm weekdays and 9am-1pm Saturday. Delivery orders needed to be faxed to the pharmacy before 5 pm when possible. -- New orders will be delivered the same day if faxed to the pharmacy before 5 pm weekday and by noon on Saturday. New orders faxed after normal delivery hours but before the pharmacy closes will be delivered the same day if you write "Need Today" clearly on the faxed order form. -- Refills faxed before the pharmacy closes will be delivered the next business day. Order when a 4 day supply remains. Check supply of medications at least 3 times per week. -- For refills needed the same day, please write "Need Today". -- STAT order are for emergencies. Please write "STAT" next to the specific order that needs to be delivered immediately. The pharmacist may call the facility for clarification of the STAT request. Resident # 2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 01/18/12, the admission orders [REDACTED]. The January 2012 MAR indicated [REDACTED]. On 01/22/12, a physician's order was received for potassium chloride, 40 mEq, now. The order was written on the MAR. The date to administer the medication was outlined, but no initials were present to denote the medication was given. On the January 2012 MAR, the dose of potassium for 01/24/12, was initialed and circled as not given. There was no rationale documented for the missed dose. The potassium chloride was not documented as given on 01/25/12. The 40 mEq of potassium chloride was documented as given on 01/26/12. After 01/26/12, the dedicated row for potassium chloride 40 mEq daily, was then marked through with a line and N.O. (new order) and D/C (discontinue) were documented on the line. There was no physician's order to discontinue the daily dose of potassium chloride 40 mEq. On 01/26/12, a physician's order was received for potassium chloride, 40 mEq, every 6 hours x 2 doses. Two doses were documented as given on 01/26/12, on the MAR. The MAR indicated [REDACTED]. An arrow was drawn to indicate it was to start on 01/27/12. Written to the right of the arrow was, "D/C 1/27/12." No potassium chloride was documented as given for this entry. There was no physician's order to discontinue the daily dose of potassium chloride 40 mEq. A physician's order, dated 01/31/12, documented, "[MEDICATION NAME] 20mg PO QD Potassium 10 mEq PO QD." The January 2012 MAR indicated Potassium 10 mEq PO QD 1/31/12." There was no documentation on the MAR indicated [REDACTED]. There was no documentation to show any potassium chloride was administered from 01/27/12 through 01/31/12. The January MAR indicated There was no documentation to show the [MEDICATION NAME] was administered on 01/31/12. The February 2012 monthly physician's orders, dated 02/01/12, documented, "...Potassium Chlor (Chloride) 40 mEq PO QD..." The February 2012 MAR indicated [REDACTED]." The MAR indicated [REDACTED]. The February 2012 MAR indicated [REDACTED]." A line was drawn through 02/01/12 through 02/07/12. The MAR indicated [REDACTED]. There was no physician's order, dated after the February monthly orders (02/01/12), to change the potassium chloride to 10 mEq. The February 2012 MAR indicated [REDACTED]." A line was drawn through 02/01/12 through 02/07/12. The MAR indicated [REDACTED]. There was no [MEDICATION NAME] administered from 02/01/12 through 02/07/12. A physician's order, dated 02/23/12, documented: "KCL 40 mEq PO q 6 hrs x 3 doses - STAT (Increase) KCL to 20 mEq PO Q Day..." The February 2012 MAR indicated [REDACTED]." The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The February 2012 MAR indicated [REDACTED]." An arrow was drawn to indicate the medication should be started on 02/24/12. The arrow was then extended (with a line drawn through the 24th and 25th) to indicate the medication should be started on 02/26/12. There was no potassium chloride documented as given to the resident on 02/24/12. The MAR indicated [REDACTED]. On 05/09/12 at 11:00 a.m., LPN #9 was interviewed about the discontinuation of the routine order for potassium chloride 40 mEq in January 2012.. The LPN stated the order of potassium chloride, 40 mEq daily, was written on the MAR indicated [REDACTED]'d (discontinued), and dated and initialed the row. The LPN stated he/she was unsure why the other entry was also marked through with N.O. (new order) and d/c'd. On 05/09/12 at 11:30 a.m., the primary care physician for the resident stated there was often a delay in receiving critical lab values. The doctor was informed of the missed potassium chloride doses and the delay in administering the STAT doses and initiating the dosage changes as ordered. The doctor stated he/she was unaware of the missed potassium chloride doses and would have sent the resident out immediately to the hospital for evaluation had he/she been made aware. The doctor stated, had the potassium chloride been administered as ordered and laboratory results had been called in a timely manner, the resident's potassium level would never have dropped to the critical level of 2.7 or below.

On 05/09/12, an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to provide laboratory services and/or to provide laboratory services in a timely manner. Resident #2 had critically low potassium levels. The resident had a low potassium level and a repeat potassium level was not obtained as ordered by the physician. Two additional potassium levels were not obtained on the date requested by the physician. Resident #7 had a [DIAGNOSES REDACTED]. When the test was obtained two days later, after a second physician's orders [REDACTED]. On 05/09/12, at 1:34 p.m., the Oklahoma State Department of Health (OSDH) verified the existence of the IJ related to the facility's failure to provide laboratory services and/or to provide them in a timely manner. At 1:35 p.m., the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), and Corporate Nurse Consultant were informed of the IJ related to the facility's failure to provide laboratory services and/or provide them in a timely manner. At 7:30 p.m., the facility submitted an acceptable plan of removal. The plan of removal documented: "Identification of Others - -- 100% Audit of Charts for potassium has been conducted by the nurse management and nurse consultants on 5/9/12. All residents with potassium will be checked that appropriate labs had been completed as ordered and physician notified of results, and ordered potassium was administered. -- Lab will be conducting a 100% audit of all Labs/Results on 5/10/12. -- Pharmacy will be conducting a 100% audit of MARS/Med Carts for medication availability and administration on 5/10/12. -- Effective immediately nurse management and nurse consultants will conduct 100% audit of all physician orders [REDACTED]. This will continue indefinitely. -- Lab representative is scheduled to meet with facility by 10 am on 5/10/12, to discuss and review the procedure. The lab will have a representative available to complete 100% audit of lab orders and results. -- On 5/9/12 at 5pm the pharmacy Vice President of national accounts was notified and is sending a (sic) specialty trained nurse for 100% audit of MAR/medication cart/medication administration/transcription and time line to improve the efficiency of ordering, delivering, transcription, and administering of medications. -- The Medical Director was notified on 5/9/12 at 6pm and will be here on 5/10/12 to discuss the above stated procedures and to discuss the communication between facility and acting physicians. The Medical Director will be an active liaison to ensure this communication/education is effective with all disciplines in the facility including acting physicians, lab, and pharmacy. Staff in-services- licensed nursing staff and certified medication aides will be in serviced on policy and procedure for lab protocol and communication with physician regarding lab results and the administration of medications ordered. On 5/9/12 at 3:00 pm (sic) 27 of 31 licensed nursing staff were in serviced. One licensed staff was in serviced at 5pm, and one was contacted by phone for the in-service. Two licensed staff were not reached, but will receive in servicing before returning to work. Systemic Changes - -- The DON or designee will review the lab logs daily at the morning meeting and on Mondays following the weekend. -- Starting immediately all residents that take potassium will have their labs reviewed daily and any order changes reviewed by the DON or the designee. any problems related to lab will be corrected immediately. -- On 5/9/12 at 3pm, the lab representative was contacted by the DON via telephone regarding critical lab procedures. At 5pm on 5/9/12, an email confirmation was received verifying the phone conversation and the changes made in the lab database regarding the procedure of calling all critical labs. All critical labs will be call to the DON, ADON, or QC nurse by the lab. The nursing administration team will call the critical lab values to the charge nurse, who will immediately call the doctor the critical lab values. If no response within one hour, the charge nurse will page the Medical Director. If no response within 30 minutes, the DON or designee will be contacted for further directions. The charge (nurse) will document communication attempts in the nurse's notes. Lab logs are to be utilized on all labs. Monitoring- The facility will monitor this critical system daily at the morning meeting, weekly at the Standards of Care meeting, and review and monitor the outcomes and processes at the Quality Assurance Meeting. This monitoring will be conducted by the Director of Nursing and Assistant Director of Nursing." The IJ was removed on 5/11/12 at 6:30 p.m., when all components of the plan of removal had been completed. The deficiency remained at a pattern level with a potential for more than minimal harm. Based on record review, interview, and observation, it was determined the facility failed to provide laboratory services and/or failed to provide them in a timely manner for 3 (#2, #4 and #7) of 8 sampled resident who had laboratory tests ordered. This resulted in an Immediate Jeopardy Situation. The facility roster documented 78 residents resided at the facility. Findings: The facility protocol for Laboratory and Diagnostic Test results documented: "- The physician will identify and order diagnostic and lab testing based on diagnostic and monitoring needs. - The staff will process test requisitions and arrange for tests. - The laboratory, . . ., will report test results to the facility..." 1. Resident # 2 was re-admitted to the facility on [DATE] with gastro-intestinal hemorrhage, [MEDICAL CONDITION], lack of coordination, muscle weakness, muscle disuse atrophy, and abnormality of gait. The careplan, dated 12/23/11, documented: Problem -- Lab: Resident is at risk for abnormal lab values R/T (related to) [MEDICAL CONDITION] Goals -- Resident's lab will be within normal range for resident thru the next 90 days. Interventions -- 1. Diet as ordered 2. Investigate and report any changes in resident's condition promptly to MD. 3. Monitor lab and report abnormal readings to MD. The admission assessment, dated 01/25/12, documented the resident was independent in decision making and required limited to extensive assistance in activities of daily living. The resident had full range of motion in all extremities and was occasionally incontinent of bowel and bladder. The assessment documented the resident had two stage II pressure ulcers present on admission, along with surgical incisions, and open [MEDICAL CONDITION] on the foot. A physician's orders [REDACTED]. A laboratory report, dated 01/21/12, documented the specimen was collected on 01/20/12 at 8:00 p.m. The results were faxed to the facility on [DATE] at 2:03 a.m. The results documented the resident's potassium was 2.9, which was low with a reference range of 3.5 - 5.1. A nurse's note, dated 01/22/12 at 3:30 p.m., documented, "pt K (potassium) level low Dr. notified order to give 40 meq now and recheck K level tomorrow 1/23/12." A physician's orders [REDACTED]. "give 40 MEQ K potassium chloride now recheck K level tomorrow 1/23." The potassium level, ordered for 01/23/12, was not requested or performed by the lab. A physician's orders [REDACTED]." A lab report for the CMP, collected on 01/24/12 and reported on 01/24/12, documented the following abnormal results: Results Range BUN 47 (H) 10 - 26 MG/DL (milligrams per deciliter) Creatinine 2.3 (H) 0.4-1.5 MG/DL Potassium 3.0 (L) 3.5-5.0 MMOL/L (millimoles per liter) Calcium 8.1 (L) 8.5 - 10.5 MG/DL Total Protein 5.5 (L) 6.0 - 8.5 GM/DL (gram per deciliter) [MEDICATION NAME] 2.7 (L) 3.0 - 5.5 GM/DL A notation at the bottom of the laboratory results documented, "serum hemolyzed - potassium may be falsely increased." A physician's progress note, dated 01/26/12, documented the results of the CBC and CMP drawn 01/24/12. A physician's orders [REDACTED]. This lab was requested but not performed by the laboratory. A Specimen Unobtained Form documented two attempted venipunctures were performed but no specimen was obtained. The form documented a follow-up attempt at obtaining the lab would be performed on the next scheduled draw date. A physician's orders [REDACTED]." This order was entered into the computer for laboratory and an unsuccessful attempt was performed on 02/17/12 to obtain the specimens by lab. A specimen unobtained form was presented to the charge nurse and a follow-up attempt scheduled for the next draw date. The specimen was collected on 02/20/12. The abnormal results of the Chem 8 were as follows: Results Range BUN 39 (H) 10 - 26 MG/DL Creatinine 2.2 (H) 0.4-1.5 MG/DL Potassium 2.7 (L) 3.5-5.0 MMOL/L (Critical Value Detected) Chloride 113 (H) 98 - 107 MMOL/L Carbon [MEDICATION NAME] 17 (L) 21 - 32 MMOL/L On 05/09/12 at 10:30 a.m., the Assistant Director of Nursing (ADON) was asked what the Specimen Unobtained Form meant by "Will attempt re-draw on next scheduled draw date?" The ADON stated it meant the lab would attempt to re-draw the specimen on the next visit to the facility. The ADON was asked when the lab was regularly scheduled and the ADON stated the lab was in the facility daily. On 05/09/12 at 11:30 a.m., the primary care physician for resident #2 was interviewed. The physician stated there was often a delay in receiving critical lab values. The physician was informed of the missed potassium chloride doses and the delay in administering the STAT doses and initiating the dosage changes as ordered. The physician stated he/she was unaware of the missed potassium chloride doses and would have sent the resident out immediately to the hospital for evaluation had he/she been made aware. The physician stated, had the potassium chloride been administered as ordered and laboratory results had been called in a timely manner, the resident's potassium level would never have dropped to the critical level of 2.7 or below. 2. Resident #7 was admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. A physician's orders [REDACTED]. The laboratory computer documented all but the [MEDICATION NAME] level was ordered and obtained on 04/02/12. A physician's progress note, dated 04/02/12, documented an additional [DIAGNOSES REDACTED]. On 04/04/12, another STAT [MEDICATION NAME] level was ordered. A physician's progress note, dated 04/04/12, documented an additional [DIAGNOSES REDACTED].?." The note documented, "Dig. ([MEDICATION NAME]) level pending." A [MEDICATION NAME] level, performed on 04/04/12, documented high results of 3.05 with a reference range of .9 - 2.0. The report documented, "critical value detected." The results were sent to the ordering physician and orders were received to discontinue the resident's [MEDICATION NAME] and send the resident to the emergency room for evaluation. A nurse's note, dated 04/05/12 at 3:15 p.m., documented, "late entry. pt sent to (hospital) for tx (treatment) & eval (evaluation) d/t (due to) - (increased) digoxen (sic) levels..." On 04/06/12, the physician's progress notes documented an additional [DIAGNOSES REDACTED]. On 04/16/12, the resident's assessment documented the resident was moderately impaired in decision making, and was dependent on others for activities of daily living. The resident was incontinent of bowel and bladder. On 05/09/12 at 07:30, LPN #10 was interviewed about the order on 04/02/12, for the [MEDICATION NAME] level STAT and stated it was overlooked. 3. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]." A physician's orders [REDACTED]." The chart was reviewed and no results were located. A comprehensive resident assessment, dated 04/10/12, documented the resident was moderately impaired in decision making and was totally dependent for all activities of daily living. The resident had limited range of motion in all extremities and had a stage II pressure ulcer. The resident had a feeding tube for nutrition and had an indwelling urinary catheter. At 4:45 p.m., on 05/09/12, the ADON was asked if the lab was ordered on [DATE]. She searched the computer and stated no, but the lab was ordered on the 30th. When asked if she could print the results, she stated the computer record was reviewed and there were no results. She was asked if the lab had been drawn and she stated she would have to do some research for that information. The computerized print out from the contracted laboratory company documented the facility nurse created the order on 03/30/12 and no results were located. A second entry was created by the facility nurse on 04/03/12. The abnormal laboratory results were as follows: Results Range Glucose 135 (H) 70 - 99 MG/DL BUN 34 (H) 10 - 26 MG/DL Calcium 8.4 (L) 8.5 - 10.5 MG/DL RBC 3.10 (L) 3.80 -5.80 MIL/CUMM Hemoglobin 9.9 (L) 12.0 -18.0 GM/DL Hematocrit 30.7 (L) 37.0 - 53.0 % RDW-CW 16.0 (H) 11.3 -14.0 %

On 05/09/12, an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to notify the physician of abnormal lab values, including critically low potassium levels for resident #2. On 05/09/12, at 1:34 p.m., the Oklahoma State Department of Health (OSDH) verified the existence of the IJ related to the facility's failure to notify the physician of laboratory results, including abnormal values and critical values. At 1:35 p.m., the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), and Corporate Nurse Consultant were informed of the IJ related to the facility's failure to notify the physician of laboratory results. At 7:30 p.m., the facility submitted an acceptable plan of removal. The plan of removal documented: "Identification of Others - -- 100% Audit of Charts for potassium has been conducted by the nurse management and nurse consultants on 5/9/12. All residents with potassium will be checked that appropriate labs had been completed as ordered and physician notified of results, and ordered potassium was administered. -- Lab will be conducting a 100% audit of all Labs/Results on 5/10/12. -- Pharmacy will be conducting a 100% audit of MARS/Med Carts for medication availability and administration on 5/10/12. -- Effective immediately nurse management and nurse consultants will conduct 100% audit of all physician orders [REDACTED]. This will continue indefinitely. -- Lab representative is scheduled to meet with facility by 10 am on 5/10/12, to discuss and review the procedure. The lab will have a representative available to complete 100% audit of lab orders and results. -- On 5/9/12 at 5pm the pharmacy Vice President of national accounts was notified and is sending a (sic) specialty trained nurse for 100% audit of MAR/medication cart/medication administration/transcription and time line to improve the efficiency of ordering, delivering, transcription, and administering of medications. -- The Medical Director was notified on 5/9/12 at 6pm and will be here on 5/10/12 to discuss the above stated procedures and to discuss the communication between facility and acting physicians. The Medical Director will be an active liaison to ensure this communication/education is effective with all disciplines in the facility including acting physicians, lab, and pharmacy. Staff in-services- licensed nursing staff and certified medication aides will be in serviced on policy and procedure for lab protocol and communication with physician regarding lab results and the administration of medications ordered. On 5/9/12 at 3:00 pm (sic) 27 of 31 licensed nursing staff were in serviced. One licensed staff was in serviced at 5pm, and one was contacted by phone for the in-service. Two licensed staff were not reached, but will receive in servicing before returning to work. Systemic Changes - -- The DON or designee will review the lab logs daily at the morning meeting and on Mondays following the weekend. -- Starting immediately all residents that take potassium will have their labs reviewed daily and any order changes reviewed by the DON or the designee. any problems related to lab will be corrected immediately. -- On 5/9/12 at 3pm, the lab representative was contacted by the DON via telephone regarding critical lab procedures. At 5pm on 5/9/12, an email confirmation was received verifying the phone conversation and the changes made in the lab database regarding the procedure of calling all critical labs. All critical labs will be call to the DON, ADON, or QC nurse by the lab. The nursing administration team will call the critical lab values to the charge nurse, who will immediately call the doctor the critical lab values. If no response within one hour, the charge nurse will page the Medical Director. If no response within 30 minutes, the DON or designee will be contacted for further directions. The charge (nurse) will document communication attempts in the nurse's notes. Lab logs are to be utilized on all labs. Monitoring- The facility will monitor this critical system daily at the morning meeting, weekly at the Standards of Care meeting, and review and monitor the outcomes and processes at the Quality Assurance Meeting. This monitoring will be conducted by the Director of Nursing and Assistant Director of Nursing." The IJ was removed on 5/11/12 at 6:30 p.m., when all components of the plan of removal had been completed. The deficiency remained at a pattern level with a potential for more than minimal harm. Based on record review, interview, and observation, it was determined the facility failed to notify the physician of laboratory results, including abnormal values and critical values for one (#2) of 8 sampled resident who had laboratory tests ordered. This resulted in an Immediate Jeopardy Situation. The facility roster documented 78 residents resided at the facility. Findings: The facility protocol for Laboratory and Diagnostic Test results documented: "- The physician will identify and order diagnostic and lab testing based on diagnostic and monitoring needs. - The staff will process test requisitions and arrange for tests. - The laboratory, . . . ., will report test results to the facility. - If the staff who first receive or review lab . . . results cannot follow the remainder of this procedure for reporting and documenting the results and their implications, another nurse in the facility (Supervisor, Charge Nurse, etc.) should follow or coordinate the procedure. - The person who is to communicate results to a physician will review and be prepared to discuss the following . . . : a. The individual's current condition and any recent changes in status, including vital signs and mental status. b. Major diagnoses, allergies [REDACTED]. c. Why the tests were obtained. d. How test results might relate to the individual's current status, treatments, or medications. e. Any concerns or issues the physician will be expected to address upon receiving the results. - Before contacting the physician, the nurse will gather and organize the information listed above and coordinate any telephone communications with others who may also need to speak with the physician. - A nurse will identify the urgency of communicating with the attending physician based on physician request, the seriousness of any abnormality, and the individual's current condition. - A nurse will try to determine whether the test was done: a. As a routine screen or follow-up. b. To assess a condition change or recent onset of signs and symptoms. c. To monitor a drug level. The reason for getting a test often affects the urgency of acting upon the results. If the reason for performing the test cannot be identified, the nurse should proceed as though the tests were ordered to assess a condition change or recent onset of signs and symptoms. Nursing staff will consider the following factors to help identify situations requiring prompt physician notification concerning lab . . . results: - The physician has requested to be notified as soon as result is received. -The result is something that should be conveyed to a physician regardless of other circumstances . . .(abnormal results . . . ) - High or toxic drug levels. . . The following may constitute exceptions to situations . . . . - . . . . . . terminally ill, or is receiving palliative care or comfort measures only. - The results are similar to (or better than) known chronic abnormally results . . . . . - The physician previously left specific guidance or orders . . . . . - The results are the same as or better than previous ones, treatment has already been instituted for an acute condition change, and the individual is stable or improving. However, nursing staff may sometimes determine that an individual's condition warrants immediate reporting of lab results despite these exceptions. If the results do not meet the preceding criteria for immediate notification, then the nursing staff will review why the test was obtained, as well as the resident's current clinical status including the presence of any signs and symptoms. a. If the resident has signs and symptoms of acute illness or condition change and he/she is not stable or improving, or there are no previous results for comparison, the the nurse will notify the physician promptly to discuss the situation, including a description of relevant clinical findings as well as the test results. b. If the individual is stable or improving and the results do not warrant immediate notification, then the nursing staff may notify the physician routinely, . . . . A physician can be notified by phone, fax, voicemail, e-mail, mail, pager, or telephone message to another person acting as the physician's agent (for example, office staff). a. Facility staff should document information about, when, how, and to whom the information was provided and the response. This should be done in the progress notes section of the medical record and not on the lab results report, because test results should be correlated with other relevant information such as the individual's overall situation, current symptoms, advance directives, prognosis, etc. b. Direct voice communication with the physician is the preferred means for presenting any results requiring immediate notification, especially when the resident's clinical status is unstable or current treatment needs review or clarification. c. For information that does not need immediate physician response, staff may use alternatives such as faxing, voice mail, or a clipboard in the facility. Alternatively, the staff and physician may also establish designated times during the day when they will review test results with the physician by phone. Physician Responses. 1. Time frames. A physician will respond within an appropriate time frame, based on the request from nursing staff and the clinical significance of the information. a. A physician should respond within one hour regarding a lab test result requiring immediate notification, and by the end of the next office day to a non-emergency message regarding non-immediate lab test notification with a request for response. . . . b. If the attending or covering physician does not respond to immediate notification within an hour, the nursing staff should contact the Medical Director for assistance. 2. Physician decisions. When responding to notification of test results, the physician and staff will discuss the implications of the test results for the resident, as well as subsequent actions. . . . Physicians or nurses who have concerns about how test results have been handled or reported should communicate such concerns to the DON (director of nurses) and/ or Medical Director. Such concerns or disagreement should not prevent timely, clinically appropriate management of a current result or clinical situation." Resident # 2 was re-admitted to the facility on [DATE] with gastro-intestinal hemorrhage, [MEDICAL CONDITION], lack of coordination, muscle weakness, muscle disuse atrophy, and abnormality of gait. The careplan, dated 12/23/11, documented: Problem -- Lab: Resident is at risk for abnormal lab values R/T (related to) [MEDICAL CONDITION] Goals -- Resident's lab will be within normal range for resident thru the next 90 days. Interventions -- 1. Diet as ordered 2. Investigate and report any changes in resident's condition promptly to MD. 3. Monitor lab and report abnormal readings to MD. The admission assessment, dated 01/25/12, documented the resident was independent in decision making and required limited to extensive assistance in activities of daily living. The resident had full range of motion in all extremities and was occasionally incontinent of bowel and bladder. The assessment documented the resident had two stage II pressure ulcers present on admission, along with surgical incisions, and open [MEDICAL CONDITION] on the foot. A physician's orders [REDACTED]." A lab report for the CMP, collected on 01/24/12 and reported on 01/24/12, documented the following abnormal results: Results Range BUN 47 (H) 10 - 26 MG/DL (milligrams per deciliter) Creatinine 2.3 (H) 0.4-1.5 MG/DL Potassium 3.0 (L) 3.5-5.0 MMOL/L (millimoles per liter) Calcium 8.1 (L) 8.5 - 10.5 MG/DL Total Protein 5.5 (L) 6.0 - 8.5 GM/DL (gram per deciliter) [MEDICATION NAME] 2.7 (L) 3.0 - 5.5 GM/DL A notation at the bottom of the laboratory results documented, "serum hemolyzed - potassium may be falsely increased." There was no documentation to show the physician was notified of the abnormal results. A physician's progress note, dated 01/26/12, documented the results of the CBC and CMP drawn 01/24/12. A physician's orders [REDACTED]." This order was entered into the computer for laboratory and an unsuccessful attempt was performed on 02/17/12 to obtain the specimens by lab. A specimen unobtained form was presented to the charge nurse and a follow-up attempt scheduled for the next draw date. The specimen was collected on 02/20/12. Handwritten on the bottom of the laboratory report was, "Faxed to (physician) 2/21/12." The abnormal results of the Chem 8 were as follows: Results Range BUN 39 (H) 10 - 26 MG/DL Creatinine 2.2 (H) 0.4-1.5 MG/DL Potassium 2.7 (L) 3.5-5.0 MMOL/L (Critical Value Detected) Chloride 113 (H) 98 - 107 MMOL/L Carbon [MEDICATION NAME] 17 (L) 21 - 32 MMOL/L A physician's progress note, dated 02/23/12, documented, "Chart reviewed I noted K+ level on 2/20/12 was 2.7-> results called to nurse but was not addressed or called to physician. Noted labs faxed 1/21/12 to our office but none received in my office." On 05/09/12 at 11:30 a.m., the primary care physician for resident #2 was interviewed. The physician stated there was often a delay in receiving critical lab values. The physician was informed of the missed potassium chloride doses and the delay in administering the STAT doses and initiating the dosage changes as ordered. The physician stated he/she was unaware of the missed potassium chloride doses and would have sent the resident out immediately to the hospital for evaluation had he/she been made aware. The physician stated, had the potassium chloride been administered as ordered and laboratory results had been called in a timely manner, the resident's potassium level would never have dropped to the critical level of 2.7 or below.