Every finding on record at Wellington Place

Based on clinical record review, document review, policy review, physician, pharmacy, and staff interviews, the facility failed to have a system in place to ensure medication orders were received from the pharmacy. This failure resulted in a physician ordered diuretic medication not being administered for 1 of 3 residents sampled (Resident #42). Resident #42 went into fluid overload (a condition where there is too much fluid volume in the body that can cause high blood pressure, swelling, and heart problems) and atrial fibrillation (irregular and often very rapid heart rhythm) which required direct admission to the hospital therefore causing an Immediate Jeopardy to the health, safety, and security of the resident. The Iowa Department of Inspections, Appeals and Licensing informed the facility of the Immediate Jeopardy (IJ) that began as of 8/02/23. The Facility Staff removed the IJ on August 8, 2023 through the following actions: a. The Administrator and Regional Director of Operations provided education 8/04/23 to the Director of Nursing (DON) regarding if multiple residents are seen during rounds, the new physician orders are to be faxed per individual resident to the pharmacy allowing the DON to better track submission and determine if the fax was transmitted to the pharmacy. b. The DON provided verbal education to Staff G, Registered Nurse (RN) on 8/07/23 regarding medication administration followed by medication administration competency 8/08/23. c. The DON provided all staff nurses with education on the medication administration policy and pharmacy services policy on 8/08/23; followed by observation of medication administration competency as each nurse reports for duty. The scope lowered from a J to a G at the time of the survey after ensuring the facility implemented the education on the medication administration and pharmacy services policies, as well as observation of nursing medication skills for competency. The facility identified a census of 44 residents. Findings include: Resident #42 Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The resident required limited assistance with bed mobility, transfer, walking in the room, corridor, and on/off the unit, toilet use, dressing, and personal hygiene. The MDS listed diagnoses of aftercare for hip fracture, peripheral vascular disease, atrioventricular block first degree (a heart rhythm disorder that causes the heart to beat more slowly than it should. It's caused by communication problems within the heart's electrical conduction system. For some people, the condition doesn't cause symptoms; for others, it may be life-threatening) and hypertension. The resident received physical and occupational therapy services and expected to discharge back to the community. A Progress Note, Health Status Note, dated 7/31/23 at 1:37 p.m. documented by Staff G, Registered Nurse (RN) detailed Resident #42 complained of increased shortness of breath with activity/exertion, exhibited 3-4+ edema (swelling), non-pitting to bilateral lower extremities, and exhibited abdominal distention. Vital Signs showed: temperature -98.2, pulse - 83, respirations - 18, blood pressure - 130/63, and oxygen saturation of 94% on room air. History of: hypertensive kidney disease with stage 1 through stage 4, sleep apnea, and polyneuropathy. A call was placed to the physician by the Director of Nursing (DON). The information had also been faxed and the facility awaited further orders. A Progress Note, Health Status Note dated 7/31/2023 at 8:39 p.m. written by Staff I, Licensed Practical Nurse (LPN) documented Resident #42 did not want to eat too much and refused his health shake. He complained of being full. A fax was sent out to the physician and the office had been called. The facility did not receive any call back. The Nursing Home Visit note dated 8/01/23 documented by the Advanced Registered Nurse Practitioner (ARNP) documented the ARNP saw the resident for edema of his legs, thighs and buttocks. Resident #42 reported his abdomen quite big. The Visit Note detailed Resident #42 weighed 181# (pounds) upon admission and the weight today (8/01/23) is 192#. He also exhibited scrotal edema. Resident #42 physical examination revealed the following: a. Vitals signs - weight 192#, blood pressure 112/68, temperature 98.1 degrees Fahrenheit (F), pulse 89 beats per minutes (BPM), respirations 18 breaths per minute (BPM), oxygen saturation range between 94% (percent) to 98% on room air. b. Lungs - clear, but appear somewhat diminished in the bases bilaterally. c. Extremities - some edema in the hips, thighs and lower extremities bilaterally, probably 1-2+ and pitting (pitting edema occurs when excess fluid builds up in the body, causing swelling; when pressure is applied to the swollen area, a pit, or indentation, will remain). The Visit Note Assessment and Plan directed to start him on Lasix 20 milligrams (mg) every day x 4 days, start daily and start daily weights. A Communication with the Physician Note dated 8/1/2023 3:51 p.m. written by the DON detailed the ARNP had been at the facility for routine rounds. They discussed Resident #42 weight, bloated feeling in the abdomen, and scrotal edema. The Resident reported increased shortness of breath when lying flat. The Facility notified the ARNP of the mutual decision to hold the bilateral lower extremity wraps until seen today. Orders received to: (1) continue holding the leg wraps until the weights reviewed by the ARNP on 8/3/23; (2) new order for Lasix 20 mg by mouth daily for 4 days; (3) daily weight before breakfast with no call for parameters for review by provider; (4) continue with plan for the resident to be seen by physician on 8/4/2023 for a 30-day visit and discharge to the assisted living. The resident's primary nurse updated and pharmacy faxed. The resident's son updated via telephone on visit, new orders, and the plan of care. An Order Summary Report signed by the ARNP and noted by the DON on 8/01/23 documented a physician order for Lasix 20 mg by mouth every day x 4 days, daily weights, and hold the leg wraps until 8/03/23. A MDS Note dated 8/1/2023 at 6:33 p.m. written by Social Services documented Resident #42 reported swelling in his legs caused him to have difficulty sleeping daily, which in turn caused him to feel tired. A Health Status Note, Progress Note dated 8/1/2023 at 9:59 p.m. written by Staff I, Licensed Practical Nurse (LPN) documented Resident 42's pulse as high and his oxygen saturation at 88 percent (normal oxygen saturation for elderly over the age of 70 is around 95%). Resident #42's August 2023 Treatment Administration Record (TAR) documented the following daily weights: a. 8/02/23 185 pounds b. 8/03/23 193 pounds c. 8/04/23 197 pounds The August 2023 Medication Administration Record (MAR) documented an order for Lasix Oral Tablet 20 mg, give 1 tablet by mouth in the morning for weight increase for 4 days at 7:00 a.m. The MAR detailed the following: a. 8/02/23 Lasix medication signed out as administered by Staff G. b. 8/03/23 Lasix medication signed out as administered by Staff G. c. 8/04/23 Lasix medication documented as a 5 indicating to hold/see progress notes by Staff H, LPN. A Communication with Physician Progress Note dated 8/03/23 at 4:36 p.m. transcribed by the DON documented the ARNP at the facility for routine rounds. Resident #42's recent weights and vital signs were reviewed. The ARNP had been informed the resident reported improved symptoms of lower abdominal bloating, discomfort, and shortness of breath when lying flat since administration of oral Lasix. The ARNP reviewed the last lab results and new orders obtained to draw a basic metabolic profile (BMP is a lab test that measures eight different substances in your blood. It provides important information about the body's chemical balance and metabolism) in the morning 8/04/23. Continue with plan for the resident to be seen by the physician on 8/04/2023 during routine rounds. Continue with plan for discharge to assisted living after the visit. Discussed plan to obtain orders for outpatient physical and occupational therapies. The physician to determine if occupational therapy needed for activities of daily living (ADL's) and lymphedema management needed. Also discussed need for the resident to have a follow up visit in 1 week. Son to be notified after the physician visits. A Health Status Note, Progress Note dated 8/3/2023 at 5:00 p.m. written by Staff J, RN, documented Resident #42 reported occasional shortness of breath when lying in bed and non-pitting swelling noted to his bilateral lower legs. An Administrative Note dated 8/04/23 at 9:37 a.m. written by Staff H documented the Lasix Oral Tablet 20 mg as being held as the resident would see the provider that morning. A Health Status Note, Progress Note dated 8/4/2023 at 1:17 p.m. documented by Staff H detailed Resident #42 had been seen on rounds by the physician. The physician discovered Resident #42 was in atrial fibrillation and wanted the Resident admitted to the hospital for telemetry monitoring. An eInteract Change in Condition Evaluation V4.2 Form dated 8/04/23 at 1:36 p.m. by Staff H documented resident #42 had new or worsening edema (swelling) and atrial fibrillation per the physician's rounds noting the change started on 8/04/23. The Evaluation detailed Resident #42 had a new irregular pulse at 105 beats per minute, swelling, and persistent bilateral edema. The Evaluation documented the physician had discovered atrial fibrillation and wanted the resident admitted for telemetry monitoring. An eInteract Transfer V4.1 Form dated 8/04/23 at 2:00 p.m. completed by Staff H documented Resident #42 transferred out direct admit per the physician's rounds to the local hospital. The Transfer Form documented Resident #42's vital signs: temperature 98.2 degrees F, pulse 105 BPM, respirations 17 BPM, blood pressure 151/97 and oxygen saturation of 97 percent (%). The 8/04/23 Clinical Note documented by the Physician documented Resident #42 was slated to discharge to assisted living today, but over the past few days developed significant amounts of swelling. He had been seen on Wednesday by the ARNP who recommended treatment with oral Lasix. However, he did not receive that at the nursing home and his swelling had not improved and his breathing had gotten somewhat worse. He is in atrial fibrillation upon exam with a rate in the low 100's. His baseline (heart) rate is about 70 (BPM). At this point given the amount of edema that he has and atrial fibrillation, recommended he be admitted to the hospital for IV diuresis (Intravenous (IV) loop diuretics play an important role in the treatment of decompensated heart failure), telemetry a technique that enables continuous tracking of the heartbeat. It measures the electrical activity of the heart. Doctors use telemetry systems to check for abnormal patterns that indicate serious heart problems), echocardiogram (EKG) an ultrasound test that checks the structure and function of your heart), labs, and better control of his atrial fibrillation. He is to be a direct admit to the hospital, bypassing the emergency room . The 8/04/23 History and Physical (H+P) for the hospital documented by the Physician documented Resident #42 had planned to discharge today to the assisted living, however, that changed when he starting having more swelling a few days ago. He had been seen by the ARNP who started him on Lasix. Unfortunately, a medication error lead to the medicine not being administered. He had a B-type natriuretic peptide (BNP lab) today which was unchanged from prior, though that was largely probably because he did not actually get his diuresis. He reports that he is feeling more short of breath. He feels like the fluid is extending into his abdomen and that he is more distended. He also has some scrotal edema along with a rash in his groin. Resident #42 reported he has never had swelling like this before. The H+P Physical Exam documented the following: a. Blood pressure 142/70, pulse 103, temperature 98.6 degrees, respirations 20, oxygen saturation 97% b. Cardiovascular - tachycardia (tachycardia means that your heart is beating much faster than normal, usually more than 100 beats per minute) present, rhythm irregular. c. Musculoskeletal - right and left lower legs with edema present. 3+ pitting edema of bilateral lower extremities extending into the abdomen and scrotum. The 8/04/23 BNP lab (A B-type natriuretic peptide (BNP) test gives the provider information about how the heart is working. This blood test measures the levels of a protein called BNP in the bloodstream. When the heart has to work harder to pump blood, it makes more BNP. Higher levels of BNP can be a sign of heart failure) showed a value of 8,313, high level (normal range is 0-450). The Assessment and Plan documented a diagnosis of congestive heart failure, unspecified heart failure chronicity. Resident now with significant weight gain, increasing bilateral edema up to his scrotum, orthopnea (shortness of breath when lying flat), and shortness of breath. Most likely in fluid overload. Also, in atrial fibrillation response with a heart rate mildly tachycardic at 100-110. Will initiate intravenous Lasix 40 mg this afternoon. Lovenox (blood thinning medication) for anticoagulation while in the hospital. A Medication Error Report completed by the DON on 8/04/23 documented resident #42 had a physician order for Lasix 20 mg by mouth daily x 4 days which the resident had not been administered on 8/2/23 and 8/3/23 during the morning medication pass. The Report detailed the physician had been notified on 8/04/23 at 9:05 a.m. of the failure to administer the medication. The Report further detailed the Lasix medication had not been sent from the pharmacy. The Report Outcome further detailed Resident #42 had been a direct admit to the hospital. The Corrective Action Taken described a verbal warning and a two-day suspension during the investigation of the nurse (Staff G) involved in the incident. The Measures Taken to Prevent a Reoccurrence of a similar error detailed education and competency skills would be completed for all nursing staff. Staff G signed the Medication Error Report on 8/07/23. A Facility Reported Incident (FRI) detailed the facility submitted information to the Iowa Department of Inspection, Appeals and Licensing on 8/07/23 at 4:33 p.m. notifying the State Agency Resident #42 had a new Lasix 20 mg daily x 4 days order. The Report identified a nurse had not administered the Lasix medication on 8/2/23 and 8/3/23 which resulted in resident harm involving hospitalization . The facility became aware of the incident on 8/04/23 and a full investigation had been initiated. During an interview on 8/08/23 at 10:14 a.m. Staff G reported Resident #42 did not receive the Lasix as ordered on 8/2/23 and 8/3/23. She stated the medication never came in from the pharmacy. She did not take the Lasix medication out of the emergency medication kit. She stated the pharmacy prefers for them to call the pharmacy to get the medication during normal business hours and not to take it out of the emergency medication kit. On 8/08/23 at 12:48 p.m. Staff K, RN, recalled he had more fluid. He always talked about having a hard time breathing at night. It seemed like his swelling went from one leg to the other. It was a 2+ swelling in the left below knee to the ankle. They were wrapping the right leg up to the hip, but she noticed the swelling above the knee as well as the ankle and foot. She would have thought the swelling would be on the right lower extremity due to his right hip replacement, but the swelling was on the left lower leg. She reported if she checked the MAR and the medication was not in the medication cart, she would call the pharmacy to find out where the medication was at. The facility has an after-hours pharmacy number that they can call. They very rarely take medications out of emergency kit. The pharmacy doesn't like them to do that. The pharmacy kind of bucks them on that. On 8/08/23 at 1:07 p.m. Staff L, LPN, reported Resident #42 had swelling to both lower extremities. Therapy had seen him and they started doing leg wraps. Everything was going good, then she noticed that his left leg stated swelling up. She had recommended to day shift to start getting daily weights to see if he was retaining fluids. Pharmacy has an on-call number they are to call if a medication doesn't come in. If she can she will pull from the emergency kit if the medication doesn't arrive or take from stock. She doesn't recall getting any actual training on what they are supposed to do with the emergency kit. Medications are signed off the EMAR after they are administered to the resident. During an interview on 8/08/23 at 1:47 p.m. Staff H reported he was supposed to be getting Lasix, but when she went to give the medication that Friday morning, the medication wasn't in the medication cart. She went to the DON and informed her she didn't have the medication to give. The Physician was going to see the resident on rounds that day so the Lasix medication was held. Resident #42 had swelling in his legs. She didn't notice a huge change from the day before, but his weight had gone up. They informed the physician he did not receive the medication as it wasn't available from the pharmacy. They usually call the pharmacy if they do not have the medication. If pharmacy cannot get the medication to them, then they can get the medication out of the emergency kit. Pharmacy is usually pretty good about getting medication out to the facility or they send someone from the facility to go pick up the medication. On the weekend, she doesn't know 100% what they would do. She would call the DON or ADON (Assistant Director of Nursing) to get the medication. On 8/08/23 at 1:58 p.m. Staff G reported she never called the pharmacy regarding the diuretic medication on 8/02/23 and 8/03/23. She had not realized Resident #42's diuretic had not been delivered from the pharmacy or that she had not given the medication. She reported she was just sick about what happened to the Resident. On 08/08/23 at 1:59 p.m. the ARNP reported she received a text from the DON informing her Resident #42 had not received the Lasix medication. She would have hoped that the medication would have helped but it is hard to know. She doesn't know how he would have responded because he never got a dose of Lasix. She expected the facility to administer the diuretic medication as ordered. She can't speak to the resident's condition if it would have prevented the hospitalization because he never received the medication to know how he may have responded. On 8/08/23 a review of the Emergency (Medication) Lock Box July 2023 record revealed the lock box had tag #089355 on from 7/27/23 - 8/04/23. The facility had not taken any medication out of the emergency lock box. During an interview on 8/08/23 at 2:23 p.m. the primary physician reported the resident had been admitted to the hospital in heart failure. He reported the hospitalization could have been prevented if the facility had given the Lasix medication as ordered by the ARNP. He reported if the Resident had received the two doses of Lasix prior to his visit on Friday (8/04/23) he would not have needed hospitalization . Unfortunately, he had atrial fibrillation and by Friday it had worsened due to the heart failure and not getting the medication. On 8/08/23 at 3:07 p.m. Staff I reported the resident had been filling with fluid. He still walked, but he commented on how much his legs were swelling. He voiced he was uncomfortable and couldn't eat. They had called and the nurse practitioner who was coming in to see the resident. During an interview on 8/08/23 at 3:48 p.m. the Director of Nursing (DON) reported Staff H informed her she couldn't find a card of Lasix in the medication cart around 8:30 a.m. Prior to that no one knew the Lasix had not come from the pharmacy or been administered. The physician had routine rounds due that day and he saw Resident #42 as the last patient of the day. The physician thought it was in the best interest of the resident to be admitted as he had atrial fibrillation with his heart rate in the 100's and he needed diuresis. She reported she called the pharmacy on 8/04/23 and the pharmacy stated they didn't fill an order for Lasix as they didn't receive the faxed order. The DON stated there were other faxes sent at the same time and they received those medication orders. Normally, if a medication is not delivered, they call the pharmacy to follow-up. The ARNP came in on 8/01/23 between 1-2 p.m. so the medication was faxed in and not taken out of the lock box. She didn't feel that resident #42 was in any acute distress to need to start the medication on 8/01/23. She expects the nurses to call the pharmacy and follow-up if a medication was not delivered to the facility. The facility will send someone to get the medication. On 8/08/23 the DON submitted a Medication Reorder Form. She reported the nurses send the medication reorder form to the pharmacy. There is no set nurse that performs the duty or a set time they send the reorder form to the pharmacy. The Medication Reorder Form just goes to the pharmacy whenever it needs to go. During an interview on 8/08/23 at 4:17 p.m. the Pharmacy Technician that services the facility reported the DON had called her the morning of 8/04/23. She reviewed the pharmacy orders for resident #42 and they had not received any Lasix orders for the resident. The pharmacy never sent any Lasix to the facility as they had never received any order for the medication from the facility. She communicated there have been numerous times when the facility faxes had come into the pharmacy blank and their staff had to call out to the nursing home to check on the physician orders. This happens at least a few times a week where she has to talk to the nurse or the DON. It is a problem. They just seem to laugh about it and nothing gets done. As far as she knows they had not taken any corrective actions. Many times they send medication order faxes at night that come in blank and she has to call the facility in the morning to have them re-fax the orders. She reported they do not want the nurses opening the emergency medication kit during normal business hours. They are to call the pharmacy with any new orders and they will schedule a delivery or the facility can send someone to pick up the medication. She checked the 8/1/23, 8/2/23, and 8/3/23 nursing home deliveries. She did not receive any Lasix order for Resident #42. The nurses should fax each persons physician orders separately. If there are 5 resident orders all together the pharmacist has to dig through all the papers which can create errors. On 8/09/23 at 2:48 p.m. the Regional Director of Operations reported the DON had sent multiple resident physician orders to the pharmacy on 8/01/23 all together as one fax. There were 5 resident's orders faxed in together. She reported when the DON had checked with pharmacy the pharmacy had stated they got all the physician orders, except Resident #42's orders. They had provided education to the DON on 8/04/23 to send all resident physician orders to the pharmacy separately. On 8/09/23 at 3:18 p.m. the Pharmacy Technician reported she had reviewed the orders and delivery slips for 8/1/23, 8/2/23 and 8/3/23 again and did not find any Lasix orders that came in for Resident #42. She remembers talking to the DON on 8/04/23 the DON asking about the Lasix order for Resident #42. She said she could get the Lasix order ready and they could come pick it up. The DON reported no, they were going to have the physician see the resident that morning. She reported a blank order sheet came in on 8/3/23 from the facility with no orders on it. The pharmacy has offered to talk to their corporate as there is definitely a communication problem, but they will not give them any corporate contact numbers. A Review of the Pharmacy Medication Packing Slips completed on 8/09/23 revealed the following: a. 8/01/23 showed Resident #42 received an order for Nystatin Topical. No Lasix delivered for Resident #42. The Packing Slip provided by the facility as part of the facility investigation did not contain a nurse signature for delivery. b. 8/02/23 revealed no Lasix delivered for Resident #42. The Packing Slip provided by the facility as part of the investigation did not contain a nurse signature for the delivery. c. 8/03/23 showed no Lasix medication delivered to the facility for Resident #42. Staff H signed for the delivery on 8/03/23 at 5:10 p.m. During an interview on 8/10/23 at 8:32 a.m. the DON reported the facility did not have a process in place to reconcile medications delivered to the facility against the physician orders that were called/faxed in. It hadn't been a problem. The nurses check off what the pharmacy delivers against the pharmacy delivery slip. They really didn't keep a list of what was ordered from the pharmacy so the nurses do not have anything to compare to when the pharmacy delivers the medications. It had been a busy day that day and it was unusual for them to have that many orders faxed to the pharmacy at one time. There were no set processes in place for the nurses to check medications delivered against the orders that were sent to the pharmacy. She had been communicating to the charge nurses' physician orders called to the pharmacy since that time so they know when the medications come in from pharmacy. There have been no undelivered medications since 8/04/23. During an interview on 8/10/23 at 11:48 a.m. the Administrator reported she felt there needed to be more investigation into why the pharmacy did not receive the physician order for Resident #42's Lasix. She felt there needs to be more checks and balances, but unfortunately the pharmacy manager is off this week so they haven't been able to sit down and meet with her to develop more solutions to know if this is an electronic issue. She said last week there was a call from the pharmacy stating there was a blank page that came through and she had to check with nursing on that. She is not sure if it is one facsimile (fax) machine or both facility fax machines that could be the problem. She reported they need to put a process into place to reconcile the medication orders placed to the pharmacy with the orders that are received from pharmacy. She placed a binder last evening 8/09/23 for the nurses to pull all orders called/faxed to pharmacy in. The nursing fax machine was set up on 8/0923 by the Regional Director of Operations to provide a fax confirmation slip which the nurses will also put with the order in the binder. She is not sure why the nursing fax machine had never been set up to provide a confirmation fax notice. The nurses are to confirm the medication delivery slip and the medications delivered with the physician orders in the binder. She is continuing to provide additional education to the nurses and follow-up on this practice. She reported they provided policy training to all nurses on their pharmacy services policy on 8/08/23. On 8/10/23 at 1:28 p.m. the DON reported the facility uses the pharmacy provided policies. The Pharmacy Ordering and Receiving Medication from the Dispensing Pharmacy Policy, provided by the facility stated medications and related products are received from the dispensing pharmacy on a timely basis. The facility maintains accurate records of medications order and receipt. The Policy Procedure for Receiving Medications from the Pharmacy directed the following: 1. A licensed nurse: a. Receives medications delivered to the facility and documents that the delivery was received and was secure. b. Verifies medications received and directions for use with the medication order form. c. Promptly reports discrepancies and omissions to the issuing pharmacy and the charge nurse/supervisor. d. Immediately delivers the medications to the appropriate secure storage area or a designee under the direct supervision of a licensed nurse. e. Assures medications are incorporated into the resident's specific allocation prior to the next medication pass. f. Signs two copies of the delivery record - one is returned to the pharmacy and one is retained at the facility.

Based on clinical record review, document review, policy review, physician, pharmacy, and staff interviews, the facility failed to administer a diuretic medication as physician ordered. This failure resulted in a significant medication error for 1 of 3 residents sampled (Resident #42). Resident #42 went into fluid overload (a condition where there is too much fluid volume in the body that can cause high blood pressure, swelling, and heart problems) and atrial fibrillation (irregular and often very rapid heart rhythm) which required direct admission to the hospital. The facility identified a census of 44 residents. Findings include: Resident #42 MDS assessment dated [DATE] showed a BIMS score of 15 indicating intact cognition. The Resident required limited assistance with bed mobility, transfer, walking in the room, corridor and on/off the unit, toilet use, dressing, and personal hygiene. The MDS listed diagnoses of aftercare for hip fracture, peripheral vascular disease, Atrioventricular block first degree (a heart rhythm disorder that causes the heart to beat more slowly than it should. It's caused by communication problems within the heart's electrical conduction system. For some people, the condition doesn't cause symptoms; for others, it may be life-threatening), and hypertension. The Resident received physical and occupational therapy services and expected to discharge back to the community. A Progress Note, Health Status Note, dated 7/31/23 at 1:37 p.m. documented by Staff G, Registered Nurse (RN) detailed Resident #42 complained of increased shortness of breath with activity/exertion, exhibited 3-4+ edema (swelling), non-pitting to bilateral lower extremities, and exhibited abdominal distention. Vital Signs showed: temperature -98.2, pulse - 83, respirations - 18, blood pressure - 130/63, and oxygen saturation of 94% on room air. History of: hypertensive kidney disease with stage 1 through stage 4, sleep apnea, and polyneuropathy. A call was placed to the physician by the Director of Nursing (DON). The information had also been faxed and the facility awaited further orders. A Progress Note, Health Status Note dated 7/31/2023 at 8:39 p.m. written by Staff I, Licensed Practical Nurse (LPN) documented Resident #42 did not want to eat too much and refused his health shake. He complained of being full. A fax out to the physician and the office had been called. The facility did not receive any call back. The Nursing Home Visit note dated 8/01/23 documented by the Advanced Registered Nurse Practitioner (ARNP) documented noted the ARNP saw the resident for edema of his legs, thighs and buttocks. Resident #42 reported his abdomen quite big. The Visit Note detailed Resident #42 weighed 181# (pounds) upon admission and the weight today (8/01/23) is 192#. He also exhibited scrotal edema. Resident #42 physical examination revealed the following: a. Vitals signs - weight 192#, blood pressure 112/68, temperature 98.1 degrees Fahrenheit (F), pulse 89 beats per minutes (BPM), respirations 18 breaths per minute (BPM), oxygen saturation range between 94% (percent) to 98% on room air. b. Lungs - clear, but appear somewhat diminished in the bases bilaterally. c. Extremities - some edema in the hips, thighs and lower extremities bilaterally, probably 1-2+ and pitting (pitting edema occurs when excess fluid builds up in the body, causing swelling; when pressure is applied to the swollen area, a pit, or indentation, will remain). The Visit Note Assessment and Plan directed staff to start him on Lasix 20 milligrams (mg) every day x 4 days, start daily and start daily weights. A Communication with the Physician Note dated 8/1/2023 3:51 p.m. written by the DON detailed the ARNP had been at the facility for routine rounds. They discussed Resident #42 weight, bloated feeling in the abdomen, and scrotal edema. The Resident reported increased shortness of breath when lying flat. The Facility notified the ARNP of the mutual decision to hold the bilateral lower extremity wraps until seen today. Orders received to: (1) continue holding the leg wraps until the weights reviewed by the ARNP on 8/3/23; (2) new order for Lasix 20 mg by mouth daily for 4 days; (3) daily weight before breakfast with no call for parameters for review by provider; (4) continue with plan for the resident to be seen by physician on 8/4/2023 for a 30-day visit and discharge to the assisted living. The resident's primary nurse updated and pharmacy faxed. The resident's son updated via telephone on visit, new orders, and the plan of care. An Order Summary Report signed by the ARNP and noted by the DON on 8/01/23 documented a physician order for Lasix 20 mg by mouth every day x 4 days, daily weights, and hold the leg wraps until 8/03/23. A MDS Note dated 8/1/2023 at 6:33 p.m. written by Social Services documented Resident #42 reported swelling in his legs that caused him to have difficulty sleeping daily, which in turn caused him to feel tired. A Health Status Note, Progress Note dated 8/1/2023 at 9:59 p.m. written by Staff I, Licensed Practical Nurse (LPN) documented Resident 42's pulse as high and his oxygen saturation at 88 percent (normal oxygen saturation for elderly over the age of 70 is around 95%). Resident #42's August 2023 Treatment Administration Record (TAR) documented the following daily weights: a. 8/02/23 185 pounds b. 8/03/23 193 pounds c. 8/04/23 197 pounds The August 2023 Medication Administration Record (MAR) documented an order for Lasix Oral Tablet 20 mg, give 1 tablet by mouth in the morning for weight increase for 4 days at 7:00 a.m. The MAR detailed the following: a. 8/02/23 Lasix medication signed out as administered by Staff G. b. 8/03/23 Lasix medication signed out as administered by Staff G. c. 8/04/23 Lasix medication documented as a 5 indicating to hold/see progress notes by Staff H, LPN. A Communication with Physician Progress Note dated 8/03/23 at 4:36 p.m. transcribed by the DON documented the ARNP at the facility for routine rounds. Resident #42's recent weights and vital signs were reviewed. The ARNP had been informed the resident reported improved symptoms of lower abdominal bloating, discomfort and shortness of breath when lying flat since the administration of oral Lasix. The ARNP reviewed the last lab results and new orders obtained to draw a basic metabolic profile (BMP is a lab test that measures eight different substances in your blood. It provides important information about the body's chemical balance and metabolism) in the morning 8/04/23. Continue with plan for the resident to be seen by the physician on 8/04/2023 during routine rounds. Continue with plan for discharge to assisted living after the visit. Discussed plan to obtain orders for outpatient physical and occupational therapies. The physician to determine if occupational therapy needed for activities of daily living (ADL's) and lymphedema management needed. Also discussed need for the resident to have a follow up visit in 1 week. Son to be notified after the physician visits. A Health Status Note, Progress Note dated 8/3/2023 at 5:00 p.m. written by Staff J, RN, documented Resident #42 reported occasional shortness of breath when lying in bed and non-pitting swelling noted to his bilateral lower legs. An Administrative Note dated 8/04/23 at 9:37 a.m. written by Staff H documented the Lasix Oral Tablet 20 mg as being held as the resident would see the provider that morning. A Health Status Note, Progress Note dated 8/4/2023 at 1:17 p.m. documented by Staff H detailed Resident #42 had been seen on rounds by the physician. The physician discovered Resident #42 was in atrial fibrillation and wanted the Resident admitted to the hospital for telemetry monitoring. An eInteract Change in Condition Evaluation V4.2 Form dated 8/04/23 at 1:36 p.m. by Staff H documented resident #42 had new or worsening edema (swelling) and atrial fibrillation per the physician's rounds noting the change started on 8/04/23. The Evaluation detailed Resident #42 had a new irregular pulse at 105 beats per minute, swelling, and persistent bilateral edema. The Evaluation documented the physician had discovered atrial fibrillation and wanted the resident admitted for telemetry monitoring. An eInteract Transfer V4.1 Form dated 8/04/23 at 2:00 p.m. completed by Staff H documented resident #42 transferred out direct admit per the physician's rounds to the local hospital. The Transfer Form documented Resident #42's vital signs: temperature 98.2 degrees F, pulse 105 BPM, respirations 17 BPM, blood pressure 151/97 and oxygen saturation of 97 percent (%). The 8/04/23 Clinical Note documented by the Physician documented Resident #42 was slated to discharge to assisted living today, but over the past few days developed significant amounts of swelling. He had been seen on Wednesday by the ARNP who recommended treatment with oral Lasix. However, he did not receive that at the nursing home and his swelling had not improved and his breathing had gotten somewhat worse. He is in atrial fibrillation upon exam with a rate in the low 100's. His baseline (heart) rate is about 70 (BPM). At this point given the amount of edema that he has and atrial fibrillation, recommended he be admitted to the hospital for IV diuresis, telemetry, echocardiogram (EKG), labs, and better control of his atrial fibrillation. He is to be a direct admit to the hospital, bypassing the emergency room . The 8/04/23 History and Physical (H+P) for the hospital documented by the Physician documented Resident #42 had planned to discharge today to the assisted living, however, that changed when he starting having more swelling a few days ago. He had been seen by the ARNP who started him on Lasix. Unfortunately, a medication error lead to the medicine not being administered. He had a B-type natriuretic peptide (BNP lab) today which was unchanged from prior, though that was largely probably because he did not actually get his diuresis. He reports that he is feeling more short of breath. He feels like the fluids is extending into his abdomen and that he is more distended. He also has some scrotal edema along with a rash in his groin. Resident #42 reported he has never had swelling like this before. The H+P Physical Exam documented the following: a. Blood pressure 142/70, pulse 103, temperature 98.6 degrees, respirations 20, oxygen saturation 97% b. Cardiovascular - tachycardia (tachycardia means that the heart is beating much faster than normal, usually more than 100 beats per minute) present, rhythm irregular. c. Musculoskeletal - right and left lower legs with edema present. 3+ pitting edema of bilateral lower extremities extending into the abdomen and scrotum. The 8/04/23 BNP lab (A B-type natriuretic peptide (BNP) test gives the provider information about how the heart is working. This blood test measures the levels of a protein called BNP in the bloodstream. When the heart has to work harder to pump blood, it makes more BNP. Higher levels of BNP can be a sign of heart failure) showed a value of 8,313, high level (normal range is 0-450). The Assessment and Plan documented a diagnosis of congestive heart failure, unspecified heart failure chronicity. Resident now with significant weight gain, increasing bilateral edema up to his scrotum, orthopnea (shortness of breath when lying flat), and shortness of breath. Most likely in fluid overload. Also, in atrial fibrillation response with a heart rate mildly tachycardic at 100-110. Will initiate intravenous Lasix 40 mg this afternoon. Lovenox (blood thinning medication) for anticoagulation while in the hospital. A Medication Error Report completed by the DON on 8/04/23 documented Resident #42 had a physician order for Lasix 20 mg by mouth daily x 4 days which the resident had not been administered on 8/2/23 and 8/3/23 during the morning medication pass. The Report detailed the physician had been notified on 8/04/23 at 9:05 a.m. of the failure to administer the medication. The Report further detailed the Lasix medication had not been sent from the pharmacy. The Report Outcome further detailed Resident #42 had been a direct admit to the hospital. The Corrective Action Taken described a verbal warning and a two-day suspension during the investigation of the nurse (Staff G) involved in the incident. The Measures Taken to Prevent a Reoccurrence of a similar error detailed education and competency skills would be completed for all nursing staff. Staff G signed the Medication Error Report on 8/07/23. A Facility Reported Incident (FRI) detailed the facility submitted information to the Iowa Department of Inspection, Appeals, and Licensing on 8/07/23 at 4:33 p.m. notifying the State Agency Resident #42 had a new Lasix 20 mg daily x 4 days order. The Report identified a nurse had not administered the Lasix medication on 8/2/23 and 8/3/23 which resulted in resident harm involving hospitalization . The facility became aware of the incident on 8/04/23 and a full investigation had been initiated. During an interview on 8/08/23 at 10:14 a.m. Staff G reported Resident #42 did not receive the Lasix as ordered on 8/2/23 and 8/3/23. She stated the medication never came in from the pharmacy. She did not take the Lasix medication out of the emergency medication kit. She stated the pharmacy prefers for them to call the pharmacy to get the medication during normal business hours and not to take out of the emergency medication kit. On 8/08/23 at 12:48 p.m. Staff K, RN, recalled he had more fluid. He always talked about having a hard time breathing at night. It seemed like his swelling went from one leg to the other. It was a 2+ swelling in the left below knee to the ankle. They were wrapping the right leg up to the hip, but she noticed the swelling above the knee as well as the ankle and foot. She would have thought the swelling would be on the right lower extremity due to his right hip replacement, but the swelling was on the left lower leg. She reported if she checked the MAR and the medication was not in the medication cart, she would call the pharmacy to find out where the medication was at. Staff K reported some people just pull the medication cards out and do whatever, but she always pulls the cards and looks at the MAR. She didn't recall a Lasix order for Resident #42. Staff K stated she signs medications off as administered after the medication is given. On 8/08/23 at 1:07 p.m. Staff L, LPN, reported Resident #42 had swelling to both lower extremities. Therapy had seen him and they started doing leg wraps. Everything was going good, then she noticed that his left leg stated swelling up. She had recommended to day shift to start getting daily weights to see if he was retaining fluids. Pharmacy has an on-call number they are to call if a medication doesn't come in. If she can she will pull from the emergency kit if the med doesn't arrive or take from stock. Medications should be signed off the EMAR after they are administered to the resident. During an interview on 8/08/23 at 1:47 p.m. Staff H reported Resident #42 had swelling in his legs. She hadn't noticed a huge change from the day before, but his weight had gone up. He had been getting leg wraps but they discontinued those. He had swelling in his legs. He was supposed to be getting Lasix, but when she went to give the medication that Friday morning, the medication wasn't in the medication cart. She went to the DON and informed her she didn't have the medication to give. The Physician was going to see the resident on rounds that day so the Lasix medication was held. They informed the physician he did not receive the medication as it wasn't available from the pharmacy. She had gone right to the DON when she couldn't find the Lasix medication as she was a newer nurse and this situation made her nervous. She reported she documents medication administration after the resident receives their medication to ensure they actually take the medication. She administered medication by taking the card out of the medication cart. She compares all the medication cards against the MAR. She compares the medication cards against the MAR again as she puts the medication cards into the medication cart before administering the medication to the resident. She signs off medication administration after the resident takes the medication(s). On 8/08/23 at 1:58 p.m. Staff G reported she never called the pharmacy regarding the diuretic medication on 8/02/23 and 8/03/23. She had not realized Resident #42's diuretic had not been delivered from the pharmacy or that she had not given the medication. She reported she was just sick about what happened to the Resident. On 08/08/23 at 1:59 p.m. the ARNP reported she received a text from the DON informing her Resident #42 had not received the Lasix medication. She would have hoped that the medication would have helped but it is hard to know. She doesn't know how he would have responded because he never got a dose of Lasix. She expected the facility to administer the diuretic medication as ordered. She can't speak to the resident's condition if it would have prevented the hospitalization because he never received the medication to know how he may have responded. During an interview on 8/08/23 at 2:23 p.m. with primary physician reported the resident had been admitted to the hospital in heart failure. He reported the hospitalization could have been prevented if the facility had given the Lasix medication as ordered by the ARNP. He reported if the Resident had received the two doses of Lasix prior to his visit on Friday (8/04/23) he would not have needed hospitalization . Unfortunately, he had atrial fibrillation and by Friday it had worsened due to the heart failure and not getting the medication. On 8/08/23 at 3:07 p.m. Staff I reported the resident had been filling with fluid. He still walked, but he commented on how much his legs were swelling. He voiced he was uncomfortable and couldn't eat. They had called and the nurse practitioner was coming in to see the resident. During an interview on 8/08/23 at 3:48 p.m. the Director of Nursing (DON) reported Staff H informed her she couldn't find a card of Lasix in the medication cart around 8:30 a.m. Prior to that no one knew the Lasix had not come from the pharmacy or been administered. The physician had routine rounds due that day and he saw Resident #42 as the last patient of the day. The physician thought it was in the best interest of the resident to be admitted as he had atrial fibrillation with his heart rate in the 100's and he needed diuresis. She reported she called the pharmacy on 8/04/23 and the pharmacy stated they didn't fill an order for Lasix as they didn't receive the faxed order. They suspended the nurse that made the error (Staff G) for two days. Staff G came in on 8/07/23 and received a verbal warning and education on medication administration. She reported they provided medication administration policy review and competency training for each nurse 8/07/23 - 8/08/23. They are continuing to do medication administration competency as each nurse reports for work. The ARNP saw Resident #42 between 1-2 p.m. on 8/01/23 so the medication had not been taken out of the emergency medication box. Resident #42 had been edematous, but he hadn't been complaining of shortness of breath at rest or sitting so they didn't start the medication on 8/01/23. He did have shortness of breath with laying flat. She didn't feel that he exhibited any acute distress to start the medication on 8/01/23. She expected the nurses to call the pharmacy and follow-up if a medication is not delivered to the facility. The facility will send someone to get the medication. She expects the nurses to administer the medications according to the physician orders. A review of Staff G's employee file on 8/08/23 revealed a disciplinary report form dated 8/07/23 which detailed an incident description of medication administration policy not being followed. The Report Form documented expected changes to review and follow the medication administration policy and standards of nursing practice. The Action taken was a verbal warning. The Medication Error Report dated 8/4/23 documented corrective action of verbal warning and 2-day suspension during the investigation. On 8/09/23 at 9:01 a.m. Staff G reported she received medication training via phone from the DON last night (8/08/23). She understands the medication pass requirements, policy, and expectations. She had been suspended for two days over the weekend due to the incident. On 8/09/23 at 9:40 a.m. Staff G reported she received a call from the facility telling her that something had happened and she was on a 2-day suspension. She then received a call from the facility on Monday morning (8/07/23) stating the State was in the facility and she needed to come in at 4 p.m. to get education. She received education on medication administration on 8/07/23 and additional medication administration training on 8/08/23. During an interview on 8/10/23 at 11:57 a.m. the Administrator stated she couldn't speak for Staff G, but missing the medication two days in a row she feels staff G didn't follow the medication rights for medication administration. She knew that Staff G hadn't been feeling well lately, but she did expect that every nurse would follow medication rights and standards or practice for safe medication administration. The Medication Administration Policy, effective date 10/10/19, provided by the facility directed medications shall be administered per the physician order. The Policy Procedure directed the following: 1. Wash hands with soap and water prior to beginning the medication pass. Waterless hand sanitizer is acceptable between residents. 2. Open the medication cart with the key held by the licensed nurse, oral medication technician (OMT) or Director of Nursing. The Medication labels will be checked against the current Medication Administration Record (MAR) for individual resident's medication pass. 3. Remove the medication with labels facing the nurse/OMT. Check the labels to the MAR. Verify the resident, drug, strength, dose, route, and hours of administration with the MAR. 4. Dispense the medication into the medication cup. 5. Return the medications to the medication cart. Close and lock the medication cart. 6. Identify the resident. Administer the medication. Assure the resident has taken the medication. Sign the medication on the MAR. The Medication Administration checklist, undated, provided by the facility directed the following: 1. Check the medication administration sheet. 2. Dispense the medication without touching the medication. 3. Identify the resident. 4. If vital signs or blood sugar monitoring are ordered, perform prior to giving the medication. 5. Administer the medication. Ensure the resident has enough fluids to swallow his or her medication. Never leave medication at the bedside. 6. Chart the medication as given. 7. Use a sanitizing solution to cleanse hands between residents. 8. Monitor for side effects for all medications given. 9. Medication carts are to be locked when out of the sight of the licensed nurse. The MAR is to be closed when not in use. 10. Medication carts are to be kept clean at all times.

Based on observation and staff interview the facility failed to serve plates without touching food surfaces and a glass by the drinking surface for 39 residents served the noon meal on 8/8/23. The facility reported a census of 44 residents. Findings include: During an observation of the noon meal on 8/7/23, Staff F, dietary aide was observed handling drinking glasses by the top of the glass, touching the drinking surface of the glass. During an observation of the noon meal on 8/8/23 Staff A, cook was observed plating the resident meals. During the observation, all resident plates (regular plates and adaptive plates) and bowls used to serve residents were touched on or in the food surface area prior to putting food on the plate or in the bowl. During the same observation on 8/8/23, Staff B, Certified Dietary Manager, Staff C, dietary aide, Staff D, dietary aide, and Staff E, Licensed Practical Nurse (LPN) all assisted in taking plates from the cook to the residents. Every one of the staff members put their thumbs on the surface of the plates between food items. During an interview on 8/8/23 at 1:12 PM, Staff B confirmed 5 residents did not receive food during the noon meal and 39 residents were served. She confirmed the 5 not receiving meals were out of the facility or did not receive meal per the care plan. When she was made aware of the observation findings she stated she has drilled and drilled not to touch those surfaces but apparently she was doing it too. During an interview on 8/9/23 at 2:08 PM Staff B stated it is her expectation that the eating and drinking surfaces would not be touched when handling tableware. She stated she was unsure if there was a policy but would look for one and provide it if there was one. During an interview on 8/9/23 at 2:15 PM Staff B stated there was not a policy for handling tableware, they just follow the food code. When asked what the food code said about handling table wear she stated she did not know but could find out.

Based on record review, facility policy review, and staff interview, the facility failed to ensure the Medical Director attended Quality Assurance (QA) meetings at least quarterly as required. The facility reported a census of 42 residents. Findings include: Review of the monthly QA meeting attendance sign in sheets from February 2021 to March 2022 revealed the facility Medical Director attended the QA meeting held in December of 2021 and the meeting held in March of 2022. The monthly QA sign in sheets for June of 2021 and August of 2021 contained the Medical Director's signature both with the note Reviewed 9/3/21 indicating they did not attend those meetings but reviewed the minutes and no other monthly sign in sheets contained the Medical Director's signature. Review of the undated QA Committee and Meeting policy provided by the facility on 4/27/22 revealed the Medical Director would attend QA meetings quarterly. On 4/28/22 at 8:47 a.m., the Administrator and Administrator in Training both acknowledged that the Medical Director failed to attended the QA meetings at least quarterly and a review of the minutes and signing off on them did not meet the requirements. They had a plan going forward to hold the QA committee meetings on days that the Medical Director conducted rounds to ensure the required attendance.

Based on clinical record review and staff interviews, the facility did not provide adequate nursing supervision for one of six residents reviewed (Resident #1). Resident #1 exited the facility and staff responded to the door alarm but failed to identify the source of the alarm. The facility reported a census of 44 residents. Findings include: The Admission Record dated 10/28/21 documented Resident #1 had diagnoses which included [CONDITION(S)], dementia, behavioral disturbance, hypertension, [CONDITION(S)] and age-related [CONDITION(S)]. According to the resident's Minimum Data Set (MDS) assessment form of 10/19/21, Resident #1 scored 10 points (of 15 points) on the brief interview for mental status (BIMS) test, indicating a moderate impairment in cognition and decision making skills. The assessment also indicated Resident #1 was independent in completing her activities of daily living (ADL's) with the exception of bathing. Resident #1 walked independently in her room and within the facility. The resident's Plan of Care documented a focus area of wandering initiated on 5/13/21. Interventions and tasks included the following: a. Approach from the front. Walk in step with the resident first before redirecting. b. Convey an attitude of acceptance toward the resident. c. Develop a pathway for resident to follow; keep the pathway free from obstacles. d. If the resident looked for family/significant other, reassure her that others know where to find her. e. Maintain a calm environment and approach to the resident. f. Wanderguard (a security device) to her right ankle. Progress Notes dated 10/25/21 at 10:42 a.m. recorded Resident #1 had been in the Director of Nursing's office twice that morning, tearful and concerned about husband who is hospitalized after a fall and [CONDITION(S)]. The resident wanted to go over to Assisted Living and get his belongings. The DON spoke with Assisted Living Director via phone with Resident #1 present to reassure her that his apartment is locked and all belongings were safe. The resident continued to be tearful and express concern. The resident spoke with her daughter for reassurance and a close friend and sister (from Assisted Living) visited to offer emotional support. The resident's Progress Notes dated 10/25/21 at 4:05 p.m. documented nursing staff were alerted by the Assisted Living Director that Resident #1 was at the Assisted Living Facility looking to see how her husband's apartment looked and worried about her husband. The facility policy titled Door Alarm Response effective 11-02-2018 directed staff to implement the following in response to implement the following: a. Staff to check the system for location of door alarming. b. Staff to IMMEDIATELY respond to the door that is alarming. Staff to walk to the door, walk outside, scan the facility grounds to identify the source of the alarm. c. If the source of the alarm is a resident , assist the resident/tenant back into the facility. Notify the nurse on duty. d. Once the door is checked and resident/tenant safety is assured, reset the door alert. e. If the source of the alarm is not identified, account for location of all residents/tenants. f. If a resident/tenant is unaccounted for, immediately implement the missing resident/tenant policy. During an interview on 12/2/21 at 12:02 p.m. Staff A, Transportation stated he heard the 700 hall door alarm sound as he was escorting a resident to his room on the 700 hall. Staff A stated he did not see anyone in the hallway, but then added that other staff were escorting residents to their rooms. Staff A stated he did not see anyone at the exit door alarm and also stated that he did not silence the door alarm. During an interview on 12/2/21 at 10:43 a.m. Staff B, Housekeeping stated she observed a person (not sure who it was) standing and a person in a wheel chair at the end of the 700 hall (near the exit door). She stated she was at the opposite end of the hallway. Staff B stated she heard the door alarm sounding when she was by the 600 hallway, did not observe anyone going through the door and that staff had already responded to the alarm. Staff B thought Staff C had responded to the sounding alarm. During an interview on 12/6/21 at 11:22, Staff C, CNA (Certified Nursing Assistant) stated she heard the door alarm sounding as she was coming around the corner to approach the 700 hall while escorting residents back to their rooms. Staff C stated she could not see the 700 hall exit door at the time the alarm started to sound. Staff C stated another resident was in the (700) hall and told Staff C, 'it wasn't me'. Staff C stated she just turned the alarm off. She did not open the door at the end of the 700 hall to see if anyone was in the hall. Staff C stated she never thought to look for a missing resident as it has never happened before. Staff C added that the alarm at the 700 hall sounds frequently because residents from Assisted Living and visitors forget to silence the alarm before entering the nursing facility. During an interview on 12/2/21 at 9:04 a.m. the Director of Nursing stated she thought staff silenced the door alarm because there was an observation of a resident seated (in a wheel chair) by the exit door, so staff reasoned that resident had pushed on the door causing it to alarm. The Director of Nursing added the resident that was observed had set off the door alarms prior to the incident with Resident #1. During an interview on 12/2/21 at 10:29 a.m. the facility's Corporate Consultant stated the facility policy is to find the source of why the door alarm sounded. If the source is unknown, then staff need to go further to look beyond the door to make sure no one is on the other side.

Based on staff interviews and review of guidance from the Centers for Disease Control, the facility failed to have an Infection Preventionist trained in infection prevention and control on staff. The facility reported a census of 42 residents. Findings include: During an interview with Staff A, Administrator on 10/18/21 at 11:20 a.m., the Administrator indicated they currently do not have an Infection Preventionist on staff. The former trained Infection Preventionist Nurse left employment on 7/28/21 but Staff D, RN (Registered Nurse) Nurse Consultant is performing this role. Staff D comes to the facility two to three times a week to cover this since the former nurse left. During an interview with Staff B, Director of Nurses (D.O.N.) on 10/18/21 at 10:30 a.m., she stated Staff D Nurse Consultant is coming to the facility two to three times a week and is the Infection Preventionist for the building. The D.O.N. stated there are no other facility staff working that is a Certified Infection Preventionist. During an interview with Staff C, Nurse Consultant on 10/18/21 at 2:13 p.m., the Consultant stated Staff D has not complete her certification for Infection Preventionist. She stated she is only part way through the modules with several left to complete before she will become certified as an Infection Preventionist. Staff C stated Staff D performed the role of Infection Preventionist for the facility since the end of July, 2021. The Centers for Disease Control (CDC) website https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhcp%2Fnursing-homes-responding.html instructs that one or more individuals with training in infection control should be on-site to provide on-site management of the facility's infection prevention and control program

Based on clinical record review, observation, staff and resident interviews and facility policy review, the facility failed to ensure routine checks of audible and Code Alert alarms. This failure resulted in the unplanned exit (elopement) of 1 of 5 residents reviewed for nursing supervision (Resident #1). The facility identified a census of 44 current residents. Findings include: According to the Minimum Data Set (MDS) assessment of 5/5/21, Resident #1 had diagnoses that included heart block, [CONDITION(S)], [CONDITION(S)], Non-Alzheimer's dementia, & [CONDITION(S)] disease. The MDS documented severe cognitive and memory impairment, as evidenced by a Brief Interview for Mental Status score of 0. Resident #1 required the assistance of one while walking and wandered in the facility daily. Resident #1's care plan, initiated on 5/10/21, documented the risk for elopement and wandering related to being disoriented to place with aimless wandering. Interventions directed staff to assess for his fall risk; to distract him by offering pleasant diversions like structured activities, food, conversation, TV or a book; to monitor for fatigue and weight loss and that he wore a wander alert (Code Alert) to his right ankle. The Incident Report dated 5/12/21 at 12:50 pm documented Resident #1 exited the facility through the main dining room door. No alarms sounded at the time of his exit and residents in the dining room witnessed the elopement. Staff A, CNA (certified nursing assistant) found the resident located almost to the parking lot. The author of the report assessed Resident #1, found no injuries, and reported the lack of sounding alarms to the Maintenance Director. The facility reported the incident to the State agency on 5/12/21. On 5/19/21 at 12:50 pm, Resident #7 stated she remembered seeing a man go out the dining room door about a week ago after lunch. The man did not say anything first, just walked out the door. Resident #7 stated the door is not normally used, so she thought it strange he went out. No alarm sounded when the man went out. Resident #7 stated she told the first person she saw in the dining room, but did not recall the staff member's name. She did not see the man fall and staff brought him back in a few moments later. On 5/19/21 at 10:20 am, the facility's Regional Director of Operations (RDO) stated that before Resident #1 exited on 5/12/21, the night shift staff were assigned to check door alarms every night at 10 pm; the task had been started by the previous Administrator through verbal instruction. Staff last checked the door alarms on 5/10/21 during the overnight shift. The RDO stated that on the 5/11/21 overnight shift, a nurse worked who normally did not work overnights so she did not know to check the alarms. The RDO stated there is a night shift cheat sheet that addressed the alarm checks, but she did not know if the overnight nurse (Staff C) had access to the cheat sheet. Since Resident #1's exit, maintenance staff now check the alarms and Resident #1 moved to the Assisted Living Memory Care unit on 5/13/21. During observation and interview with the Maintenance Director on 5/19/21 at 2:40 pm, observation revealed the main dining room door as oriented to the northwest (NW) of the dining room. The NW dining room door contained two alarms: an audible alarm that sounded upon opening and a Code Alert alarm that sounded when triggered by a Code Alert device. The Maintenance Director stated after Resident #1 exited, he checked the system and found a blown breaker, and that both alarms were on the same electrical circuit, so neither would sound. Interview and observation with Staff D, CNA on 5/20/21 at 10:05 am revealed that about lunchtime on 5/12/21, she came to the dining room after delivering resident room trays. Resident #7 waved at her and told her 'he went out the door', the NW (main) dining room door. Staff D could not see Resident #1 and pushed the NW door open to follow; no alarm sounded. Staff D called out on the walkie-talkie that they had a resident exit. Observation during the interview revealed Staff D found Resident #1 near the parking lot south of the facility, about ½ block from where he exited; the observation revealed Resident #1 traveled a paved path to the south parking lot. Staff D stated that Resident #1 wore pants, shoes, and a long sleeved shirt when found, his clothing was dry, and it did not appear that he fell . During interview on 5/20/21 at 11:50 am, Staff E, CNA stated on 5/12/21, she took her break in the parking lot and heard a call on the walkie-talkie. She initially saw Staff D, and then saw Resident #1 in the same location described by Staff D. Staff E stated that Resident #1 did not want to go back in right away, but did with the assistance of staff. Staff E stated Resident #1's shoes and pants were free of grass, mud, and stains when found and she did not think that he fell . Two staff assisted residents to eat lunch in the dining room on 5/12/21 at the time of Resident #1's exit; Staff F and Staff G. On 5/24/21 at 11:15 am, Staff F, RN (Registered Nurse) stated when Resident #1 exited the dining room on 5/12/21; she sat with her back to the NW dining room door. Staff F heard Resident #7 tell Staff D she thought someone went outside. Staff D went outside immediately; no alarm sounded. Staff D stated Resident #1 was outside of the facility 1 - 2 minutes. On 5/24/21 at 1:50 pm, Staff G, CNA stated on 5/12/21, she helped two residents to eat with her back to the dining room door. Staff G remembered hearing Staff D say 'aah', she looked up and saw the door swing shut, and then Staff D exited the door immediately after. Staff G stated no alarms sounded. Review of the Door Alarm Check form on 5/19/21 for May 2021 showed no documented checks done on 5/1, 5/2, 5/5, 5/6, 5/7, or 5/11/21. During interview on 5/19/at 2:45 pm, the facility's Provisional Administrator stated that two nurses primarily work the night shift, Staff A and Staff B. During a phone interview on 5/20/21 at 4:50 am, Staff A, RN stated she worked 12-hour overnight shifts, three days per week. Before Resident #1's exit, staff did not check the audible door alarms, only Code Alert bracelets during night shift. She stated to check a Code Alert, they used testing box at the nursing station to check if the bracelet functioned. Staff A did not test the Code Alert box at the door. Staff A stated it has always been that way, she could not recall who trained her on the task and staff have never checked the audible door alarms on the overnight shift. During a phone interview on 5/20/21 at 8:15 am, Staff B, RN stated the nurse who trained her to nights instructed her to view all audible door alarms for a green light. If not green, then she should open the door to listen for an alarm. Staff B stated she had never needed to open a door with an audible alarm at night, the lights always showed green. For Code Alert bracelets, she would take a hand-held device from the nursing station and use it to check the bracelet for function. Staff B stated she had received no direction to check the Code Alert system at the doors. She was not sure if the system had changed or not, but she still checks for green lights on audible door alarms and does code alert bracelet checks. During an interview on 5/20/21 at 12:25 pm, Staff C, LPN (Licensed Practical Nurse) stated she worked on 5/11/21 from 10 pm to 6 am, as there was no one else available. Staff C stated she had not worked nights recently and worked nights maybe once or twice in the last year; she just filled in. Staff C stated she thought there might be a checklist for overnight duties, but she did not see it that night. Staff C did not check door alarms that night; she may have learned to do so years ago, but she could not remember. Staff C stated that on 5/12/21, the Provisional Administrator called her and asked if she had checked door alarms 5/11/21 night shift and she had not, so she told her that. The Wander Guard (Code Alert) policy for Long Term Care, effective 2/6/19, instructed that function of door alarms and the wander guard systems shall be checked daily. -

Based on observation, staff and resident interviews, the facility failed to ensure all residents were offered a bedtime snack daily as reported by five residents during a group interview. The facility census was 48 residents. Findings include: 1. During the group interview on 11/14/16 at 1:00 p.m., five of five residents present reported they were not routinely offered a bedtime snack. Two of the residents stated they would like to have one. During observation on 11/16/16 at 2:50 p.m., a snack cart sat in the hallway with no staff around it. Staff A, Certified Nurse Aide, CNA was on the opposite end of the hall. During interview at the time, Staff A stated residents were not offered a bedtime snack every night. Staff A stated residents were offered a bedtime snack two to three times per week because dietary staff did not always leave a snack cart out after the evening meal. Staff A stated they routinely gave diabetic residents a bedtime snack. During interview on 11/16/16 at 3:00 p.m., the Director of Nursing stated they did not know if residents were offered a bedtime snack or how that worked. During interview on 11/16/16 at 3:07 p.m., Staff B, dietary aide stated kitchen staff took a snack cart out every evening but if they did not see a CNA it would be left in the kitchenette and CNA's may not have known it was there.

Based on a review of the quality assurance meeting sign in sheets and staff interview, the facility failed to ensure the Medical Director attended all quarterly quality assurance meetings. The facility census was 48 residents. Findings include: 1. On 11/16/16 at 2:25 p.m., the Administrator provided the facility quarterly quality assurance meeting sign in sheets for the past year. A review of the attendance sheets revealed the Medical Director was not in attendance for the last quarterly meeting held December 17, 2015. During interview at the time, the Administrator stated the Medical Director could not always be present for the meetings. The Administrator stated no one had attended the meeting in the Medical Directors place but the Medical Director had reviewed the meeting minutes later. A review of the minutes for the meeting revealed the Medical Director signed as reviewed on 1/8/16.

Based on observation, clinical record review and staff interview, the facility failed to ensure medications were kept secured at all times and failed to ensure residents received adequate supervision and appropriate assistive devices to prevent accidents. The facility census was 48 residents. The facility identified 40 residents as cognitively impaired. (Resident #13) Findings include: 1. Observation on 5/23/12 at 7:03 a.m., revealed an unlocked and unattended medication cart in front of the medication room with the following items inside: a. resident oral medications b. ointments and creams c. lancets d. disinfectant wipes e. inhalers f. nebulizer medications. During interview on 5/23/12 at 7:03 a.m., Staff A, Director of Nursing confirmed and verified the medication cart needed to be kept locked at all times. 2. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #13 had [DIAGNOSES REDACTED]. The MDS assessment documented the Brief Interview for Mental Status score of 10 and documented the resident required extensive assistance with bed mobility, locomotion on and off the unit, dressing, toilet use and personal hygiene. The MDS assessment documented the resident utilized a wheelchair for mobility device and had a fall with no injury. The Fall Risk assessment dated [DATE], documented the resident had fallen in the last 31-180 days. The Resident Care Plan with a team conference dated 4/24/12, documented the resident at risk for falls related to history of fall and cerebrovascular accident: Intervention include: a. Transfer with assist of one with gait belt. b. Ambulates with assist of one, gaitbelt and front wheeled walker. c. In event of fall assess for injury. d. Offer and assist to use before and after meals, hour of sleep and as needed. e. Keep items that are used frequently with in reach. f. Ensure proper footwear. g. Resident has glasses, ensure glasses are clean and in good repair. h. Call light with in reach when in room. i. Remind resident to use brakes with transfers. j. Anti-roll back device on wheelchair. k. Personal alarm in chair or wheelchair dated 5/2/12 Observation on 5/24/12 at 9:01 a.m., revealed the resident propelling him/her self in the hallway with the cord to the personal alarm hanging down the back of the wheelchair, not attached to the alarm box. Observation on 5/24/12 at 9:12 a.m., revealed resident sitting in the wheelchair with the cord hanging down the back of the wheelchair not attached to the resident. Observation on 5/24/12 at 9:17 a.m., revealed resident continued to sit in the wheelchair with alarm not attached and no staff around. Observation on 5/24/12 at 9:26 a.m., revealed resident continued to sit in the wheelchair with alarm not attached and no staff around. Observation on 5/24/12 at 9:38 a.m., revealed resident sitting in the wheelchair with no alarm attached and no staff around. Observation on 5/24/12 at 9:45 a.m., revealed the alarm continued to hang down the back of the wheelchair unattached. During interview on 5/24/12 at 9:50 a.m., Staff B, licensed practical nurse confirmed and verified the alarm needed to be attached at all times.

Based on resident and staff interviews, the facility failed to offer a snack at bedtime to residents on a regular basis. The facility census was 48 residents. Findings include: 1. During group interview conducted on 5/23/12 at 10:30 a.m., five of six residents identified as interviewable by the facility stated they do not receive a snack in the evening. One resident stated they received a snack because they were diabetic. All residents in group stated snacks were at the nurses station but you have to ask for staff to get one for you. During interview on 5/24/12 at 3:25 p.m., Staff E, cook and Staff F, dietary manager stated specific snacks were sent for diabetic residents and for residents with special diet orders and there was fruit for the other residents. Staff E and Staff F stated there were other items such as health shakes and crackers/cookies in the nurses station kitchenette if residents requested. The snack cart was delivered to the nurses station every evening about 7:00 p.m. and evening nursing staff were to take the cart around to offer snacks to residents. During interview on 5/24/12 at 3:44 p.m., Staff C, certified nurse aide, CNA stated snacks are passed to residents that are awake and sitting by the nurses station. Staff C stated residents that are in their room do not get offered a snack. During interview on 5/24/12 at 3:48 p.m., Staff D, CNA stated residents that are in their rooms do not get offered snacks, the residents that are diabetics get a snack before bed. During interview on 5/24/12 at 9:55 a.m., Staff A, registered nurse stated that at the monthly resident council meetings the monthly agenda includes asking residents specifically about receiving a bedtime snack and no concern was voiced.

Based on observation and staff interview, the facility failed to provide a backflow/overflow preventer for the kitchen's ice machine. The facility census was 50 residents. Findings include: 1. During initial tour on 04/19/11 at 8:45 a.m., the Dietary Supervisor was unable to identify the backflow preventer for the large ice machine in the main kitchen area. He/she would check with the Maintenance man to locate the backflow preventer. During observation on 04/20/11 at 10:55 a.m., the Dietary Supervisor indicated a connector towards the ceiling as the backflow preventer. The surveyor pointed out to the Supervisor, that the connection as the backflow preventer valve for the city's water and not for the facility's water. During observation on 04/21/11 at 2:15 p.m., the Maintenance Supervisor stated the ice machine's manual documented no backflow preventer on the inside of the machine. The Maintenance Supervisor pointed out instructions of the back of the ice machine to set up a backflow preventer correctly. The maintenance supervisor noted the machine had no backflow installed on the ice machine. During an interview on 04/21/11 at 9:50 a.m., Staff E, Certified Nursing Aide passed ice water to all the residents, three times a day. Staff E stated dietary brings out the ice from the kitchen ice machine. The resident's dietary records indicated no resident's with ordered thicken liquids.

Based on observation, clinical record review and staff interview, the facility failed to follow the menu for one of one resident observed on pureed meals. The facility census was 50 residents. Findings include: 1. The scheduled menu for 04/20/11, documented residents on a pureed diet to receive one (1) serving of pureed roast pork (2 ounces) at the noon meal. The physician's dietary order report dated 3/19/11 to 4/19/11, documented four residents in the facility on pureed diets. Observation on 04/20/11 at 10:35 a.m., revealed Staff B, Cook placed 8 ounces of cooked roast pork and four slices of buttered bread in the blender, pureed the mixture, measured the total amount at two cups and noted each resident to receive 1/2 cup of pureed pork. Staff B placed the four servings in a steam pan and into the steam oven. Observation at the noon meal, revealed Staff B used a size 16 scoop (equaled to 1/4 cup) to serve the roast pork to the four residents. Staff B did not look at the scoop conversion chart to see the size needed for a 1/2 cup each. The scoop needed to be a size 8 scoop. The residents on a pureed diet did not receive the required amount of roast pork. Observation after the served meal, Staff B revealed 1/2 cup of leftover pureed roast pork. . Staff B stated there should be no leftovers since he/she prepared and served for four residents on a pureed diet and did not understand why there had been pureed meat left.

Based on observation, clinical record review and staff interview, the facility failed to verify physician's orders after a clinical procedure was completed for one of thirteen residents reviewed. The facility census was 50 residents. (Resident #3) Findings include: 1. The Physician's Orders sheet signed and dated by the physician on 04/07/11, documented Resident #3 had [DIAGNOSES REDACTED]. A Physician Consultation sheet dated 03/10/11, documented the resident had a past medical history that included hypertension, Lyme Disease, and mitral valve regurgitation. The Minimum Data Set ((MDS) dated [DATE], documented the resident had no short- or long-term memory deficit and no cognitive skills concerns. The MDS documented the resident independent with activities of daily living except required limited assistance with dressing. The General Discharge Information after an outpatient procedure at the hospital dated 04/12/11, documented medications for the resident to "continue these medications which have not changed". Medications on the discharge paper and not listed on the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] a. [MEDICATION NAME], 25 mg tablet every morning (blood pressure and water pill); b. K-Dur, 10 milliequivalent (mEq) tablet every morning ( potassium replacement pill); c. [MEDICATION NAME], 10 mg tablet every evening (blood pressure pill); d. [MEDICATION NAME] (Cipro), 500 mg tablet every 12 hours for five (5) days (start 4/13/11)(antibiotic pill). The Nurse's Notes dated 04/13/11 at 10:45 a.m., documented the resident returned from LaCrosse yesterday with orders for Cipro, 500 mg by mouth every 12 hours for 5 days. The nurse did not document notification with the current physician regarding different medications on the readmission information record. During an interview on 04/20/11 at 6:55 a.m., the Director of Nursing (DON), stated the General Admission Information dated 04/12/11 as the latest physician orders, but the medications listed are not the correct medications the resident is to be on. The DON stated the medications listed on the general discharge information sheet came from a few years ago and not from the current physician. The DON stated the staff nurse should have clarified the medications on the order sheet with the resident's current physician. The DON stated he/she would clarify the medications with the current physician. During an interview on 04/22/11 at 8:00 a.m., the DON verified the facility identified the physician's orders as a concern at the Quality Assurance (QA) meeting in January 2011. The QA committee decided the DON and MDS Coordinator should check the accuracy of all physician orders before staff nurses use the General Admission Information sheet. The QA committee's minutes dated 03/17/11, documented for the DON and MDS Coordinator to review the medication transcription process with the computer generated MARs and Treatment Administration Records (TARs). The MDS Coordinator to enter the orders for new residents into the system and Staff G, Medical Records to enter the current resident changes with the DON to complete the final review of the computer changes.

Based on record review and resident and staff interviews, the facility failed to ensure one of three residents reviewed were free of significant medication errors and failed to receive medication as physician ordered (Resident #1). The facility reported a census of 51 residents. Findings include: 1. The admission physician orders [REDACTED]. The admission orders [REDACTED]. The orders directed staff to: a. Perform an Accu check (blood sugar check) three times a day before meals, b. Administer Sliding scale regular [MEDICATION NAME] R insulin as follows: 150-199 - 2 units 200-249 - 4 units 250-299 - 6 units 300-349 - 8 units greater than 349 - 10 units A physician prescription dated 1/5/11, documented Insulin regular ([MEDICATION NAME]-R) 100 unit/milligram injection; inject under skin three times a day before meals; indications [MEDICAL CONDITION] The diabetes.webmd.com/blood glucose identified a fasting blood glucose identified normal as: Fasting blood glucose-70 to 99 2 hours after eating glucose-70 to 145 Random (casual)-70-125. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The nurse ' s notes dated 1/5/11 at 3:30 p.m. indicated the resident as admitted to the facility with [DIAGNOSES REDACTED]. The nurse ' s notes dated 1/5/11 at 11:15 p.m., indicated the resident as found unresponsive, very diaphoretic and lung sounds congested. The Accu check tested at only 20. Intramuscular [MEDICATION NAME] (to raise the blood sugar level) 1 milligram was given. After a few minutes Accu check tested 23. The resident was sent to the emergency room . The nurses notes dated 1/6/11 at 2:00 a.m., documented the resident as admitted to the hospital with [REDACTED]. An emergency room report dated 1/6/11, documented the resident received 100 units of [MEDICATION NAME] regular insulin at 4:00 p.m. and 8:00 p.m. on 1/5/11. The resident ' s blood sugar before the 8:00 p.m., dose tested at 145. The night nurse checked the resident and noted an Accu check of 20. The resident was given [MEDICATION NAME] 1 mg intramuscular. A supervisor Conference form dated 1/6/11; documented on 1/5/11 Staff A was primary nurse for skilled admissions to the facility. It was Staff A's responsibility to complete an admission assessment and paperwork including checking the MAR indicated [REDACTED]. Therefore, Staff A incorrectly administered [MEDICATION NAME] Regular Insulin, 100 units subcutaneous at 4:00 p.m. and 8:00 p.m. No scheduled dose of insulin was ordered, only sliding scale according to completion of Accu checks before meals. This resulted in the resident becoming extremely hypoglycemic. This could have been fatal for the resident and was very poor nursing judgment. Staff A failed to follow the 5 rights of medication administration resulting in an almost fatal situation. Staff A was terminated. During interview on 1/27/11 at 11:15 a.m., Resident #1 stated she/he had been in a motor vehicle accident and today was day 50 since the date of the accident. The resident was asked about the first night in the facility. The resident laughed and stated he/she remembered a nurse giving him/her a shot (insulin) in the stomach, and then later, another shot in the left arm. The resident stated she/he knew had received insulin injections while at the hospital and really did not understand why, until the nurses had stated because of not eating. The resident recalled getting the second shot, and did not physically feel any different at the time. The resident did recall being tired, but also stated it had been a long day, being transferred from the hospital to the facility. The resident stated had recalled seeing the curtain in their room and people trying to get her/him to eat graham crackers. Later the resident recalled staff and ambulance staff tried to get him/her to eat toast and jelly. On 1/26/11 at 12:22 p.m., Staff B (Director of Nursing) was interviewed and refused to write a statement on the witness statement forms provided by the Department, but instead typed a statement on 1/27/11. Staff B stated on 1/5/11, the facility accepted Resident #1 as a new skilled admission. The resident was admitted to the facility that afternoon. Staff B stated Staff A reported to work that day at 2:00 p.m. Staff A received report from the previous day nurse and was instructed would be admitting Resident #1 later in the afternoon. Prior to the resident arriving to the facility, the MDS (Minimum Data Set) nurse, Staff C had received discharge orders via facsimile. At times Staff C helped with admission paperwork. Staff C noted the new orders, sent the orders to the pharmacy via facsimile and gave the medication list to Staff D (health information technician) to transcribe on the computer. Staff D typed the list and then gave the paperwork to the resident's charge nurse (Staff A) to review. At that time not all of the admission paperwork was completed. Staff C had just started the one form in order to get the medication information started and sent to the pharmacy. During the investigation it was revealed the discharge orders read [MEDICATION NAME] R insulin 100 units/ml, inject under skin four times a day with meals. Staff C wrote the order down as insulin regular sliding scales (see other side for scale) on the admission physician order [REDACTED]. Staff C had some confusion about when Accuchecks should be given and called the discharge physician and received a clarification order for Accuchecks to be administered three times a day with meals and placed the order into the chart. When Staff C passed the medication list over to Staff D to be transcribed onto the computer, Staff D typed the order as [MEDICATION NAME] R insulin 100 U four times a day subcutaneous with administration times as 8:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m. Staff D also transcribed at the bottom of the same computer generated Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Staff A supposedly reviewed the orders, signed them and continued with the admission assessment. At 4:00 p.m., Staff A went to the resident's room completed an Accucheck with the results of 145 and administered 100 units of [MEDICATION NAME] R insulin to the resident. At 8:00 p.m., Staff A went back to the resident ' s room, failed to complete an Accucheck and administered 100 units of [MEDICATION NAME] R insulin again. During an interview on 1/27/11 at 8:43 a.m., Staff C completed a written statement. Staff C stated upon hire a charge nurse orientation is completed before the nurse is even introduced to the floor. The orientation included reviewing the resident admission packet. For most admissions to the facility the charge nurse completed the process from start to finish. On occasion Staff C helped with the admission by filling out information such as name, date of birth, physician name, [DIAGNOSES REDACTED]. It was also a chance for any clarification to be obtained. Due to the extent of information Staff C had regarding Resident #1, Staff C thought it was beneficial for them to start the packet when the information arrived at the facility from the hospital. With all admission's, Staff D prints a MAR, treatment administration record (TAR) and a physician order [REDACTED]. All information printed would be the same, therefore if the nurse reviewed the MAR/TAR from the printed physician orders [REDACTED]. Staff C stated they were in the building on 1/5/11 until 4:30 p.m., and at no time did Staff A come to them for further clarification. On 1/27/11 at 9:56 a.m., Staff D was interviewed and stated had worked at the facility in the Medical Records Department for eight and one half years. Staff D stated she/he were responsible for entering the demographic information of the new admission into the computer. Staff D stated she/he entered the medication list received from the admission nurse into the computer in order to generate the MAR, TAR and physician order [REDACTED].

Based on clinical record review, facility policy review and staff interview, the facility failed to report a potential allegation of neglect to the Department of Inspections and Appeals as facility policy directed for one resident reviewed (Resident #1). The facility identified a census of 51 residents. Findings include: The facility abuse form titled Dependent Adult Abuse Reporting, dated 7/19/2004, directed any staff having witnessed or having reason to believe that there had been mistreatment of [REDACTED]. This mistreatment may include abuse, involuntary seclusion, neglect and/or misappropriation of property. 1. The admission physician orders [REDACTED]. The admission orders [REDACTED]. Orders included: a. Accu check three times a day before meals b. Sliding scale regular [MEDICATION NAME] R insulin as follows: 150-199 - 2 units 200-249 - 4 units 250-299 - 6 units 300-349 - 8 units greater than 349 - 10 units A physician prescription dated 1/5/11, documented Insulin regular ([MEDICATION NAME]-R) 100 unit/milligram injection; inject under skin three times day before meals; indications [MEDICAL CONDITION] The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The Nurses Notes dated 1/5/11 at 3:30 p.m., documented the resident as admitted to the facility with [DIAGNOSES REDACTED]. The Nurses Notes dated 1/5/11 at 11:15 p.m., documented the resident as found unresponsive, very diaphoretic and lung sounds congested. The Accu check tested at 20. Intramuscular [MEDICATION NAME] 1 milligram given. After a few minutes the Accu check tested 23. The ambulance crew arrived at 11:35 p.m. The blood sugar tested at 43. The resident was sent to the emergency room . The Nurses notes dated 1/6/11 at 2:00 a.m., documented the resident as admitted to the hospital with [REDACTED]. An emergency room report dated 1/6/11, documented the resident received 100 units of [MEDICATION NAME] regular insulin at 4:00 p.m. and 8:00 p.m. on 1/5/11. The resident ' s blood sugar before the 8:00 p.m., dose was okay. The night nurse checked the resident and noted an Accu check of 20. The resident was given [MEDICATION NAME] 1 mg intramuscular. A supervisor Conference form dated 1/6/11, documented on 1/5/11 Staff A was the primary nurse for skilled admissions to the facility. It was Staff A's responsibility to complete an admission assessment and paperwork including checking the MAR indicated [REDACTED]. Therefore, Staff A incorrectly administered [MEDICATION NAME] Regular Insulin, 100 units subcutaneous at 4:00 p.m. and 8:00 p.m. No scheduled dose of insulin was ordered, only sliding scale according to completion of Accu checks before meals. This resulted in the resident becoming extremely hypoglycemic. This could have been fatal for the resident and was very poor nursing judgement. Staff A failed to follow the 5 rights of medication administration resulting in an almost fatal situation. Staff A was terminated. On 1/26/2011 at 12:22 p.m., the Director of Nursing indicated the facility asked the emergency room physician to complete a major injury determination form and did so concluding this was a minor injury and the resident would return to baseline. Based on that determination the facility did not report the incident to the Department of Inspections and Appeals. During an interview on 2/17/11 at 12:59 p.m., the Administrator and Director of Nursing acknowledged they did not report the incident as an alleged abuse, due to their understanding of the definition of abuse.