Bethesda Dilworth

Based on interview, observation, and record review, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation when the shift change narcotic count was not completed and one of the narcotic count sheets for one resident was inaccurate (Resident #7). The sample was 14. The census was 152 with 130 in certified beds. Review of the facility's Inventory Control of Controlled Substances Policy, revised 8/2023, showed:-Purpose: This policy sets forth the procedures for inventory control of controlled substances and establishes guidelines for the investigation of missing medications;-Scope: Level 2 policy affecting contracted pharmacies, Human Resources, nursing staff, and nursing management;-Responsibility: It will be the responsibility of the nursing staff members to know and comply with this policy and procedure. It is the responsibility of the Director of Nursing (DON) to maintain, enforce, and monitor compliance of this policy;-Policy: Practice processes will be followed to establish inventory control of all controlled substances. An investigation will be conducted on all missing medications;-Practice: -Inventory Control:--All controlled substance delivered to the communities for an individual resident will immediately be added to Controlled Substance Log by the person signing the delivery receipt or electronically signed into the electronic dispensing device, if so designated;--Community should ensure that incoming and outgoing nurses and/or Certified Medication Technicians (CMTs) count all Scheduled II though V controlled substance and tramadol (pain medication) daily with both documenting verification on the Controlled Substance Log;-Investigation Guidelines for Missing Medications or Suspected Diversion:--It is the responsibility of all nursing staff members to immediately report all missing medications or suspected diversions to the Administrator or DON/designee. Examples of reporting instances could include the following:---Shift-to-shift count or daily reconciliation from electronic dispensing device does not correctly reconcile;---Improper controlled substance or as needed (PRN) documentation. Discrepancies noted on any controlled substance records. Review of Resident #7's medical record showed:-admission date 8/7/25;-Diagnoses included rheumatoid arthritis (chronic joint disease that causes pain and swelling), chronic kidney disease, heart failure, low back pain, and diabetes. Review of the resident's electronic Physician Order Sheet (ePOS), showed an order, dated 1/19/26, for oxycodone-acetaminophen (narcotic pain medication used for moderate to severe pain) 10-325 milligram (mg), one tab for pain every six hours at 0300, 0900, 1500, and 2100. Observation on 3/19/26 at 9:45 A.M., showed CMT B at the CMT medication cart. He/She opened the narcotic box, which showed the resident's card of oxycodone-acetaminophen 10-325 mg. CMT B removed one pill from the card and verified the card had a remainder of four pills. During an interview on 3/19/26 at 9:50 A.M., CMT B said he/she signs out the controlled substance medications as he/she goes along during the medication pass. He/She watches the resident take their medication. Counts of the narcotic medications are completed by staff at the beginning and end of each shift. Any discrepancies should be immediately reported to the nurse. If the medication card appears to be tampered with, CMTs are to notify the nurse and waste the medication. Observation on 3/19/26 at 9:56 A.M., showed CMT B administered the oxycodone-acetaminophen to the resident. CMT B did not sign the medication out of the controlled substance book prior to administering the medication to the resident.Observation and interview on 3/19/26 at 10:00 A.M., showed CMT B at the medication cart with the controlled substances book. He/She opened the book to sign out the oxycodone-acetaminophen he/she had just administered to the resident. The controlled substance sheet showed the previous quantity was six pills and CMT B signed out one, for a total of five pills. CMT B opened the narcotic box and verified four pills, not five, remained in the resident's medication card. He/She notified Licensed Practical Nurse (LPN) A, as LPN A walked by the cart, of the discrepancy. CMT B said he/she arrived late to the facility this morning and the medication counts were not done. During an interview on 3/19/26 at approximately 10:05 A.M., LPN A said counts should be done at the beginning and end of each shift. He/She assumed the counts were done this morning, but did not verify. During an interview on 3/19/26 at 11:16 A.M., the DON said she was aware of the discrepancy on the narcotic sheet. She expected counts to be completed by staff at the beginning and end of each shift. Narcotic medications should be signed out immediately upon removal. After each resident, the medication should be signed out immediately. During an interview on 3/19/26 at 12:00 P.M., the Administrator and DON said CMT B was sent for a drug screen and will be suspended pending investigation. They have started an investigation and have attempted to reach the night shift CMT. They expected CMT B to have counted with the nurse when he/she arrived at the facility this morning. During an interview on 3/19/26 at 3:30 P.M., the Administrator said she expected staff to follow policy. The narcotic counts should be done by staff before and after each shift.

Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assure the resident's Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) accurately reflected the resident's status for one of three residents investigated for hospice (Resident #147). The facility identified 19 residents on hospice. The census was 145 with 126 in certified beds. Review of Resident #147's medical record, showed diagnoses included dementia, Chronic Obstructive Pulmonary Disease (COPD, lung disease), depression, anxiety, and malnutrition;-An electronic physician order sheet (ePOS) showed an order dated [DATE], for a Hospice consult;-A hospice election form showed hospice services began [DATE]. Review of the resident's significant change MDS, dated [DATE], showed:-Assessment Reference Date (ARD) [DATE];-Special services received while a resident: Hospice Care not marked;-Does the resident have a condition or chronic disease that may result in life expectancy less than six months: No. Review of the resident's medical record, showed he/she expired at the facility on [DATE]. During an interview on [DATE] at approximately 2:00 P.M., with the Administrator and the Director of Nursing (DON), the DON said she did not do the MDS assessment but she would have expected for the resident's MDS to have been coded accurately and to accurately reflect the resident's status. The resident's MDS should have reflected he/she had a prognosis for a life expectancy of less than six months and that he/she received hospice care.

Based on interview and record review the facility failed to follow their grievance policy and procedure for residents and family members to voice grievances and prompt the facility to resolve grievances for one resident (Resident #9). The failure has the potential to affect all residents. The sample size was 13. The census was 146 with 119 in certified beds.Review of the facility's Resident and Family Grievances policy, revised, February 2025, showed: -Purpose: To establish written guidelines for the filing of residents' grievances and to ensure that appropriate investigation and actions are promptly taken; Customer feedback is an important source of information about an organization's performance; The verbal or written resident grievances received by staff, physicians, and administration provide vital information about improvement opportunities. -Definitions: A resident grievance is a formal or informal written or verbal complaint that is made to the facility by a resident, or the resident's representative, regarding the resident's care when the complaint is not resolved at the time by staff present and the complaint involves actual or potential abuse or neglect; If the complaint cannot be resolved at the time of the complaint by staff present, is postponed for later resolution, or, is referred to by other staff for later resolution, or requires investigation and or further actions for resolution, then the complaint is considered a grievance. A complaint is considered resolved when the resident and or resident representative are satisfied with the actions taken on their behalf; Grievance Official is the Administrator and or designee. The Grievance Official is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; leading any necessary investigation by the community; maintaining the confidentiality of all information associated with grievances; issuing written grievance decisions to the resident; and coordination with state and federal agencies as necessary in light of specific allegations; Prompt efforts to resolve include facility acknowledgement of a complaint and or grievance and actively working to resolve that complaint and or grievance. -Responsibility: It is the responsibility of the Grievance Official and all management staff to understand and enforce this policy; It is the responsibility of all employees to abide by this policy. -Resident rights: Residents have the right to voice a concern or grievance to the community or any other entity that hears grievances; A resident or family member should also report any grievances regarding retaliation or discrimination. The law prohibits owners, administrators, and staff of any long-term care facility from retaliating in any way when handling a resident concern. -Grievances: It is the policy of the facility to create an atmosphere in which its residents or family members feel free to voice concerns related to their care or living conditions without discrimination or reprisal (act of retaliation); Grievances are encouraged to be communicated to any staff member, an outside party, or the Grievance Official as soon as possible; Notification of dissatisfaction with resident care or service will be investigated promptly, corrective action will be taken where appropriate, and the results of the entire process including the details of the concern and actions taken, will be documented thoroughly and reported thorough the Quality Assessment and Performance Improvement (QAPI) Committee; -Procedure: A grievance may be filed: Completing the grievance form located in the designated areas in the facility by placing it in the grievance box and or submitting it to the Administrator; Anonymously in writing by placing in the grievance box or submitting a grievance via the facility compliance hotline; Reporting to facility staff; -Process: Grievances will be entered on a resident grievance report by the person receiving the report either on a paper or electronic submission and routed to the Grievance Official; Upon review of the grievance, the Grievance Official may initiate an investigation and route it to the appropriate department manager, if applicable, for follow up; Upon receiving the resident grievance, the supervisor or manager will gather pertinent documents and details for review; This includes contacting the resident or family to confirm previously provided information and to notify residents of their right to have assistance from an impartial non-affiliated advocate; The Grievance Official will review all information; Plans of action may require consultation with various management levels, depending on the nature of the concern and/or validation; A written response to the grievance may be requested from all staff members or physicians who were named in the grievance, staff members who witnessed the situation, or staff members who can provide additional information; The facility should make prompt efforts to resolve the grievance; The resident and/or responsible party has a right to obtain a written decision regarding his or her grievance; A monthly grievance log of resident concerns and actions taken will be maintained by the Grievance Official. Review of the Resident #9's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/30/25, showed:-The resident is cognitively intact;-The resident uses wheelchair and walker;-The resident is dependent on assistance from staff for toileting, hygiene, bathing, lower body dressing, putting on and taking off footwear;-The resident requires partial to moderate assistance from staff to sit to stand, chair to bed to chair transfers, toilet transfers, and walking 10 feet;-The resident is occasionally incontinent of bowel and bladder;-Diagnoses included: Urinary tract infection (UTI), arthritis, malnutrition (poor nutrition), tremors, vertigo (dizziness), repeated falls, age-related physical debility, difficulty in walking, cognitive communication deficit, dysphagia (difficulty swallowing). Review of the resident's care plan, in use while the resident was at the facility, showed:General information: Listen to the resident's perceptions of illness with understanding and empathy; Engage the resident and the resident's family in a discussion about expectations and goals for the resident's health. Review of the social service notes, showed:-On 8/1/25 at 1:08 P.M., Discharge planning narrative note; Concerns for resident falling due to water, a grape, and a smashed cracker on the floor; -On 8/1/25 at 2:32 P.M., Discharge planning narrative note; Concerns from resident's family member; Concerns for resident falling due to water on the floor, a grape on the floor and a smashed cracker on the floor; The resident waited in a brief for a long time and got up to change the brief by him/herself and ended up falling; The resident is not getting pain medications and the resident's mind is fluctuating; Concerns that staff did not follow up on the resident's recent fall; Concerns that staff are going to take it out on the resident because staff is upset that the resident's family member spoke up; The resident's family member said staff do not speak with him/her and no one greets him/her after the family member spoke up about his/her concerns; The family member doesn't want to get anyone in trouble and feels reluctant to report issues; The resident said he/she has been in bed for days and that he/she asked to get up and walk, and the nursing staff told the resident, No. There was a sarcastic jab made when the staff was placing the sign in the resident's room about falling; Staff threw crumbs away but it was actually a pill and a half of pain medication; The resident said he/she never saw a doctor and never got an x-ray when he/she fell. During an interview on 9/3/25 at 10:30 A.M., Social Worker (SW) B said the resident's family member voiced his/her concerns to him/her related to the resident's nursing care. SW B copied and pasted his/her entire note, dated 8/1/25, onto a Word document, printed it off and handed it to Nurse Manager (NM) A. SW B said he/she did not complete an official grievance form. He/She expected NM A to follow up with the resident's issues since they were all nursing care related. SW B did not know who the Grievance Official was for the facility. During interviews on 9/3/25 at 10:45 A.M. and 2:30 P.M., NM A said he/she wasn't sure if a list was provided to him/her by SW B. NM A could not locate the list in his/her office or on e-mail. The only concern that NM A was aware of was the resident's family member requested an x-ray after the resident's fall. NM A did not fill out a grievance form or address any other concerns besides the fall that were located in SW B's notes. NM A said he/she frequently had conversations with the resident and the resident's family member and verbally communicated to the resident and the resident's family member with any resolutions. All complaints and grievances should be addressed immediately if possible. NM A is familiar with the grievance form and said the Grievance Officer was the Administrator. During an interview on 9/4/25 at 11:33 A.M., Family Member C said he/she met with SW B and informed SW B of all the complaints he/she had about Resident #9's nursing care. SW B asked FM C if he/she would like to file an official complaint and FM C said, Yes. FM C said he/she never heard back from the facility about his/her complaints. FM C said he/she never spoke to NM A or anyone from the facility management team. FM C said he/she visited Resident #9 daily at the facility. When FM C was visiting Resident #9, he/she would also inform the nursing staff of nursing care issues but felt as though staff lacked empathy and attentiveness related to FM C's concerns. During interviews on 9/3/25 at 1:50 P.M. and 2:55 P.M., the Clinical Services Director said SW B is new to the facility and SW B had reached out to another Social Worker for direction related to Resident #9's family member's complaints. The family member's complaints were not placed on a formal grievance form. The resolution to the complaints relies on the form. Department heads are notified of grievances, and the Administrator, who is the Grievance Officer, is responsible to follow up with a resolution. She would expect staff to follow the facility grievance policy and its steps. 2585284

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure on-going resident centered therapeutic activities were provided to residents in the evenings and weekends as an integral part of their psychosocial well-being. In addition, the facility failed to ensure activities were offered to all residents who wished to attend (Residents #140, #155 and #99). This deficient practice had the potential to affect all residents in the facility who wished to attend activites. The sample size was 25. The census was 145 with 126 in certified beds.1. During an interview on 7/23/25 at 8:31 A.M., the administrator said the Garden Terrace activity's calendar was the main calendar used for all activities in the facility.
Review of the Garden Terrace Activity's Calendar, dated June 2025, showed:
-Monday through Friday, no activities offered after 2:30 P.M.;
-Saturdays, Catholic Mass at 10:30 A.M. in the chapel;
-Sundays, no activities offered.
Review of the Garden Terrace Activity's Calendar, dated July 2025, showed:
-Monday through Friday, no activities offered after 3:00 P.M.;
-Saturdays, Catholic Mass at 10:30 A.M., in the chapel;
-Sundays, no activities offered except for non-Denominational church service on 7/20/25 at 2:00 P.M.
2. Review of Resident #140's Activity's Evaluation, dated 6/9/25, showed:
-Activity Interest: BINGO, card games, hand crafts, sewing, social conversations with other residents.
Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/11/25, showed:
-Mild cognitive impairment;
-No behaviors;
-Very important for favorite activities and religious services;
-Diagnoses included high blood pressure, diabetes and paraplegia.
During an interview on 7/17/25 at approximately 12:00 P.M., the resident said he/she was admitted about a month ago for rehab. He/she was interested in participating in activities but was never offered any activities outside of physical therapy. He/She was interested in playing BINGO and socializing with other residents.
During an interview on 7/21/25 at 8:21 A.M., the resident said he/she was not offered activities over the weekend. If he/she had known there was a church service, he/she would have attended.
Observation on 7/21/25 at 2:17 P.M., showed residents played BINGO in the activity's room. Resident #140 was not present.
Observation and interview on 7/21/25 at 2:30 P.M., showed the resident sat in his/her wheelchair in his/her room and watched television. He/She said he/she did not know BINGO was going on at the present time and would have attended.
3. Review of Resident #155's medical record, showed:
-admitted [DATE];
-Diagnoses included stroke, osteoarthritis, high blood pressure and altered mental status.
Review of the resident's Activities Evaluation, dated 7/21/25, showed:
-Activity Interest: BINGO and card games, painting, low impact exercise, books;
-Activity Notes: He/she is a nice lady/man who can make his/her needs known.
During an interview on 7/17/25 at 11:30 A.M. and 7/18/25 at 1:02 P.M., the resident said he/she enjoyed playing bingo and other card games. He/She also enjoyed church services. He/she was interested in activities, but had not been offered activities, but did not want to get anyone in trouble for not offering.
During an interview on 7/21/25 at 8:17 A.M., the resident said he/she was not offered activities over the weekend. He/she did not know the facility had church services and would have enjoyed participating.
Observation on 7/21/25 at 2:17 P.M., showed residents played BINGO in the activity's room. Resident #155 was not present.
Observation on 7/21/25 at 2:28 P.M., showed the resident lay in bed.
4. Review of Resident #99's medical record showed:
-Active diagnoses including high blood pressure, bipolar disorder (a psychological illness that causes unusual shifts in mood) and chronic obstructive pulmonary disease (COPD, lung disease);
-Intact cognitive function.
Review of the resident's progress notes, showed a note from the Activities Department staff on 7/19/25 at 3:40 P.M., showed the resident had been interviewed concerning his/her lack of participation in facility activities, and the resident noted the lack of mentally stimulating activities. The resident noted he/she preferred math and science-based activities, and the facility did not seem to provide those types of activities.
During an observation and interview on 7/18/25 at 9:31 A.M., the resident said he/she was admitted to the facility a couple years ago and was happy with care provided by the facility, but the facility did not have activities that felt stimulating to him/her. He/She enjoys math and science, and most of the activities are pretty simple. He/She was not aware of any specific activity plan set up for him/her by the activity department but had never been asked to participate in setting one up.
During interview on 7/23/25 at 9:10 A.M., Certified Nursing Assistant (CNA) B said the resident does not often come out of his/her room during the day but is always pleasant with staff. When asked what type of activities the resident likes, CNA B said the resident liked coffee, and often asked for it in the afternoon, but was otherwise unaware of any activities the resident participated in. CNA B was unsure if the resident was on any 1-to-1 or resident-specific activities plan that may help develop activities the resident is interested in.
5. During a group interview on 7/21/25 at 1:04 P.M., six residents, whom the facility identified as alert and oriented, attended the group meeting. All six residents said activities were not offered during the weekends or in the evenings. The activities provided by the facility were good, but they wanted more. One resident said, we are bored on the weekends. All six residents said the facility could use activities on the weekends and during the evenings.
6. During an interview on 7/21/25 at 2:35 P.M., Activities Assistant A said there were four staff working in activities. At the moment, they did not have an Activity's Director. Activities staff worked Monday through Friday from 8:00 A.M. to 4:00 P.M. One staff will work the weekend, and they try to do activities during the weekend. Residents have expressed concern about the lack of activities during the weekend. During the weekend, CNAs were responsible for offering activities to residents. If they are busy with care, they may forget to offer activities. The residents were bored during the weekend.
7. During an interview on 7/23/25 at 11:38 A.M., the Administrator and Director of Nursing (DON) said residents should be offered activities. There should be on-going activities on the weekends and evenings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure two dependent residents received Activities of Daily Living (ADL) care (Residents #2 and #8). The sample was 25. The census was 145 with 126 in certified beds.Review of the facility's ADL care policy, dated October 2022, showed:-Purpose: To provide grooming and hygiene for each resident, assisting with bathing, dressing and elimination as needed;-Policy: It shall be the policy of the facility that each resident receives assistance with ADLs as needed throughout each day. Consideration will be given to making the experience as home-like and individual as possible;-Procedure: Give nail care as needed. Assist each resident with grooming. 1. Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/1/25, showed:-Diagnoses included anxiety and heart failure;-Cognitively intact;-Substantial/maximal assistance required for shower/bath;-Supervision or touch assistance required for personal hygiene. Review on 7/21/25, of the resident's July 2025 shower sheets, showed:-On 7/14/25 the resident received a bed bath;-No other shower sheets for July were provided. Review of the resident's care plan, in use at the time of the survey, showed:-Resident needs assistance with activities of daily living (ADL) care but can do some of his/her own with set up assistance;-Resident requires maximum assistance for dressing, grooming/hygiene. Observation on 7/17/25 at 10:30 A.M., showed the resident awake in his/her room and watching TV. The resident's nails appeared long and had dark matter under them. Observation and interview on 7/21/25 at 9:57 A.M., showed the resident's nails to be long with dark matter under them. The resident's left and right feet both had dry peeling skin on the soles and tops of the feet. The resident said staff had not cleaned or treated his/her feet recently. Observation on 7/22/25 at 12:47 P.M., showed the resident's nails to be long with matter under them. The resident's left and right feet both had dry peeling skin on the soles and tops of the feet. 2. Review of Resident #8's quarterly MDS, dated [DATE], showed:-Diagnoses included major depressive disorder, schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves), and epilepsy (seizure disorder);-Moderately impaired cognition;-Dependent for shower/bathe;-Substantial/maximal assistance required for personal hygiene. Review on 7/21/25, of the resident's July 2025 shower sheets, showed:-On 7/18/25, the resident received a bed bath and his/her hair was washed;-On 7/11/25, the resident refused a bath or shower. Review of the resident's care plan, in use at the time of the survey, showed:-Goal: Resident has a goal of maintaining my independence and have his/her needs met to his/her satisfaction with assistance;-Interventions: Resident requires extensive two-person assistance with transfers using a Hoyer lift (full body mechanical lift).-Resident requires extensive two-person assistance with dressing, toileting, grooming, bathing, and bed mobility. Observation and interview on 7/17/25 at 11:35 A.M., showed the resident in his/her bed awake. The resident's nails appeared long and jagged with dark matter under them. The resident's hair was oily and stringy. The resident had a patch of chin hair. He/She said he/she would like staff to assist him/her with cleaning his/her hands, washing his/her hair, and getting rid of the chin hair. Observation on 7/18/25 at 11:54 A.M., showed the resident in his/her room in bed. The resident's hands appeared dirty with matter on them and the resident's nails were dirty with matter under them. The resident had a patch of chin hair. Observation on 7/21/25 at 10:40 A.M., showed the resident awake in his/her bed after finishing breakfast. The resident's hands appeared dirty with food debris. The resident's nails had matter under them. Observation on 7/22/25 at 8:38 A.M., showed the resident awake in his/her bed after finishing breakfast. The resident's hands appeared dirty with food debris. The resident's nails had matter under them. At 12:49 P.M., the resident sat in his/her bed and ate his/her lunch with his/her hands. The resident's hands still had the dried food matter from his/her breakfast. 3. During an interview on 7/23/25 at 8:18 A.M., Licensed Practical Nurse (LPN) C said staff should wash resident's hands before and after meals. Certified Nursing Assistants (CNAs) should ensure residents are receiving nail care during showers. If a resident refuses care that should be documented on the shower sheet and the nurse should be informed so that staff can ask the resident again at a later time. Moisture lotion is used for Resident #2's feet. Residents should receive treatments even if they refuse a shower or bath. Nurses should inform the Director of Nursing (DON) if treatments are not working on dry skin. 4. During an interview on 7/23/25 at 8:40 A.M., the DON and Administrator said staff should ensure residents' hands are clean after they eat meals. They would expect nail care to be provided to residents as needed or during showers/baths. They would expect nursing staff to be asking residents if they want their facial hair shaved. They would expect staff to be using moisture lotion on residents if they have dry skin and to inform the DON if the treatment is not working.

Based on observation, interview and record review, the facility failed to ensure an acceptable skin management program was maintained to prevent pressure injury development and to report changes timely to the physician. The facility failed to complete wound assessments, including assessment and documentation of the location, stage, size, wound characteristics, periwound (the area around the wound) and wound edge description for two residents. (Residents #1 and #2). In addition, the facility failed to follow their policy for wound photographs and measurements for three residents (Resident #1, #2, and #3). The facility failed to contact Resident #1's physician prior to entering an order for a treatment. Additionally, the facility failed to follow their policy and complete a Situation, Background, Assessment, and Recommendation (SBAR) when new and/or worsening wounds were observed and failed to notify the physician and family for three residents (Resident #1, #2, and #3). Resident #1's pressure ulcer worsened, developing drainage and a foul odor. The resident required emergency surgery and was diagnosed with sepsis. Treatment orders were not followed for two of four sampled residents (Residents #1 and #2). The sample was 4. The census was 151.
The Administrator was notified on 4/9/25 of an Immediate Jeopardy (IJ), which began on 3/29/25. The IJ was removed on 4/9/25 as confirmed by surveyor on-site verification.
Review of the facility's policy, Wounds: Treatment of Pressure and Non-Pressure Injuries, including Staging and Documentation, revised 10/23, showed:
-Purpose: To provide guidelines for use in wound assessment, treatment, and documentation;
-Responsibility: It is the responsibility of the Director of Nursing (DON) to oversee this policy and procedure;
-Policy: The facility Wound Product Selection Guide will be used as guidelines to determine appropriate treatments. A physician's order is required for all wound treatment;
-A. General Principles of Wound Care:
-1. Before choosing an intervention or treatment for a wound, it is important to identify the type of wound. Review the following documentation (attached) to determine the wound type and treatment protocol:
-Pressure Injuries;
-2. Keep the wound clean. Cleanse with wound cleanser or normal saline. Wound cleanser is preferable since it has the necessary pressure (8 pounds per square inch (psi)) to cleanse the wound properly. Use of betadine or hydrogen peroxide on open wounds is not recommended as they have been shown to be toxic to wound tissue;
-3. For dry wounds add moisture and for wet wounds add absorbent dressing;
-4. Protect the wound with appropriate dressing (See attached facility Health Group Wound Product Selection Guide. If the integrity of the dressing is compromised either by
drainage/exudates or movement, it should be changed;
-5. Maceration (softening and breakdown of skin tissue due to prolonged exposure to moisture) - Protect peri wound with products that prevent moisture to wound edges such as skin prep, cavilon, zinc oxide. Refer to facility formulary;
-6. Interventions should be taken to reduce edema and pressure related to the wound such as offloading heels and repositioning;
-7. Individualize turning schedule;
-8. Evaluate mattress type and add specialized mattress if indicated. Refer to Support Surfaces Algorithm;
-B. Assessment/Documentation:
-1. Any wound is to be assessed by a licensed nurse or licensed practitioner. The location, stage, size, odor, undermining (separation of wound edges from the surrounding healthy tissue, creating a space or pocket under the wound surface), tunneling (channel or passageway that extends from a wound or ulcer deep into the underlying tissues), exudates (fluid that leaks out of blood vessels into nearby tissues), necrotic tissue (tissue that is dead or dying), and presence of absence of granulation tissue (tissue that forms during the wound healing process), peri-wound and wound edge description should be noted and documented in the resident's medical record at least weekly. Wound assessment documentation should be completed for pressure Injuries and recommended for any other skin issues of concern;
-a. Location: Describe the precise location of the wound in anatomical terms;
-b. Staging: (Pressure Injuries):
-1. Suspected Deep Tissue Injury (DTI): Persistent non-blanchable (skin condition where redness or discoloration does not fade or disappear when pressed upon) deep red, maroon, or purple discoloration. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss. If necrotic (tissue that is dead or dying) tissue, subcutaneous (area below the skin) tissue, granulation (process of forming new tissue and blood vessels as part of the healing process of a wound) tissue, fascia (connective tissue that surrounds and connects various structures within the body, including muscles, bones, nerves, and organs), muscle, or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable (Slough (dead tissue) is present, the actual base and condition of the ulcer cannot be determined), Stage 3 (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) or Stage 4 (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (thick, dry, and leathery crust of dead tissue that forms over a wound or burn. It is typically black, brown, or gray in color) may be present on some parts of the wound bed. Often includes undermining or tunneling.). Do not use deep tissue pressure injury to describe vascular, traumatic, neuropathic, or dermatologic conditions;
-2. Stage 1 Pressure injury: Non-blanchable erythema of intact skin. Intact skin with a localized area of non-blanchable redness which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature or firmness may precede visual changes. Color changes do not include purple or maroon discoloration as these may indicate deep tissue pressure injury;
-3. Stage 2 Pressure Injury: Partial thickness skin loss with exposed dermis. The wound bed is viable, pink, red, moist and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough (dead tissue, typically appearing as a yellow, tan, or white fibrous material, that may be present in a wound bed) and eschar are not present. These injuries commonly result from adverse microclimate (specific climatic conditions, including temperature, humidity, and airflow, immediately surrounding the skin's surface) and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), This stage should not be used to describe skin tears, tape burns, abrasions, perinea I dermatitis (inflammation of the skin in the perineal area, the region between the anus and genitals), maceration, or excoriation (abrasion or wearing away of the skin's surface, resulting in raw, irritated, or red patches);
-4. Stage 3 Pressure Injury: Full thickness tissue loss. Full-thickness loss of skin in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity (having excess body fat or being obese) can develop deep wounds. The bridge of the nose, ear, occipital (posterior, or back, region of the head) and malleolus (bony protuberance (bulge, lump, or projection on a body surface) on either side of the ankle joint) do not have subcutaneous tissue and Stage 3 Injuries can be shallow. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury;
-5. Stage 4 Pressure Injury: Full thickness skin and tissue loss. Full-thickness skin and tissue loss with exposed or directly palpable (capable of being felt by touch) fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury;
-6. Unstageable Pressure Injury: Visualization of the wound bed is necessary for accurate staging. Full thickness tissue loss in which the base of the injury is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. However, stable (dry, adherent, intact without erythema or fluctuance (wave-like sensation or movement that is felt when palpating (examining by touch) a fluid-filled area of the body)) eschar on the heels serves as the body's natural (biological) cover and should not be softened or removed;
-c. Size:
-Measure the wound in centimeters (cm) including the length, width, and depth. Measure wound from healed margins to healed margins vs. edge to edge. Use clock coordinates when measuring depth with 12 o'clock representing toward the head.
Using clock coordinates measure and document any tunneling or undermining using a cotton tip applicator. Tunneling is a passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound. Undermining is the destruction of tissue or injury extending under the skin edges (margins) so that the pressure injury is larger at its base than at the skin surface;
-d. Odor: Describe the odor of the wound as none, mild, or foul (after cleaning);
-e. Color: Describe the color of the involved area. Note options for documentation here include describing the wound bed (including granulation tissue, slough, or eschar) in terms of color such as pink, red, yellow, white, black, or brown and estimate percentage of colors;
-f. Surrounding tissue (Periwound): Assess the surrounding tissue and document the involved areas i.e., inflammation, maceration or wet wound edges, tenderness, warm or cool to touch, skin turgor, hypertrophic (abnormally enlarged)/callused/thickened, or any other finding;
-g. Drainage: Describe the type, amount, and color of the drainage (exudates). Examples: yellowish green, gray, serosanguinous (fluid that contains both serum (clear, watery part of blood) and blood typically appears as a pinkish-red or yellowish fluid), etc.-amount: zero, small, moderate, and large;
-h. Pain: Describe pain related to the wound and incorporate interventions to reduce pain in the care plan. Document interventions and outcomes in the medical record.
-C. Monitoring of Wounds: Weekly wound rounds will be made by the DON or designee to assess all wounds (Pressure and Non-Pressure Injuries);
-Monitor wounds for signs and symptoms of infection such as purulent (containing or producing pus) exudates, peri-wound warmth, swelling, induration, or erythema (erythema may not be easily determined in residents with dark skin pigmentation), increased pain or tenderness around the site or delayed wound healing. Findings such as elevated white blood cell (WBC), bacteremia, sepsis, or fever may signal an infection related to a pressure injury area or co-existing infection from a different source.
-If any of the above symptoms develop, intervene appropriately, including notification of the physician and obtaining orders. Update the Plan of Care as appropriate;
-If the wound fails to show some evidence of progress toward healing within 2 weeks, the wound and the resident's overall clinical condition should be reassessed, and the treatment plan reevaluated. The decision to change, modify or remain with the same treatment plan should be documented. Rationale for continuing with the same treatment should be well documented;
-When a wound is present monitoring should include the following:
-An evaluation of the injury if no dressing is present:
-An evaluation of the status of the dressing, if present (whether it is intact, if there is drainage, is it or is it not leaking). If the dressing is leaking, it must be changed;
-The condition of the area surrounding the injury can be observed without removing the dressing;
-The presence of complications, such as signs of increasing area of ulceration or soft tissue infection, increased redness or swelling around the wound or increased drainage from the wound;
-If pain is present, and if so, assess it is being adequately controlled;
-See Assessment section of this policy and procedure regarding weekly assessment and documentation;
-Although the above information refers to pressure injury monitoring, the same should apply for all wounds, including heels with eschar;
-In addition, it is recommended monitoring be completed on all healed wound sites and documented weekly during skin assessments. Remember that the skin of healed
wounds and surrounding area are always more susceptible to breaking down again;
-Based on assessment, the resident's clinical condition, choices and identified needs, basic or routine care should include:
-Turning and positioning, protecting heels;
-Keep clean and dry;
-Provide appropriate support surface;
-Monitor and maintain nutrition and hydration status, where feasible;
-Evaluate drug regimen;
-Incorporate interventions into Plan of Care and revise as condition of the resident indicates;
-F. Documentation:
-It is critical that all caregivers document their observations and activities. For example, CNAs are critical to the process by reporting abnormal skin observations, documenting nutrition and hydration aspects, turning and positioning, peri-care, etc.;
-Nurses also have a variety of documentation responsibilities as indicated throughout and are critical to the process of documenting interventions that have been taken to avoid pressure injuries;
-G. Use of Wound photography: Photography will include wounds that are pressure injuries, arterial or venous wounds.
-Wound photographs will be taken upon admission or readmission to the community, weekly, upon discovery, as needed and upon discharge;
Review of the facility's policy, Skin integrity, Assessment and Prevention of Wounds/Other Skin Conditions, revised 9/22, showed:
-Purpose: To prevent avoidable skin breakdown and pressure injuries, provide guidelines for the treatment of impaired skin and guidelines for documentation;
-Policy: All residents will be assessed for the risk of skin breakdown. Risk factors identified will be evaluated. Interventions will be developed and implemented to minimize or stabilize the risk. Interventions will be care planned;
-I. Assessment:
-A. The admitting nurse will complete a head to toe skin assessment (body check) and risk assessment (Braden Score) to determine the absence, presence, any existing skin impairment or risk for skin impairment and document accordingly. If there, are existing impairments, implement appropriate interventions, including notification of the physician and obtaining treatment orders. If there are no existing impairments, document there are none;
-B. For residents who do not already have skin impairment, utilize the Braden score and the Pressure Injury Prevention Points from the National Pressure Injury Advisory Panel (NPIAP) to assist in identification of preventative measures;
-Document these measures on the residents care plan:
-Severe risk: Braden of less than 9;
-High risk: Braden of 10-12;
-Moderate Risk: Braden of 13-14;
-Mild Risk: Braden of 15-18;
-C. The Braden Scale is to be completed:
-On admission;
-Weekly for the first four weeks after admission;
-Quarterly;
-Significant change in condition;
-II. Prevention: The following are guidelines, which should be implemented based on medical history and physical assessment using an interdisciplinary team approach. Note: On admission, the facility Skin Prevention Protocol will be implemented if ordered by the physician;
-A. Residents at risk should be monitored, paying particular attention to bony prominences and pressure caused by ill-fitting shoes or medical devices such as splints, braces, casts, compression stockings, oxygen cannulas, pommel cushions, etc. certified nurse aide (CNA) will report any abnormal findings to a nurse. Some examples of reportable observations are:
-Reddened skin;
-Blanching (skin turns pale or white when pressure is applied, and then returns to its normal color when the pressure is released);
-Bluish or purple skin mark;
-Black or red heel;
-Rashes;
-Swelling or change in skin temperature;
-Denuded (worn away) or raw skin;
-Skin tears;
-Pain;
-Other unusual conditions;
-Abnormal findings will be assessed by a licensed nurse and appropriate interventions and documentation completed by that nurse;
-D. Using results of the most recent risk assessment, implement the following interventions:
-1. Sensory/Perception:
-If the resident has sensory perception/cognition impairment, pay particular attention to any moaning or signs of restlessness. Change of position on a routine schedule will reduce pressure and aid in providing comfort. An individualized turning/positioning schedule is advised and must be communicated to the CNA;
-Encourage the cognitive resident to change positions frequently if able to do independently and/or alert staff immediately if he/she has incontinent episodes or needs assistance to change position;
-2. Moisture:
-Minimize skin exposure to moisture, including urine and feces;
-Keep residents clean and dry. Establish a bowel and bladder program, when appropriate;
-Cleanse perineal area with perineal wash after each incontinent episode per facility protocol. Perineal wash is preferable to soap and water; if soap and water are used, gently rinse well and pat dry. Avoid using hot water;
-Apply moisture barrier product to exposed skin surfaces to provide protection from future incontinent episodes;
-3. Activity and Mobility:
-Note any limitations in mobility or activity;
-For limited mobility, implement the following;
-a. For bed and chair bound residents turning and repositioning and the use of support surfaces should be individualized (refer to the Support Surfaces Algorithm);
-e. Avoid positioning the resident on bony prominences;
-4. Pressure Reduction:
-Appropriate pressure reducing positioning devices should be used;
-Special attention should be given to heels, ankles, and between bony prominences (knees, ankles, etc.) as well as to the coccyx;
-Heels should be elevated off the bed surface. Example: Place a pillow under the legs and knees and calves. Heels are then suspended or floating off the end of the pillow. Heel lift devices may also be used;
&nbs

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify three residents physician and the representative/appropriate family member after the residents had a change in condition (Resident #1, #2, and #3). The sample was 4. The census was 151.
Review of the facility's policy, Reporting of Condition Changes, incidents and injuries, revised 1/23, showed:
-Purpose: To provide an orderly process for reporting changes in condition, incident or injuries involving residents;
-Responsibility: It will be the responsibility of the licensed nurses to know and follow this policy;
-Policy: It is the facility policy to report condition changes, incidents or injuries involving residents;
-Practice: When reporting changes in condition or incidents, the following procedure should be followed:
-1. Evaluate symptoms and/or injury. Complete overall head to toe assessment including taking vital signs, temperature and neuro checks as indicated. Document assessment and findings on SBAR (communication tool- Situation, Background, Assessment, Recommendation);
-3. Serious incidents, i.e., fractures, head injuries, uncontrolled bleeding or acute changes in resident conditions are reported to the physician at the time of occurrence. Be prepared, such as using SBAR format, to report to the physician results of the assessment, including pertinent information relative to items such as medications, lab results, etc. Per individual physician's order, any non-emergent issues may be reported to the physician at a later time, such as the next business day, if so specified within their order;
-5. The resident representative/appropriate family member should be notified of any change in physician orders, including a change in diet, medications, treatments, etc.;
-Documentation:
-1. If an incident occurred, chart the incident in the resident's medical record;
-2. Document objective details of incident and nursing interventions/corrective measures taken;
-4. All charting should include notification of doctor and resident representative/appropriate family member.
1. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/14/25, showed:
-admission date: 3/7/25;
-Severe cognitive impairment;
-Diagnoses included high blood pressure, weakness, acute kidney injury, and altered mental status.
Review of the resident's face sheet, showed:
-Emergency contact and next of kin (NOK) contact information including phone numbers.
Review of the resident's skin assessment, dated 3/8/25 at 10:38 A.M., showed the coccyx (small triangular bone at the base of the spinal column) with erythema (redness of the skin).
Review of the resident's medical record, dated 3/8/25, showed no notification to the physician or family member.
Review of the resident's skin assessment, dated 3/13/25 at 12:49 P.M., showed the coccyx with pressure ulcer and blister to right heel.
Review of the resident's medical record, dated 3/13/25, showed no notification to the physician or the family regarding coccyx pressure ulcer.
Review of the resident's physician orders, dated 3/13/25 at 8:00 A.M., showed:
-Pressure ulcer, coccyx, BID (twice a day), clean with soap water, apply Calvida (treats discomfort associated with wet skin, urine, and stool), BID and as needed (PRN) for soiling;
-Blister, heel, right, BID, skin prep BID to heel. Please float (elevating the foot off the bed reducing or eliminating pressure on the heel to promote healing and protect from injury) heels at all times.
During an interview on 4/9/25 at 10:19 A.M., Registered Nurse (RN) D said the SBAR he/she filled out for the resident on 3/13/25 listed the coccyx at the beginning of the SBAR, but in the appearance and evaluation findings, he/she only listed the finding of the blister to right heel and orders for skin prep BID to the right heel. RN D said he/she spoke to the Nurse Practitioner (NP) about the right heel. He/she stated the Nurse Manager (NM) was aware of the coccyx wound, and he/she asked RN D put in the order for the coccyx. RN D put the order in for BID so the nurses would look at the coccyx twice a day. RN D did not speak to a physician prior to entering the order for the coccyx.
Review of the eKare (a mobile wound measurement and documentation system collecting information at the point of care and supporting the management of wounds) wound assessment, coccyx pressure ulcer measurements, dated 3/26/25, showed:
-Wound 2: Coccyx:
-Etiology: Pressure injury: Stage 1 (Non-blanchable erythema of intact skin. Intact skin with a localized area of non-blanchable redness);
-Onset date: 3/26/25;
-Measurements: 4.5 centimeters (cm) x 2.4 cm x 0.6 cm;
-Color: Red (R, granulated tissue, tissue that forms during the healing process of wounds): 29%, Yellow (Y, slough, yellow, tan, gray, green or brown): 43%, Black (B, eschar (thick, dry, and leathery crust of dead tissue that forms over a wound or burn. It is typically black, brown, or gray in color)): 28%;
-Wound 3: Right buttock:
-Etiology: Pressure injury: Stage 1;
-Onset date: 3/26/25.
Review of the eKare wound assessment, right buttock pressure ulcer measurements, dated 3/29/25 at 11:10 A.M., showed:
-Wound 2: Coccyx (photo and measurements are of right buttocks):
-Measurements: 4.0 X 3.0 X 0.3 cm;
-Drainage: Minimum: Clear, thin watery (serous);
-Odor: Malodorous (unpleasant smell)
Review of the resident's medical record, dated 3/29/25, showed no notification to the physician or family.
During an interview on 4/4/25 at 2:24 P.M., Licensed Practical Nurse (LPN) B said he/she worked on 3/30/25. He/She applied Calvida around the foam dressing. The resident had drainage and a foul odor. He/She did not contact the physician.
2. Review of Resident #2's admission MDS, dated [DATE], showed:
-admission date: 2/20/25;
-Moderate cognitive impairment;
-Diagnoses included high blood pressure, hemiplegia (paralysis of one side of the body) or hemiparesis (weakness or paralysis on one side of the body), peripheral vascular disease (PVD, blood vessels outside the heart and brain narrow, become blocked, or spasm) or peripheral arterial disease (PAD, arteries in the arms and legs narrow due to the buildup of plaque, on the artery walls) and diabetes mellitus.
Review of the resident's face sheet, showed:
-Emergency contact and NOK contact information including phone numbers.
Review of the resident's eKare Wound assessment reports, dated 3/3/25 - 3/11/25, showed:
Wound 3: Left buttocks:
-Etiology: Pressure injury, stage 1;
-Onset date: 3/11/25;
-Assessment: No odor or drainage;
-Stage 2 (Partial thickness skin loss with exposed dermis. The wound bed is viable, pink, red, moist and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough (dead tissue, typically appearing as a yellow, tan, or white fibrous material, that may be present in a wound bed) and eschar are not present);
-Measurements: 3.7 cm x 2.3 cm x 0.1 cm.
Review of resident's medical record showed no notification to the physician or family completed for Wound #3 that was identified on 3/11/25.
Review of the resident's eKare Wound assessment reports, dated 3/18/25, showed:
-Wound #4: Right heel, calcaneus (heel);
-Etiology: Pressure injury, stage 1;
-Onset date: 3/11/25;
-Last assessment date: 3/18/25;
-Assessment:
-No odor;
-Drainage minimum: Clear, thin, watery (serous);
-Stage 2;
-Measurements: 7.3 cm x 6.8 cm x 1.0 cm;
-Wound #5: Left heel, calcaneus;
-Etiology: Pressure injury, stage 1;
-Onset date: 3/18/25;
-Assessment: No odor or drainage;
-Stage 2;
-Measurements: 7.0 cm x 6.4 cm x 0.6 cm;
Review of resident's medical record showed no notification to physician or family completed for Wound #4 and Wound #5 that were identified on 3/18/25.
3. Review of Resident #3's admission MDS, dated [DATE], showed:
-admission date: 3/7/25;
-Cognitively intact.
Review of the resident's face sheet, showed:
-Emergency contact and NOK contact information including phone numbers.
Review of the resident's eKare wound assessment, dated 3/10/25, showed:
-Wound #5: Coccyx:
-Etiology: Pressure injury: Stage 1;
-Onset date: 3/10/25;
-Measurements: 3.7 cm x 6.0 cm x 0.1 cm.
Review of the resident's medical record, dated 3/10/25, showed no notification to the physician or family.
Review of the resident's medical record, showed:
-3/11/25 at 4:26 P.M.:
-Skin abnormalities general: None;
-3/19/25 at 1:32 P.M.:
-Skin integrity general: Intact;
-Skin abnormalities general comment: reddened buttocks;
Review of the resident's medical record, dated 3/19/25, showed no notification to the physician or family.
4. During an interview on 4/3/25 at 10:14 A.M., LPN E said if a resident has a new or worsening wound, he/she notifies the nurse manager (NM) and she will look at the wound and take photos of the wound. The NM then notifies the wound physician (WP) and/or the physician. Changes are documented on the SBAR and the nurse or the NM will complete the SBAR. LPN E said on the weekends, the nurse on the floor is responsible for making notifications and documenting any changes but during the week, the nurse manager takes care of it.
During an interview on 4/3/25 at 9:41 A.M., the NM said she is responsible for the weekly wound report for her floor. While rounding with the wound physician, if a resident has a decline in a wound, he/she does not call and inform the resident's family. If an order is changed for a wound, he/she does not call and notify the resident's family. With new admissions and new consults, he/she contacts the wound physician so she can start to follow the resident. On 4/3/25 at 2:19 P.M., the NM said if a resident has a new or worsening wound, the CNA reports it to the nurse. The nurse completes an assessment, fills out an SBAR and is responsible for notification to the physician and family.
During an interview on 4/9/25 at 8:37 A.M., the Administrator and Director of Nurses said they expected staff to notify the physician and family if a resident has a new or worsening wound and for it to be documented in an SBAR. They expected the physician to be notified if a treatment needed to be changed because that is a change in condition and an SBAR should be completed. They expected staff to be knowledgeable of and follow the facility's policy and procedures.
MO00252102
MO00252195

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement an effective discharge planning process that focused on the resident's discharge goals and needs, desire to be discharged , the resident's capacity for discharge, including caregiver support availability, capacity, and capability to perform required care, and failed to involve the resident, family member, and the interdisciplinary team (IDT) in developing a discharge plan, with interventions to meet the resident's discharge goals and needs to ensure a smooth and safe transition to the post-discharge setting and reduce factors leading to preventable readmissions. The facility failed to document and include the evaluation of the resident's discharge needs and failed to discuss the results of the evaluation with the resident and family, and incorporate it into the discharge plan, which is a part of the comprehensive care plan. The facility failed to discuss with the resident, and the family member, and document the implications and/or risks of being discharged to a location that is not equipped to meet the resident's needs and attempt to ascertain why the resident chose to return home, failed to document that other, more suitable, options of locations that are equipped to meet the needs of the resident were presented and discussed, failed to document that despite being offered other options that could meet the resident's needs, the resident refused those other more appropriate settings, and failed to determine if a referral to Adult Protective Services or other state entity charged with investigating abuse and neglect is necessary. The facility failed to identify changes in the resident's conditions, which impacted the discharge plan, and warranted revisions to interventions. The facility failed to identify post-discharge needs for nursing services for wound care, possible modifications to the home, and activities of daily living (ADL) assistance. The resident was discharged to home, alone, without required home health care services, and without education or instructions of how to care for the coccyx/sacral wound. Five residents were sampled, and problems were identified with one (Resident #5). The census was 149.
Review of the facility's policy for Discharge of a Resident, affecting the Social Services Department, revised 7/2022, showed:
-Purpose: A recapitulation of the resident's stay at the facility will be part of the permanent medical record when the resident is discharged from the facility;
-Responsibility: It is the responsibility of the assigned Social Worker to document a discharge summary;
-Policy: A discharge summary must be documented for a resident that discharges without an anticipated return to the facility;
-Practice:
-The discharge summary will include but is not limited to the following:
-Statement of reason for admission to the facility;
-Reason for discharge;
-Psychosocial concerns or special arrangements regarding the resident's condition;
-Resident's response to the discharge plan;
-Resident/family involvement, including any advance notice of the discharge and notification of the right to appeal a Medicare or Medicare Advantage discharge;
-Date and time for the discharge;
-Discharge destination and transportation arrangements;
-The discharge summary is a permanent part of the medical record.
Review of the facility policy's for Discharge/Transfer of a Resident, revised 12/2022, showed:
-Purpose: To provide guidelines when discharging or transferring a resident to another health care residence, another bed within the residence, or when leaving against medical advice;
-Responsibility: It is the responsibility of all departments to see that the resident's transfer/discharge plans are complete and appropriate. For residents who receive care covered by Medicare A, it is their responsibility to see that the resident has utilized his/her Medicare A benefits to the fullest within the guidelines established by CMS;
-Policy: Bethesda communities comply with federal regulations to permit each resident to remain in the community, and not transfer or discharge the resident unless the transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the community;
-Non-emergency discharges, initiated by the community, return not anticipated:
-Document the reasons for the transfer or discharge in the resident's medical record, and in the case of necessity for the resident's welfare and the resident's needs cannot be met in the community;
-Contents of the transfer/discharge notice must include:
-The reason for transfer or discharge;
-The effective date of transfer or discharge;
-The location to which the resident is transferred or discharged ;
-An explanation of the right to appeal the transfer or discharge;
-Orientation for transfer or discharge must be provided in a form and manner that the resident can understand and documented to see that a safe and orderly transfer is affected;
-Assist with transportation arrangements and any other arrangements as needed;
-Assist with any appeals as desired by the resident;
-When a resident exercises his or her right to appeal a transfer or discharge, the facility will not transfer or discharge the resident while the appeal is pending, unless the failure to discharge or transfer would be endangering the health or safety of the resident or other individuals in the facility;
-The physician shall document medical reasons for transfer or discharge in the medical record, when the reason for transfer or discharge is for any reason other than nonpayment of the stay or the community ceasing to operate;
-Anticipated Discharges:
-Obtain physicians' orders for discharge and instructions or precautions for ongoing care;
-A member of the interdisciplinary team completes relevant sections of the Discharge Summary;
-The nurse caring for the resident at the time of discharge is responsible for seeing that the Discharge Summary is complete;
-A recap of the resident's stay that includes the diagnosis, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results;
-A final summary of the resident's status;
-Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over the counter);
-A post-discharge plan of care that is developed with the participation of the resident to adjust to his or her new living environment;
-Education for discharge must be provided and documented to see that a safe and orderly transfer occurs, in a form and manner that the resident can understand. Depending on the circumstances, this education may be provided by various members of the interdisciplinary team;
-The nurse/designee will assist with transportation arrangements and any other arrangements as needed;
-The comprehensive, person-centered care plan shall contain the resident's goals for admission and desired outcomes and shall be in alignment with the discharge;
-Specific to rehabilitation and therapy center for discharge to home or another facility:
-Discharge planning will be established and discussed through the Utilization Review meeting and the discharge date established when the report indicates plateauing and/or the resident has met goals;
-If necessary, rehabilitation services will make a home visit prior to discharge to assess physical environment, making recommendations as necessary;
-Once the resident has utilized his/her Medicare A benefits to the fullest within the guidelines established by CMS, it is the responsibility of the discharging residence to notify the resident of the determination of discharge in writing, within 48 hours prior to discharge, that the resident has met his/her established rehabilitative goals and/or that the qualifying medical necessity for a skilled stay in a Medicare A bed has been met or exhausted and the need for discharge planning is eminent;
-The Social Service Staff/Designee will obtain the signature of the resident/resident representative on the notice as stated above;
-The residence will keep the copy of the notice in the medical record in the Social Services section;
-The resident/resident representative will be given the original notice;
-The Social Worker will consult with resident/resident representative regarding discharge plans and their choice of Home Health Care and durable medical equipment (DME) provider and alert the IDT to upcoming discharge via email;
-Nursing will obtain physician orders including any Home Health Care, DME providers or equipment, and medications to be sent home with resident;
-Social Services will send a Discharge Notification letter with attached discharge orders to the resident's Primary Care Physician via fax, mail, or electronically;
-A copy of the Discharge Notification letter and the fax confirmation, if applicable, will be placed in the medical record;
-Day of discharge:
-Nursing will assist to pack belongings (reference Inventory sheet to be sure all belongings are sent with the resident);
-Nursing will send medications with the resident per contract pharmacy policy and procedures;
-Complete the discharged Resident Medication Transfer Record. Print only the necessary discharge
information. Have resident/resident representative sign the form. Make a copy of the form and give the original to the resident;
-Fax the signed discharged Resident Medication Transfer Record to the pharmacy. Place the copy and fax confirmation in the medical record;
-Nursing will prepare resident for discharge;
-Nursing will complete a Discharge/Transfer progress note, complete and print Discharge Instructions, and have the resident/resident representative sign and date the Discharge Instruction sheet and receive a copy;
Discharge to home:
-Social Worker will consult with Resident/Resident Representative regarding discharge plans and choice of home health care and DME provider that is certified;
-Nursing will obtain a physician order including any home health care of DME and medications to be sent home with resident. Nursing will notify Social Services that the discharge order has been obtained;
-Nursing will obtain order from physician;
-Social Worker will arrange/assist with transportation as necessary;
-Social Services and Nursing will provide pertinent medical information.
Review of the facility's policy for Return to Home, affecting all Nursing, Social Service, and Rehabilitation (Rehab) Staff, revised 5/2023, showed:
-Purpose: All residents returning home from The Rehab and Therapy Center should be at the highest possible level of function in order to promote a safe return home and reduce the risk of injury or re-hospitalization;
-Responsibility: It is the responsibility of all Nursing, Social Service, Dietary and Rehab staff to promote that all residents achieve their maximum level of function prior to discharge from the Rehab and Therapy Center;
-Policy: All residents will be observed for a designated amount of time prior to discharge from the Rehab and Therapy Center to a home setting to see that they are able to function at and maintain the highest level of independence that they achieved during their rehab stay;
-Practice:
-Within one week of admission, the Interdisciplinary team will set care plan goals with resident and/or family based upon their prior level of function;
-Interventions will be implemented by IDT members to help resident achieve these goals during their stay;
-It is communicated to the resident and their family, that the resident will be observed for a designated period of time to monitor they are safe to return home;
-Therapy will provide Nursing with recommendations that indicate what ADLs the resident is able to perform independently and what ADLs the resident requires assistance with. Nursing will encourage the resident to
perform all ADLs as independently as possible and only provide assistance when necessary;
-The resident will be provided with the appropriate DME to use during their therapeutic stay, in order to achieve the highest level of independence, in the Rehab Center. However, DME brought from home is preferred if that is what the resident will be using upon return to home;
-The resident's room will be adapted to simulate the home setting as much as possible while maintaining safety. Example: the resident's bed will remain at the height of the bed at home;
-When it is determined that the resident has met all goals or plateaued in therapy and at their highest level of function, therapy will set a last covered day for therapy;
-An indicator will be placed next to the resident's name plate on the room to indicate that the resident is in the return to home phase of rehab. The return to home phase of rehab includes not only ADL independence
tasks but could include disease knowledge and management if applicable. The indicator will alert staff that the resident will be discharging soon and should be encouraged to be as independent and knowledgeable as possible to promote a safe return home. This will also be communicated to the resident and their caregivers;
-Nursing staff is responsible for documenting in the resident's medical record, their ability to perform ADL tasks to the highest level of function, the amount of assistance or cues required as well as education and response to learning as applicable;
-Nursing and Therapy staff will review documentation and residents level of function to verify that the resident is maintaining their highest level of function. If a decline is noted, discharge plan will be re-evaluated to see if additional services are required.
Review of Resident #5's undated facility face sheet (first page of a medical record with the resident's demographics, medical diagnoses, family contacts, and physician contacts) showed:
-No admission date;
-Diagnoses of:
-Diabetes mellitus with insulin use;
-Chronic (long-term/ongoing) congestive heart failure (CHF, heart unable to pump enough blood to meet the body's needs);
-Permanent atrial fibrillation (an arrhythmia/irregularity in heartbeat);
-Atherosclerotic heart disease (plaque buildup inside of arteries of the heart);
-Transient ischemic attack (TIA, a brief neurological dysfunction caused by blocked or reduced blood flow to a part of the brain);
-Cerebral infarction (stroke) without residual deficits;
-Major depressive disorder;
-Chronic kidney disease stage 3 (moderate kidney damage with loss of half the kidney's function, causing high blood pressure, anemia, and bone disease);
-Peripheral vascular disease (PVD, a narrowing of the blood vessels that restricts blood flow and mostly occurs in the legs);
-Hypothyroidism (low thyroid hormone production, resulting in slowing the speed of the life-sustaining chemical activity/metabolism of the body);
-Gastro-esophageal reflux disease (GERD, a digestive disorder that occurs when stomach acid flows back into the esophagus, also called acid reflux);
-Inappropriate diet and eating habits.
Review of the resident's undated Care of Resident Profile (CORP, plan of care) report, showed:
-Resident's goal was to return home after short term rehabilitation;
-Resident received significant medications: antidepressants, diuretic (water pill), antiplatelets (blood thinner), hypoglycemics (lower blood sugar) and anticonvulsants (prevent seizures);
-Required one person assistance with transfers, use of front wheeled walker with ambulation, bed mobility, bathing, grooming and dressing;
-Resident at risk for falls due to weakness:
-Ensure personal items are within reach;
-Make frequent rounds to ensure safety;
-Goal-To reduce the risk factors that contribute to fall risk and to minimize injury related to falls throughout this review period;
-Resident always wore protective briefs to protect clothing and dignity:
-Staff to assist with changing when soiled;
-Staff to assist with peri-care as needed and requested;
-Goal-To maintain the current level of continence, remain clean and dry, and minimize the risk of skin breakdown through this next review period;
-Resident required no assistance with eating and the goal was to improve/maintain current nutritional status:
-Was on a pureed diet (no reason for pureed diet given);
-Required encouragement to eat meals and drink fluids;
-Staff to monitor meal intake and report anything below 50% to the nurse;
-Resident was diabetic and required sliding scale insulin;
-Goal-To manage diabetes through good food choices and monitoring of blood sugar;
-Received a routine antidepressant, for diagnosis of depression:
-Staff to monitor for unwanted side effects such as mood swings, or aggressive behaviors;
-Goal-To maintain a stable mood with reduced anxiety and be free of unwanted side effects;
-Staff to check skin daily, during care, and inform the nurse of any skin issues:
-Staff to reposition frequently;
-Staff to let the nurse know if there were any new areas of redness or skin impairment;
-Standard pressure reducing mattress and wheelchair cushion in place;
-Goal-To reduce the risk factors that could contribute to skin impairment or optimize wound healing through next review period;
-Resident had a pressure wound on the coccyx (no date):
-Staff to monitor area for signs and symptoms of infection and alert the nurse of any changes;
-Staff to keep the dressing clean, dry, and intact;
-Staff to ensure the low air loss mattress (LAL, a medical-grade mattress that helps prevent and treat pressure ulcers by using air cells to distribute body weight and circulate air to keep skin dry) was working, before helping the resident into bed;
-The resident was at risk for bleeding due to anticoagulant use:
-Monitor for any signs of bleeding and notify my nurse immediately;
-Goal-To minimize my risk for bruising and bleeding related to these medications through the next review period;
-Resident was at risk for pain due to recent hospital stay:
-Resident had pain medication and non-pharmacological interventions to help relieve pain;
-Goal-To maintain a comfort level that does not interfere with ADLs through the next review period;
-Persons who participated in developing this plan: There were no electronic or handwritten signatures, signifying who or whom wrote this plan of care.
-No documentation of the resident's learning disability, due to a mild intellectual impairment, and no further documentation of detailed discharge planning.
Review of the resident's nurse admission electronic checklist assessment, dated 10/16/24, with no time of admission, showed:
-Living situation, listed as independent at home;
-No evident barriers to learning;
-Resident used wheelchair for mobility;
-Skin integrity, localized abnormality (no additional information provided);
-Preventative skin care, barrier cream (a topical product that creates a physical barrier between the skin and moisture/irritants from loss of bowel/bladder control);
-Edema location, generalized (generalized edema-fluid accumulates throughout the entire body);
-History of fall last three months;
-Weak gait (walk);
-Independent with ADLs, but required one person partial/moderate assistance to:
-Move from a bed to chair transfer;
-To go from lying to sitting on side of the bed;
-To go from sitting on side of the bed to lying;
-To safely move from a bed to chair transfer;
-To go from sitting to standing;
-Transfer on and off the toilet;
-To roll left to right in bed;
-Transfer in and out of a car;
-To pick up an object.
Review of the resident's Social Worker (SW) E note, dated 10/17/24 at 10:07 A.M., showed the SW was familiar with the resident as the resident was at the facility not long ago. The resident lived alone, and his/her goal was to return back home, once he/she was done with therapy.
Review of the resident's physician's assessment, dated 10/17/24 (no time), showed:
-The resident had a history of severe aortic valve stenosis (a heart valve disease that occurs when the aortic valve becomes so narrow that it cannot fully open, thereby reducing blood flow from the heart to the body), permanent atrial fibrillation, diabetes, and coronary artery disease (CAD, the coronary/heart arteries narrow or become blocked);
-The resident re-admitted to the hospital after a recent discharge to home, from rehabilitation services at the facility, because he/she fell the next day, on 10/12/24, at home;
-The resident was seen that morning, up in the chair, and the resident said he/she was not ready to go home (referring to his/her discharge from the facility to home on [DATE]), got dizzy and fell;
-Past medical history showed the resident had a learning disability, due to a mild intellectual impairment;
-Impression/Plan:
-Chronic coccygeal wound;
-Wound care team to follow while at facility.
Review of the resident's physiatry (specializing in maximizing physical function, through physical therapy, to foster independence and improve quality of life) Nurse Practitioner (NP) A history and physical evaluation, dated 10/17/24 at 8:53 A.M., showed:
-Chief complaint: Mobility deficit (a disability that limits a person's ability to move) and ADL deficits, secondary to frequent falls;
-The resident had been getting short of breath and dizzy and was hospitalized for falls;
-The hospital diagnosed the resident with CHF exacerbation (a worsening or flare-up of a pre-existing chronic condition), which was the likely cause of the resident's dizziness and shortness of breath;
-The resident had a [NAME] procedure (a minimally invasive surgery that implants a device in the heart to reduce the risk of stroke) for his/her diagnosis of atrial fibrillation;
-The resident reported a poor appetite and said he/she just wanted tomato soup;
-The resident lived in a home alone, with a Life Alert device (a device worn, with a button, that connects users to a monitoring center in the event of an emergency);
-Gait-Not attempted at this visit;
-The resident's assessment showed:
-ADL and mobility dysfunction, secondary to frequent falls;
-Deconditioning (the physical and mental changes that occur when someone is inactive for a period) and gait instability: The resident was at high risk for functional impairment without therapy;
-The resident's full physical and occupational therapy (OT) evaluations were still pending.
Review of NP A's history and physical evaluation, dated 10/24/24 at 8:31 A.M., showed:
-Chief complaint: Mobility deficit and ADL deficits, secondary to frequent falls;
-The resident returned from the hospital after having the transcatheter aortic valve replacement (TAVR, a minimally invasive procedure that replaces a diseased aortic valve with a man-made valve) and the hospital recommended the right groin site be watched;
-The resident's assessment showed:
-ADL dysfunction and mobility dysfunction secondary to frequent falls;
-Deconditioning and gait instability: The resident was at high risk for functional impairment without therapy;
-The resident's full physical and OT evaluations were still pending.
Review of the resident's physician order sheets (POS), no date, showed:
-For wound care Treatment Administration Record (TAR):
-10/24/24 at 8:38 P.M., pressure ulcer, buttock, foam dressing (a wound covering made of polyurethane or silicone foam that absorbs fluid, helps wounds heal, and are used to treat wounds with moderate to heavy
drainage), twice daily, peri-wash (a perineal cleanser), and cleanse with commercial wound cleanser, apply foam dressing twice daily, and as needed;
-10/24/24 at 8:44 P.M., pressure ulcer, coccyx, apply foam dressing, twice daily, peri-wash, and apply Calvida cream (a skin protectant/barrier cream with zinc oxide) twice daily, and as needed.
Review of the resident's physician's assessment, dated 10/25/24 (no time), showed:
-Primary diagnosis of aortic valve stenosis;
-The resident was seen that morning, after completion of TAVR;
-There were no reports of shortness of breath or dizziness since having the procedure;
-The resident asked for something for pruritus (itching/scratching your skin);
-Generalized excoriation (no locations given);
-No acute (new) concerns reported per the resident's nurse;
-Visit diagnoses:
-Debility and generalized weakness:
-Able to ambulate with the use of a walker without difficulty;
-Continue physical therapy (PT) and OT;
-Pruritus (no location given):
-New order given to nurse to start hydroxyzine (medication used as an antihistamine to stop itching and as a tranquilizer);
-Chronic coccygeal wound:
-Wound care team to follow while at facility.
Review of the resident's physician's assessment, dated 10/28/24 (no time), showed:
-Primary diagnosis of pruritus;
-The resident was in bed that morning, admitted to being tired, and not received his/her pruritus medication;
-The resident was ambulating well;
-Visit diagnoses:
-Debility and generalized weakness:
-Able to ambulate with the use of a walker without difficulty;
-Continue PT and OT;
-Pruritus (no location given):
-New order given to nurse to start hydroxyzine twice daily again, for three days, then change to as needed;
-Chronic coccygeal wound:
-Wound care team to follow while at f

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pressure ulcer treatments as ordered and failed to notify the physician when the ulcer developed drainage and a foul odor, shortly before the resident was discharged . The resident was discharged to home, alone, without home health registered nursing care services, and without education or instructions of how to care for the coccyx/sacral wound. Five residents were sampled, and problems were identified with one (Resident #5). The census was 149.
Review of the facility policy for Skin Integrity, Assessment, and Prevention of Wounds/Other Skin Conditions, revised on 9/2022, showed:
-Purpose:
-To prevent avoidable skin breakdown and pressure injuries;
-Provide guidelines for the treatment of impaired skin;
-Provide guidelines for documentation.
-Policy:
-All residents will be assessed for the risk of skin breakdown;
-Risk factors identified will be evaluated;
-Interventions will be developed and implemented to minimize or stabilize risk;
-Interventions will be care planned.
-Assessment:
-The admitting nurse will complete a head-to-toe skin assessment and Braden risk assessment (an assessment tool used to determine a resident's risk for developing pressure ulcers) to determine the absence, or presence, of any existing skin impairment or risk for skin impairment and document accordingly;
-If there are existing impairments, implement appropriate interventions, including notification of the physician and obtaining treatment orders;
-If there are no existing impairments, document there are none;
-For residents who do not already have skin impairment, utilize the Braden score to assist in identification of preventative measures;
-Document these measures on the resident's care plan;
-Severe risk: Braden of less than 9;
-High risk: Braden of 10-12;
-Moderate risk: Braden of 13-14;
-Mild risk: Braden of 15-18;
-The Braden Scale is to be completed:
-On admission;
-Weekly for the first four weeks after admission;
-Quarterly;
-Significant change in condition.
-Examples of other risk factors, which should be considered, are:
-Previous history of pressure injuries;
-Diagnoses such as diabetes, thyroid disease, congestive heart failure, peripheral vascular disease, and cardiovascular disease;
-Poor intake of protein;
-Resident's refusal of care and treatment.
-Prevention:
-Residents at risk should be monitored;
-An individualized turning and positioning schedule is advised and must be communicated to the Certified Nurse Assistant (CNA), to reduce pressure and aid in providing comfort;
-Keep residents clean and dry to minimize skin exposure to moisture from urine and feces;
-Apply a moisture barrier product to provide protection from incontinent episodes;
-Note any limitations in mobility or activity;
-For residents who are at severe risk, additional pressure reducing devices should be considered;
-For residents who are at severe risk, skin care preventative measures are in place, such as skin prep, Cavilon cream, or other protective ointment;
-Consult the dietitian for nutritional concerns;
-Offer supplemental nutrition such as fortified foods, vitamin and mineral supplements when applicable, and monitor, evaluate and document;
-CNA will report any abnormal findings to a nurse;
-Abnormal findings will be assessed by a licensed nurse and appropriate interventions and documentation completed by that nurse;
-All assessments, interventions, and outcomes must be documented in the medical record.
Review of the facility's policy for Treatment of Pressure and Non-Pressure Injuries, Staging and Documentation, revised on 10/2023, showed:
-Purpose: To provide guidelines for use in wound assessment, treatment, and documentation.
-Policy:
-The Wound Product Selection Guide will be used as guidelines to determine appropriate treatments;
-A physician's order is required for all wound treatment.
-Practice:
-General Principles of Wound Care:
-Before choosing an intervention or treatment, it is important to identify the type of wound;
-Keep the wound clean;
-For wet wounds add absorbent dressing;
-For dry wounds add moisture;
-Protect wound with the appropriate dressing;
-Protect periwound (the outside skin area surrounding the wound) with products to prevent maceration (skin softening and break down because of prolonged exposure to moisture) with products such as skin prep (protective wipes, that form a protective barrier film, which help to shield the skin from moisture and friction), Cavilon cream (a transparent skin protectant that creates a protective barrier from bodily fluids, friction, and adhesives) or zinc oxide (topical ointment to protect and treat the periwound area);
-Interventions should be taken to reduce edema (swelling) and pressure, such as off-loading (reduce or eliminate pressure) the heels and repositioning;
-Individualize a turning schedule;
-Evaluate mattress type and add specialized mattress if indicated;
-Assessment and Documentation:
-Any wound is to be assessed by a licensed nurse or licensed practitioner;
-Weekly documentation, at least, of the wound location, stage (a classification system used to categorize the severity of a wound based on the depth of tissue damage and the extent of tissue loss), size, odor, undermining (the wound area that lies beneath the wound opening is larger than the hole or entrance of the wound; like a cavity or cavern), tunneling (when a chronic wound forms a channel or tract that extends from the skin's surface into deeper tissue), exudates (the fluid that leaks out of blood vessels into a wound), necrotic tissue (dead or dying tissue in a wound, prevents healing, can appear dry, black, leathery, or discolored, swollen, and smelly), presence or absence of granulation tissue (new connective tissue that forms in a healing wound and is red, bumpy, and moist), periwound, and wound edge description;
-Location: Describe the precise location of the wound in anatomical terms;
-Staging:
-Suspected deep tissue injury-persistent non-blanchable (when pressure applied to the reddened skin area, the area does not turn lighter color, or blanch, indicating a problem with capillary blood flow to the area) deep red, maroon, or purple discoloration;
-Stage I pressure injury-non-blanchable erythema (reddened skin) of intact skin;
-Stage II pressure injury-partial skin loss (damage to the epidermis/top layer of skin, and possibly the dermis/second layer of skin, but not the subcutaneous tissue (layer of fatty tissue underneath the skin), appearing as a shallow, open wound, with red or pink base, or an intact or ruptured serum-filled blister) with exposed dermis;
-Stage III pressure injury-full-thickness (wound that extends past the top two layers of skin) loss of skin in which adipose (fat) tissue is visible, granulation tissue may be visible, slough (white, yellow, tan, gray or green dead tissue) or eschar (layer of dead, hardened tissue that forms over a wound, appearing as a dry crust of scab) may be visible but does not obscure the depth of tissue loss, undermining and tunneling may be present, but there is no exposed/visible fascia (a thin layer of connective tissue that surrounds and supports every organ, muscle, bone, and nerve in the body), tendon (a fibrous connective tissue that attaches a muscle to a bone or other structure), ligament (a band of connective tissue that connects bones to other bones), cartilage (a flexible, tough, connective tissue that protects bones and joints, and gives structure to parts of the body like the ears and nose), muscle or bone;
-Stage IV pressure injury-full thickness skin and tissue loss with exposed, or directly palpable, fascia, bone, tendon, muscle, cartilage in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining, and/or tunneling often occur;
-Unstageable-When the wound bed is covered by slough and/or eschar, not allowing the true depth to be visualized. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined.
-Size:
-Measure the wound in centimeters (cm), including the length, width, and depth;
-Measure from the healed margins to the healed margins;
-Use clock coordinates to measure and document any tunneling or undermining.
-Odor:
-Describe the odor of the wound as none, mild, or foul, after cleaning.
Color:
-Describe the color of the involved area, and wound bed, in terms of color such as pink, red, yellow, white, black, or brown and estimate percentage of colors;
-Surrounding Tissue (periwound): Assess the tissue surrounding the wound and document the involved areas, such as inflammation, maceration, wet wound edges, tenderness, warm or cool to touch, skin turgor (ability of the skin to return to its original shape after being pinched or pulled), hypertrophic (overgrown), callused, thickened, or any other finding;
-Drainage: Describe the type, amount, and color of the drainage;
-Pain:
-Describe pain related to the wound;
-Incorporate interventions to reduce pain in the care plan;
-Document interventions and outcomes in the medical record.
-Monitoring of wounds:
-Weekly wound rounds will be made by the Director of Nursing or designee to assess all wounds (pressure and non-pressure);
-Monitor wounds for signs and symptoms of infection such as purulent exudates, periwound warmth, swelling, induration (hardening), erythema, delayed wound healing, or increased pain or tenderness around the site;
-Blood work with elevated white blood cells, bacteremia (bacteria present in the blood), sepsis (a life-threatening condition that occurs when the body's immune system has an extreme response to an infection, and can lead to organ failure, shock, and death if not treated promptly) or fever, may signal an infection related to the pressure ulcer;
-If any of the above symptoms develop, intervene appropriately, including notification of the physician and obtaining orders and update the plan of care as appropriate;
-If the wound fails to show some evidence of progress toward healing within two weeks, the wound and resident's overall clinical conditions should be reassessed, and the treatment plan re-evaluated;
-The decision to change, modify, or remain with the same treatment plan should be documented;
-The rationale for continuing with the same treatment should be well documented;
Documentation:
-It is critical that all caregivers document their observations and activities. For example, CNAs are critical to the process by reporting abnormal skin observations, documenting nutrition and hydration, turning and positioning, peri-care, etc.;
-Nurses also have a variety of documentation responsibilities as indicated throughout and are critical to the process of documenting interventions that have been taken to avoid pressure injuries;
-The definition of Avoidable means that the resident developed a pressure injury, and the facility did not do one or more of the following:
-Evaluate the resident's clinical condition and pressure injury risk factors;
-Define and implement interventions consistent with resident's needs and goals, and consistent with recognized standard of practice;
-Monitor and evaluate the impact of the interventions;
-Revise the interventions as appropriate.
-Document presence or absence of skin impairment of any kind on admission, transfer, and discharge. If present, describe the condition or wound thoroughly;
-Skin condition should be assessed within two hours of admission, re-admission or return from LOA and documented;
-The residents' skin conditions are to be documented at least weekly;
-Documentation encompasses, at a minimum, all assessments, interventions, including prevention measures taken, monitoring of nutrition and hydration, and interventions taken to address underlying diseases that might impact risk for skin breakdown or wound healing;
-Documentation is key to show that everything is being done to prevent those avoidable pressure injuries and heal pressure injuries.
Review of Resident #5's undated facility face sheet (first page of a medical record with the resident's demographics, medical diagnoses, family contacts, and physician contacts), showed:
-No admission date;
-Diagnoses:
-Diabetes mellitus with insulin use;
-Chronic (long-term/ongoing) congestive heart failure (CHF, heart unable to pump enough blood to meet the body's needs);
-Permanent atrial fibrillation (an arrhythmia/irregularity in heartbeat);
-Atherosclerotic heart disease (plaque buildup inside of arteries of the heart);
-Transient ischemic attack (TIA, a brief neurological dysfunction caused by blocked or reduced blood flow to a part of the brain);
-Cerebral infarction (stroke) without residual deficits;
-Major depressive disorder;
-Chronic kidney disease stage 3 (moderate kidney damage with loss of half the kidney's function, causing high blood pressure, anemia, and bone disease);
-Peripheral vascular disease (PVD, a narrowing of the blood vessels that restricts blood flow and mostly occurs in the legs);
-Hypothyroidism (low thyroid hormone production, resulting in slowing the speed of the life-sustaining chemical activity/metabolism of the body);
-Gastro-esophageal reflux disease (GERD, a digestive disorder that occurs when stomach acid flows back into the esophagus, also called acid reflux);
-Inappropriate diet and eating habits.
Review of the resident's nurse admission electronic checklist assessment, dated 10/16/24, with no time of admission, showed:
-Skin integrity, localized abnormality (no additional information provided);
-Preventative skin care, barrier cream (a topical product that creates a physical barrier between the skin and moisture/irritants from loss of bowel/bladder control);
-Edema location, generalized (generalized edema-fluid accumulates throughout the entire body);
-History of fall last three months;
-Weak gait;
-Living situation, independent at home;
-Independent with activities of daily living;
-Required one person partial/moderate assistance to move from a bed to chair transfer;
-Required one person partial/moderate assistance to go from lying to sitting on side of the bed;
-Required one person partial/moderate assistance to go from sitting on side of the bed to lying;
-Required one person partial/moderate assistance to safely move from a bed to chair transfer;
-Required one person partial/moderate assistance to go from sitting to standing;
-Required one person partial/moderate assistance for toilet transfer;
-Resident uses wheelchair for mobility;
-Required one person partial/moderate assistance to roll left to right in bed;
-Required one person partial/moderate assistance for car transfer;
-Required one person partial/moderate assistance to pick up an object;
-No evident barriers to learning.
Review of the resident's nurse admission skin assessment, dated 10/16/24 at 7:08 P.M., showed:
-Skin color, general: Usual for ethnicity;
-Skin temperature: Warm;
-Skin moisture, general: Dry;
-Skin turgor, general: Elastic;
-Skin integrity, general: Localized abnormality;
-Mucous membrane color: Pink;
-Mucous membrane description: Moist;
-Preventative skin care: Barrier cream;
-Sensory perception Braden: Slightly limited.
Review of the resident's weekly nurse skin flowsheet, showed:
-10/16/24 at 7:08 P.M.:
-Skin color general: Usual for ethnicity;
-Skin temperature: Warm;
-Skin moisture general: Dry;
-Skin turgor general: Elastic;
-Mucous membrane color: Pink;
-Mucous membrane description: Moist;
-Preventative skin care: Barrier cream;
-Sensory perception Braden: Slightly limited.
Review of the resident's Braden scores, showed:
-10/16/24 at 7:08 P.M., slightly limited (no other information or score listed).
Review of the resident's Braden scores, showed:
-10/17/24 at 7:50 P.M.:
-Sensory Perception: Slightly limited;
-Moisture: Occasionally moist;
-Activity: Chairfast;
-Mobility: Very limited;
-Nutrition: Adequate;
-Friction and shearing: Problem;
-Braden Score: 14 (moderate risk).
Review of the resident's physician's assessment, dated 10/17/24 (no time), showed:
-Primary diagnosis of orthostatic hypotension (a sudden significant drop in blood pressure when one stands up, or sits up from a lying position);
-The resident had a history of severe aortic valve stenosis (a heart valve disease that occurs when the aortic valve becomes so narrow that it cannot fully open, thereby reducing blood flow from the heart to the body), permanent atrial fibrillation, diabetes, and coronary artery disease (CAD, the coronary/heart arteries narrow or become blocked);
-The resident re-admitted to the hospital after a recent discharge to home, from rehabilitation services at the facility, because he/she fell the next day, on 10/12/24, at home;
-The hospital found the resident had positive orthostats (referring to orthostatic hypotension);
-Cardiology, in the hospital, scheduled surgery for a transcatheter aortic valve replacement (TAVR, a minimally invasive procedure that replaces a diseased aortic valve with a new one, and is most often used in older adults who are not healthy enough for regular valve surgery), on 10/22/24, for severe aortic stenosis;
-The physician documented the resident was seen that morning, up in the chair, and the resident said he/she was not ready to go home (referring to his/her discharge from the facility to home on [DATE]), got dizzy and fell;
-Past medical history showed the resident had a learning disability, due to a mild intellectual impairment;
-Medications listed, as received during the recent hospitalization:
-Hydrophilic wound dressing (a sterile paste applied to wounds to absorb exudate and promote healing), to affected area twice daily (affected area not listed);
-Physical examination:
-Skin warm and dry with no rash or jaundice;
-Impression/Plan:
-Chronic coccygeal (tailbone area) wound;
-Wound care team to follow while at facility.
Review of the resident's physiatry (specializing in maximizing physical function, through physical therapy, to foster independence and improve quality of life) Nurse Practitioner (NP A) history and physical evaluation, dated 10/17/24 at 8:53 A.M., showed:
-Chief complaint: Mobility deficit (a disability that limits a person's ability to move) and activities of daily living (ADL, basic self-care tasks performed independently to maintain daily life, like getting in and out of bed, chairs, or vehicles, dressing, bathing, toileting, mobility, and managing bladder and bowel functions) deficits, secondary (a result of) to frequent falls;
-The resident had been getting short of breath and dizzy and was hospitalized for falls;
-The hospital diagnosed the resident with CHF exacerbation (a worsening or flare-up of a pre-existing chronic condition), which was the likely cause of the resident's dizziness and shortness of breath;
-The resident had a [NAME] procedure (a minimally invasive surgery that implants a device in the heart to reduce the risk of stroke) for his/her diagnosis of atrial fibrillation;
-The resident reported a poor appetite and said he/she just wanted tomato soup;
-The resident lived in a home alone, with a Life Alert device (a device worn, with a button, that connects users to a monitoring center in the event of an emergency);
-Gait-Not attempted at this visit;
-The resident's assessment showed:
-ADL and mobility dysfunction, secondary to frequent falls;
-Deconditioning (the physical and mental changes that occur when someone is inactive for a period) and gait instability: The resident was at high risk for functional impairment
without therapy;
-The resident's full physical and occupational therapy (OT) evaluations were still pending.
Review of the resident's weekly nurse skin flowsheet, showed:
-10/17/24 at 7:50 P.M.:
-Skin color general: Usual for ethnicity;
-Skin temperature: Warm;
-Skin moisture general: Dry;
-Skin turgor general: Elastic;
-Mucous membrane color: Pink;
-Mucous membrane description: Moist;
-Preventative skin care: Barrier cream;
-Sensory perception Braden: Slightly limited;
-Moisture Braden: Occasionally moist;
-Activity Braden: Chairfast;
-Mobility Braden: Very limited;
-Nutrition Braden: Adequate
-Friction and shear Braden: Problem
-Braden score: 14.
-10/18/24 at 9:29 P.M.:
-Skin color general: Usual for ethnicity;
-Skin temperature: Warm;
-Skin moisture general: Dry;
-Skin turgor general: Elastic;
-Mucous membrane color: Pink;
-Mucous membrane description: Moist;
-Preventative skin care: Barrier cream;
-Sensory perception Braden: Slightly limited;
-Moisture Braden: Occasionally moist;
-Activity Braden: Chairfast;
-Mobility Braden: Very limited;
-Nutrition Braden: Adequate
-Friction and shear Braden: Problem
-Braden score: 14;
-10/19/24 at 11:39 P.M.:
-Skin color general: Usual for ethnicity;
-Skin temperature: Warm;
-Skin moisture general: Dry;
-Skin turgor general: Elastic;
 

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents received care consistent with professional standards. Staff failed to ensure a resident admitted from the hospital with a peripherally inserted central catheter (PICC, a thin, flexible tube that is inserted into a vein in the upper arm and guided (threaded) into a large vein above the right side of the heart, used to administer long term antibiotics and other medications) line, had orders for the PICC line including PICC line maintenance. Staff failed to verify why the PICC line was in place and failed to obtain and ensure continuity of antibiotic administration from the hospital related to a bacterial infection. The resident was not administered antibiotic medication for two days after admission into the facility (Resident #1). In addition, the facility failed to ensure a resident admitted with a PICC line placed at the hospital on 8/23/24, when admitted to the facility received PICC line orders including PICC line maintenance and dressing change orders (Resident #2). The facility identified 3 residents whom had intravenous (IV) or PICC lines in place. Resident #2 was not included on that list. The census was 152.
Review of the facility's central vascular access device (CVAD) dressing change policy, dated 2021, showed:
-To be performed by: the nurse is responsible and accountable for obtaining and maintaining competence with infusion therapy within the scope of practice;
-Considerations:
-CVADs include PICC;
-The catheter insertion site is a potential entry site for bacteria that may cause a catheter related infection;
-A transparent (clear) dressing is the preferred dressing;
-The preferred skin antiseptic agent is below 0.5 percent (%) chorhexidine (used to prevent infection) in alcohol solution;
-Nurses caring for patients receiving infusion therapies must adhere to aseptic non-touch technique (ANTT, the practice of avoiding contamination by not touching key elements, the inside surface of a sterile dressing where it will be in contact with a wound) for all infusion related procedures as a critical aspect of infection prevention;
-Guidance:
-Performing sterile dressing changes using ANTT:
-Upon admission, if transparent dressing is dated, clean, dry and intact the admission dressing change may be omitted and scheduled for 7 days from the date on the dressing label. Ensure orders are in place;
-Upper arm circumference with PICC, and external catheter length measurements must still be completed as part of the initial assessment;
-At least weekly;
-If the integrity of the dressing has been compromised (wet, loose or soiled);
-Assessment of the vascular access site is performed:
-Upon admission and during dressing changes;
-Before and after administration of intermittent infusion;
-At least once a shift when not in use;
-Routinely for signs and symptoms of infusion related complications;
-Assessment of vascular site and the entire arm with PICC, for infusion related complications include the absence or present of:
-Erythema (redness);
-Drainage;
-Swelling in induration (compare arm circumferences to baseline measurement to detect possible catheter-associated venous thrombosis (clot), a 3 centimeter (cm) increase in arm circumference and edema were associated with upper-arm deep vein thrombosis (DVT, a clot lodged in a deep vein or artery blocking blood flow);
-Change in the skin temperature or tenderness at the site;
-Integrity of transparent dressing;
-Numbness or tingling;
-Length of external catheter is obtained:
-Upon admission;
-During dressing changes;
-Upon suspicion in change of length;
-If signs or symptoms of complication are present;
-PICCs, upper arm circumference (10 cm above antecubital space elbow joint) is obtained:
-Upon admission if no insertion measurement is available, then weekly;
-If signs or symptoms of complications are present;
-Compare to baseline measurement to detect possible catheter associated thrombosis is present.
Review of the prescribing and ordering medication policy, dated 4/2002, showed:
-Purpose: to establish guidelines for properly obtaining physician orders and processing the orders;
-Policy:
-There must be evidence of a diagnosis, condition, or indication for use on the medical record for medications;
-admission orders:
-Obtain admission orders from the physician. Note: check the transfer sheet from the discharging facility as a reference. Transfer orders may only be used as a guide. They may not be used as admission orders. Check with the resident and/or family also to determine what medications they resident may have been on;
-When obtaining admission orders from the physician, review the list of medication they resident has been on and clarify what the physician wants to be discontinued and what medications the resident should remain on.
1. Review of Resident #1's hospital attending physician note, dated 8/8/24, showed:
-History of Present illness (HPI): the patient suspected of seizure activity. In the emergency department the patient noted to have a fever, elevated heart rate and irregular laboratory results. He/She met sepsis (blood infection) criteria. IV fluids and antibiotics started. Due to patient difficulty in communication, health information gathered from next of kin at bedside;
-Assessment and plan:
-Sepsis with septic shock and organ dysfunction suspect due to bacterial infection:
-Plan:
-Admit to intensive care unit (ICU) for further therapy and treatment;
-Begin IV vancomycin (antibiotic) or IV ceftriaxone (antibiotic).
Review of the hospital interventional radiology nurse note, dated 8/13/24, showed: PICC placed to the left brachial vein.
Review of the hospital Discharge summary, dated [DATE], showed:
-Hospital course: the blood culture tested positive for and grew group B strep (infection) and started on IV ceftriaxone. The patient improved and transferred out of the ICU for step down monitoring. He/She had a PICC line placed in the left upper extremity on 8/13/24 and will be discharged to a nursing facility with plans to receive a once a day ceftriaxone until 8/25/24 and weekly laboratory values per infectious disease (ID);
-Medication list: did not include antibiotic orders;
-Antibiotic surveillance labs: complete blood count (CBC, tests for general overall health), Chemistry 7 (chem 7, monitors various chemicals and minerals in the blood), and c-reactive protein (CRP, tests for inflammation).
Review of the facility's admission flow sheet, dated 8/16/24, showed:
-IV: yes.
Review of the admission Physician Order Sheet (POS), showed no admission orders regarding PICC or IV antibiotics.
Review of the progress notes, showed no documented attempts to contact the resident's physician or the discharging hospital regarding the PICC line.
Review of the facility's Nurse Practitioner's progress note, dated 8/19/24, showed:
-HPI: resident history of Down syndrome (a condition in which a person has an extra copy of chromosome 21) and seizure disorder. The resident had a recent hospital stay related to bacterial septicemia. He/She was discharged to the skilled nursing facility for skilled therapy and IV antibiotics;
-Interval history: NOK is at bedside and reported the resident did not get his/her IV antibiotics over the past weekend. The NOK stated the concerns were expressed to weekend nursing staff and no changes occurred. The facility Assistant Director of Nursing (ADON) and the hospital ID contacted. Orders were obtained. The hospital discharge paperwork did not include orders for IV antibiotics;
-IV ABT not on DC list, added this morning;
-Ceftriaxone 2g (2,000 mg) once every 24 hours.
Review of the POS, showed:
-On 8/19/24: Change IV tube every 24 hours;
-On 8/19/24: Ceftriaxone 2 g/50 milliliter (ml) osomotic dexrose IV solution, first dose: 8/19/24 and stop: 8/28/24 for strep bacterium;
-On 8/19/24: Heparin flush 10 units/ml. For PICC line maintenance every 12 hours.
Review of the Medication Administration Record (MAR), showed:
-On 8/19/24, administration of Ceftriaxone 2G completed.
During an interview on 9/12/24 at 3:58 P.M., the Director of Nursing (DON) said the resident was admitted with a PICC line in place. Staff attempted to contact the physician for orders regarding the PICC line and the physician did not return the call over the weekend. The nurse should have called the discharging hospital for additional orders for the PICC line. The hospital discharge paperwork showed the resident was receiving antibiotics through a PICC line and the antibiotics were to continue, but the discharge medication list did not list the antibiotic. On the following Monday, the ADON called the hospital ID physician and obtained the order for continued antibiotics. The resident did not receive the antibiotics over the weekend.
2. Review of Resident #2's hospital transfer orders, dated 8/27/24, showed:
-Discharge diagnoses: pyelonephrisis (kidney infection) and renal abscess;
-PICC line placed left brachial vein on 8/23/24;
-Additional instructions: Osteomyelitis on left hip. ID was consulted and recommended to continue antibiotics for 8 weeks. Meropenem (antibiotic) 1 G (1,000 mg) in 0.9 percent (%) normal saline in 50 ml for 49 days;
-Insertion site above antecubital: 11 cm;
-Initial limb circumference: 23 cm;
-Catheter length: 43 cm.
Review of the resident's POS, showed:
-Admit to facility: 8/27/24;
-An order, dated 8/28/24: Meropenem 1, 000 mg per IV every 8 hours for 49 days. First dose: 8/29/24, Stop date: 10/16/24. Indication: antibiotic for abscess;
-No orders were noted for PICC line maintenance or dressing changes.
Review of the facility admission flow sheet, dated 8/27/24, showed:
-IV: yes.
During observation and interview on 9/12/24 at 12:55 P.M., the resident said he/she had an infection in his/her kidney and needed antibiotics for 30 days. He/She pulled up his/her left shirt sleeve and exposed a PICC to the left brachial vein. The dressing was undated. The edges of the transparent dressing were rolled up and appeared gray in color. The resident said the dressing had not been changed since he/she admitted into the facility. The staff administer the antibiotic every day. The access site is not painful.
During an interview on 9/12/24 at 2:58 P.M., Registered Nurse (RN) F said when a resident is admitted to the facility with an intact IV or PICC line, it is the admitting nurse's responsibility to verify why the access line is in place. All IVs and PICC lines should have orders for dressing changes and maintenance. If an access line dressing or the line itself is not maintained, the resident could develop an infection or the line could become blocked and unusable.
During an interview on 9/12/24 at 3:58 P.M., the DON said if a resident is admitted with an IV or PICC line in place, the admitting nurse is responsible to verify why the line is present. If the hospital discharge paperwork does not address the reason for the IV or PICC, the nurse should call the hospital or the physician for additional information. All IVs and PICCs should have corresponding orders for dressing changes and maintenance. All PICC line dressings should be dated, timed and changed every 7 days.
MO00241346

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide adequate supervision for one resident (Resident #1) who required staff assistance with transfers and mobility when going to bed. On [DATE], after the resident became adamant about staff putting him/her to bed, staff removed the resident from a sit to stand lift (a medical device that assists individuals with limited mobility in standing up from a seated position) and performed a 2-person assist transfer. The resident's right foot was caught under the bed during the transfer and sustained a comminuted tibial plateau fracture (a break in the lower bone below the knee that breaks into the knee joint and is displaced and not aligned) involving the medial (the bony surface on the top of the shin bone that corresponds to the big toe) and lateral (the surface that corresponds to the pinky toe) tibial plateau without significant displacement. The sample size was 3. The census was 149.
Review of the facility's Mechanical Lifts, Use of policy and procedure, revised 3/2024, showed:
-Purpose: To establish proper guidelines for safely moving or transferring a resident from one place to another;
-Responsibility: It is the responsibility of all nursing personnel to follow this policy;
-Policy: Resident's transfer needs should be assessed upon admission, quarterly and PRN (as needed).
Review of the facility's Condition Changes, Incidents, Injuries-Reporting of policy and procedure, revised 1/2023, showed:
-Purpose: To provide an orderly process for reporting changes in condition, incident or injuries involving residents;
-Policy: It is the facility's policy to report condition changes, incidents or injuries involving residents;
-Practice:
-Serious incidents, i.e., fractures, head injuries, uncontrolled bleeding or acute changes in resident conditions are reported to the physician at the time of occurrence.
Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed:
-Moderate cognitive impairment;
-Sit to Stand: Substantial/Maximal assistance;
-Chair/bed to chair transfer (The ability to transfer to and from a bed to a chair or wheelchair): Substantial/Maximal assistance;
-Diagnosis included: Seizure Disorder (Nerve cell activity in the brain is disturbed) or Epilepsy (A chronic neurological disorder that causes a person to have two or more unprovoked seizures that occur more than twenty-four (24) hours apart), Muscle weakness (generalized), weakness.
Review of the resident's physical therapy plan of care, dated [DATE], showed:
-Treatment Diagnosis: Weakness;
-Precautions: Transfers with standup lift or pivot (the person bears at least some weight on one or both legs and spins to move their bottom from one surface to another).
Review of the resident's care plan, last updated on [DATE], showed:
-Focus: At risk for falls related to decreased mobility;
-Goal: Maintain independence and have needs met to resident's satisfaction with assistance;
-Intervention: Require extensive two (2) person assistance with transfers using stand up lift.
Review of the resident's physician orders, showed no order for transfer status.
Review of the emergency resident encounter documentation, dated [DATE] at 12:41 P.M., showed:
-Lower extremity problem (from nursing home-was being transferred to bed and right leg got caught; concerned for tibial fracture);
-Resident being evaluated for a complaint of fall with resultant right lower extremity pain, especially right knee pain, which occurred last night;
-Findings:
-Severe bony demineralization. Acute, nondisplaced intra-articular tibial plateau fracture. Fracture lines involve both the medial and lateral tibial plateaus and extending anteriorly through the midline;
-Final Impression:
-Closed fracture of right tibial plateau;
-Fall, initial encounter;
-Acute pain of right knee.
Review of SBAR (Situation, Background, Assessment, Recommendation, assessment tool), dated [DATE], showed:
-Situation - Pain
-New Pain Evaluation: Yes;
-Pain Present: Yes, actual, or suspected pain;
-Primary Pain Location: Knee;
-FACES Pain Scale (A self-report measure of pain intensity) Rating: 6 = Hurts even more;
-FACES Pain Score Rating: 6;
-Appearance and Evaluation Findings: Appearance, Evaluation Comments: Resident had rung call light and asked for something for pain. When asked about his/her pain, resident stated he/she has pain in his/her right knee. Resident stated that when being transferred into bed, his/her right foot was caught under the bed and then he/she felt a pain in his/her right knee. Upon assessing resident, his/her right knee is warm and appears slightly swollen;
-11:40 A.M., x-ray returned with possible tibia (shin bone) fracture. New orders to send the resident to ER (emergency room).
Review of the facility's investigation, showed:
-On [DATE], the DON (Director of Nursing) spoke with Certified Nurse Assistant A. CNA A said he/she and CNA B had finished the resident's shower on the evening of [DATE]. When they went to transfer the resident to bed, the sit to stand battery did not have charge. The resident was upset when they asked him/her to wait, so they did an assist of two transfer;
-Performance management conference form, dated [DATE], showed:
-CNA A; Reason for conference: Failure to render a service within the scope of duties as defined by the employee job description;
-On [DATE], the DON spoke with CNA B. CNA B said after the resident's shower, they attempted to get the sit to stand for a transfer and the battery would not work. The resident was upset when asked to wait so they did an assist of two transfer. He/She went to LPN (Licensed Practical Nurse) C to tell him/her they transferred the resident with a two person assist;
-Performance management conference form, dated [DATE], showed:
-CNA B; Reason for conference: Failure to render a service within the scope of duties as defined by the employee job description.
-On [DATE], the Administrator spoke with the resident regarding the incident on [DATE]. The resident reported he/she wanted to go to bed and told the CNA. The CNA told him/her the battery died during a shower he/she was giving, and the resident had to wait for it to charge. The resident stated he/she told the CNA he/she wanted to go to bed, and he/she didn't want to wait. The resident stated that he/she asked the CNA if he/she would just put him/her to bed. The CNA left the room and came back with another CNA, and they transferred him/her to bed. The resident stated when he/she was in bed, he/she started to feel his/her leg was hurting. The resident said he/she told the nurse.
During an interview on [DATE] at 1:05 P.M., the resident said his/her leg got caught under the bed. He/She kept screaming and telling them his/her leg was stuck but they kept putting him/her to bed. He/She was hurt. His/Her right knee was hurt. Observation showed the resident pointed to his/her right knee. The resident said staff usually used the lift, so he/she didn't know why they picked him/her up and tried to put him/her in bed. He/She said the staff didn't realize his/her foot was caught until after he/she was in bed. The resident said CNA B was one staff, but he/she didn't know the other staff's name. He/She said CNA B wasn't there and he/she usually worked evenings.
During an interview on [DATE] at 12:51 P.M., the DON said she didn't have a sit to stand assessment form for the resident. She said therapy was going to send over whatever notes they had. She saw the facility's policy said the resident must be assessed initially before using the sit to stand and routine intervals thereafter. Therapy makes a recommendation and they can follow it, but as a nurse, she can down grade the recommendations but can not ever go above the recommendations and the same thing for hospital recommendations.
During an interview on [DATE] at 3:07 P.M., the Administrator and DON said the resident was hurt during a fall and had a fracture just above the knee. The Administrator said the resident could use a sit to stand or pivot for transfers.
During an interview on [DATE] at 10:42 A.M., CNA A said he/she and CNA B didn't drop the resident. He/She said the resident used a sit to stand lift. They used the sit stand lift that day, but the battery went dead. CNA A and CNA B charged the battery, but it didn't work. He/She told the resident the battery was dead, but the resident demanded to be put in bed. CNA A got another staff to help transfer the resident. They angled the resident towards his/her bed and put on the gait belt. No sit stand was used. He/She had the resident's upper body and stood on the left side of the bed. CNA B was on the right side. Once the resident was sitting on the bed, CNA B pivoted his/her shoulders, and he/she pivoted the resident's legs into bed. Once the resident sat on the bed, CNA A said the resident said, Oh you hurt my leg. The resident didn't scream or yell. CNA A said he/she didn't see what the resident's leg was caught on. The CNA's looked at the resident's legs and didn't see anything. He/She asked if the resident was ok and then told the nurse after the transfer that the resident said his/her leg hurt. CNA B went to tell LPN C. CNA A didn't understand what happened and didn't get vital signs because he/she didn't think it was severe. CNA A asked the resident again if he/she was ok and the resident said yes. The resident didn't show any indications that anything was wrong. When he/she came in to work the next day, the resident had told the night nurse, LPN E, that his/her leg was hurt. The resident told LPN E because he/she was afraid to tell them. The resident told LPN E his/her leg hurt. LPN E called the physician to get orders for an x-ray because the resident was in pain. CNA A said he/she didn't talk to LPN C directly. He/She said the resident didn't fall. If he/she had fallen, it would have taken more than the two of them to get the resident up because the resident was dead weight.
During an interview on [DATE] at 11:02 A.M., LPN C said he/she knew the resident and was familiar with his/her care. He/She said the resident used a sit to stand. LPN C said he/she didn't talk to CNA A that day about the resident at all on [DATE]. CNA B came up to him/her and said they had to transfer the resident like a two person. LPN C asked CNA B, why they transferred the resident without the sit to stand. When he/she again asked CNA B why they did the transfer without the sit to stand again, CNA B threw up his/her hands and walked away. LPN C said the facility had a lot of sit to stand lifts in the building and staff could have gotten one from somewhere else. LPN C told CNA B he/she shouldn't have picked the resident up without the sit to stand. CNA B never told him/her what happened to resident or anything about pain. The resident told him/her that CNA B two personed me. LPN C asked the resident why he/she would let someone do that. It's not safe. LPN C and the Staffing Coordinator, who was working as a Certified Medication Technician (CMT) that shift, said CNA B never came back to tell the resident had been hurt.
During an interview on [DATE] at 11:50 A.M., the Staffing Coordinator said he/she worked over as a CMT on the evening the event happened with the resident. He/She was sitting at the desk with LPN C ordering medications. CNA B walked to the desk. LPN C was doing an admission. CNA B said he/she and CNA A two person the resident into bed. LPN C asked CNA B what did he/she say. CNA B repeated him/her and CNA A performed a two person transfer to put the resident in bed. CNA B said the battery was dead. That didn't make since because they could have gotten a battery from another floor. CNA B got mad at them for telling him/her he/she could have gotten a battery from another floor. CNA B huffed and walked off. He/She didn't come back to the desk to tell the resident was hurt or had an injury. CNA B transferred the resident with CNA A because the resident was adamant about getting into bed. When the Staffing Coordinator went to pass medications on a different day he/she saw the resident with a knee immobilizer (device used to maintain stability of the knee). The resident told him/her CNA B and CNA A transferred him/her with a two-person transfer. He/She didn't know why the resident had it on. The Staffing Coordinator said he/she went to tell LPN C about the immobilizer on the resident's leg. LPN C went to look at the log and saw the resident went out over the weekend to the hospital and came back with that on his/her leg.
During an interview on [DATE] at 2:21 P.M., the Administrator said she expected staff to follow the mechanical lift and all other policies. She expected staff to follow the resident's plan of care and use a sit to stand lift during transfers. The Administrator expected staff to tell the nurse if the resident said he/she was hurt and if there was an incident, with or without injury. If nursing had been aware of the resident's injury, she expected staff to complete the required assessments. The Administrator said she felt like staff thought they provided care for the resident's needs. The DON said she had told staff many times to go to other floors to get batteries. The Administrator and DON said they were told the battery was dead and staff checked another battery for the sit to stand lift but it didn't work. They both said staff told them the resident was adamant about going to bed, so they put him/her to bed. If the resident would have had to sit in the wheelchair, he/she would have been upset. Once he/she became adamant about getting into bed, staff put the resident to bed. The Administrator could not say whether it would have been safer for the resident to sit and wait until the battery charged or to get one from another floor because either way, the resident would have been upset.
MO00234994

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their abuse and neglect policy by not reporting timely after an incident involving one resident (Resident #1) and two staff, who performed an improper transfer which resulted in the resident sustaining a comminuted tibial plateau fracture (a break in the lower bone below the knee that breaks into the knee joint and is displaced and not aligned) involving the medial (the bony surface on the top of the shin bone that corresponds to the big toe) and lateral (the surface that corresponds to the pinky toe) tibial plateau without significant displacement. The sample size was 3. The census was 149.
Review of the facility's Resident Abuse, Neglect, and Exploitation policy and procedure, revised 7/2023, showed:
-Purpose: To provide guidelines for identifying, investigating, and reporting resident abuse, neglect, and exploitation, (which includes misappropriation of the resident's personal property) including any reasonable suspicion of a crime directed toward the resident;
-Responsibility: It is the responsibility of the Administrator of each residence to monitor compliance of this policy. Department Managers and Supervisors must know, understand, and enforce this policy. All employees of the facility must know, understand, and abide by this policy;
-Abuse Definitions:
Serious bodily injury: An injury involving extreme physical pain; involving protracted loss (serious bodily harm that results either in a diminished quality of life for the victim or their death); requiring medical intervention such as surgery, hospitalization physical rehabilitation;
-Covered individual: Anyone who is an owner, operator, employee, manager, agent, or contractor of the facility;
-The following procedure for investigation and reporting a suspected or actual abuse/neglect situation will be adhered to by all employees;
-Procedure for complaint of/or suspected/observed resident abuse/neglect/exploitation or who discovers, and unexplained incident/injury should make an immediate report to his/her Administrator and disrupt any acts of abuse;
-An investigation shall be initiated immediately. Any allegation must be fully investigated and self-reported to an appropriate state agency;
-Each covered individual shall report immediately, but not later than two hours after forming the suspicion, if the events that cause the suspicion involve abuse or result in serious bodily injury, or not later than twenty-four (24) hours if the events that cause the suspicion do not result in serious bodily harm;
-Upon completion of the investigation, the following actions may be warranted:
-Appropriated disciplinary action of the responsible employee, up to and including discharge, shall be taken. Any disciplinary action taken shall be fully documented;
-The final results of the investigation shall be reported within five (5) working days of the initial notification of DHSS (Department of Health and Senior Services).
Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed:
-Moderate cognitive impairment;
-Sit to Stand: Substantial/Maximal assistance;
-Chair/bed to chair transfer (The ability to transfer to and from a bed to a chair or wheelchair): Substantial/Maximal assistance;
-Diagnosis included: Seizure Disorder (Nerve cell activity in the brain is disturbed) or Epilepsy (A chronic neurological disorder that causes a person to have two or more unprovoked seizures that occur more than twenty-four (24) hours apart), Muscle weakness (generalized), weakness.
Review of the resident's care plan, revised [DATE], showed:
-Intervention: Require extensive two (2) person assistance with transfers using stand up lift;
-Goal: Maintain independence and have needs met to my satisfaction with assistance;
-Focus/Problem: At risk for falls related to decreased mobility.
Review of the emergency resident encounter documentation, dated [DATE] at 12:41 P.M., showed:
-Lower extremity problem (from nursing home-was being transferred to bed and right leg got caught; concerned for tibial fracture);
-Resident being evaluated for a complaint of fall with resultant right lower extremity pain, especially right knee pain, which occurred last night;
-Findings: Severe bony demineralization. Acute, nondisplaced intra-articular tibial plateau fracture. Fracture lines involve both the medial and lateral tibial plateaus and extending anteriorly through the midline;
-Final Impression:
-Closed fracture of right tibial plateau;
-Fall, initial encounter;
-Acute pain of right knee.
Review of the facility's investigation, showed:
-On [DATE], the DON (Director of Nursing) spoke with Certified Nurse Assistant (CNA) A who said he/she and CNA B had finished the resident's shower on the evening of [DATE]. When they went to transfer the resident to bed, the sit to stand battery did not have a charge. The resident was upset when they asked him/her to wait, so they did an assist of two transfer;
-Performance management conference form, dated [DATE], showed:
-CNA A; Reason for conference: Failure to render a service within the scope of duties as defined by the employee job description;
-On [DATE], the DON spoke with CNA B. CNA B said after the resident's shower, they attempted to get the sit to stand for a transfer and the battery would not work. The resident was upset when asked to wait so they did an assist of two transfer. He/She went to LPN (Licensed Practical Nurse) C to tell him/her they transferred the resident with a two person assist;
-Performance management conference form, dated [DATE], showed:
-CNA B; Reason for conference: Failure to render a service within the scope of duties as defined by the employee job description;
-On [DATE], the Administrator spoke with the resident regarding the incident on [DATE]. The resident reported he/she wanted to go to bed and told the CNA. The CNA told him/her the battery died during a shower he/she was giving, and the resident had to wait for it to charge. The resident stated he/she told the CNA he/she wanted to go to bed, and he/she didn't want to wait. The resident stated that he/she asked the CNA if he/she would just put him/her to bed. The CNA left the room and came back with another CNA, and they transferred him/her to bed. The resident stated when he/she was in bed, he/she started to feel his/her leg was hurting. The resident said he/she told the nurse;
-No documentation to show the facility notified DHSS of the incident or injury.
During an interview on [DATE] at 1:05 P.M., the resident said while staff were transferring him/her back to bed, the resident said CNA B and another staff put him/her back to bed by picking him/her up together. The resident said CNA B was one staff, but he/she didn't know the other staff name. The resident said his/her leg got caught under the bed as he/she was being turned into the bed. He/She kept screaming and telling CNA B and the other staff member his/her leg was stuck, but they continued to put him/her to bed. The resident was hurt. His/Her right knee was hurt. Observation showed the resident pointed to his/her right knee. The resident said staff usually used the lift, so he/she didn't know why they picked him/her up and tried to put him/her in bed. He/She said the staff didn't realize his/her foot was caught until after he/she was in bed.
During an interview on [DATE] at 10:42 A.M., CNA A said he/she and CNA B didn't drop the resident. He/She said the resident used a sit to stand lift. They used the sit stand lift that day, but the battery went dead. CNA A and CNA B charged the battery, but it didn't work. He/She told the resident the battery was dead, but the resident demanded to be put in bed. Once the resident sat on the bed, CNA A said the resident said, Oh you hurt my leg. The resident didn't scream or yell. CNA A said he/she didn't see what the resident's leg was caught on. The CNA's looked at the resident's legs and didn't see anything. He/She asked if the resident was ok and then told the nurse after the transfer that the resident said his/her leg hurt. CNA A said he/she didn't talk to the nurse directly about what took place.
During an interview on [DATE] at 11:02 A.M., Licensed Practical Nurse (LPN) C said he/she knew the resident and was familiar with his/her care. He/She said the resident used a sit to stand. CNA B came up to him/her and said they had to transfer the resident like a two person. LPN C asked CNA B why they transferred the resident without the sit to stand. When he/she again asked CNA B why they did the transfer without the sit to stand again, CNA B threw up his/her hands and walked away. CNA B never came back to say the resident had been hurt.
During an interview on [DATE] at 3:07 P.M., the Administrator and DON said the resident was hurt during a transfer. He/She had a fracture just above the knee. They said the resident got x-rays and was sent out to the hospital. The Administrator said the resident was a sit to stand transfer at the time of the fall. The staff involved received disciplinary action. She didn't report it to DHSS because the incident was witnessed, and it was not an unknown injury.
MO00234994

Based on interview and record review, the facility failed to provide an appropriate immediate discharge letter to one of four sampled residents (Resident #1). The letter failed to contain the effective date of discharge, specific location to where the resident was transferred and discharged , failed to provide information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request, along with the failure to inform the resident he/she can return to the facility if an appeal is filed. Additionally, the Long-Term Care Ombudsman's office address was incorrect, and no email address was listed. The census was 147.
Review of the facility's Discharge/Transfer of a Resident policy, dated 12/2022, showed:
-The facility complies with federal regulations to permit each resident to remain in the community, and not transfer or discharge the resident unless:
-The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the community;
-The safety of the individuals in the community are endangered due to the clinical or behavioral status of the resident;
-Contents of the transfer/discharge notice must include:
-The reason for transfer or discharge;
-The effective date of transfer or discharge;
-The location to which the resident is transferred or discharged ;
-An explanation of the right to appeal the transfer or discharge to the State, including:
-The name;
-The address (mailing and email);
-The telephone number of the State entity which receives such requests;
-The information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
-The name, address (mailing and email), and telephone number of the Office of the State Long-Term Care Ombudsman.
Review of Resident #1's face sheet, showed his/her diagnoses included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety and osteoarthritis left shoulder replaced with left artificial shoulder joint and admission for orthopedic aftercare.
Review of the resident's Discharge Assessment-Return Anticipated, Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/13/24, showed:
-Intact cognition;
-No behavioral symptoms;
-No rejection of care;
-Pain intensity, on scale of 0-10, was 8;
-High risk opioid drug class;
-Diagnoses included orthopedic condition, hypertension (high blood pressure), dementia and anxiety disorder.
Review of the resident's undated Resident Profile Report (plan of care), showed it did not identify the resident had a history of psychotic disturbance, mood disturbance, anxiety, or aggressive behavior. It showed the resident had periods of agitation regarding his/her pain medication changes made by the physician. The resident had periods of trying to block people from entering his/her room. Staff were to remind the resident to keep his/her room accessible for safety.
Review of the resident's Situation-Background-Assessment-Recommendation (SBAR, a form completed by nurses, regarding important resident information/condition, to facilitate and increase the probability of effective, accurate, communication between health care professionals), dated 2/13/23 at 12:53 P.M., showed:
-At 8:15 A.M., the resident was barricading his/her door and said he/she only wanted to talk to his/her physician. The resident's facility physician was called and said he would be at the facility shortly. The resident was told his/her physician would be there shortly to talk with him/her. The resident said he/she was leaving and called a taxi. The resident refused to open the door. The resident's physician arrived and they (the nurse and the physician) visited with the resident. The resident said he/she was leaving against medical advice (AMA). The resident's ex-spouse was called and informed the resident wanted to leave. The ex-spouse said neither he/she, nor any other family member, was going to pick the resident up. The resident then stated he/she wanted to leave with the police, because he/she was mad and did not want to pay for the taxi, so the resident called the police. The police arrived, were informed of the resident's behaviors, and shown the sharp object that was in resident's hand while he/she was lying in bed and demanding the lights stay off. The sharp object was later found in the resident's sink. The resident was up and walking around his/her room the entire morning. The resident's physician gave the order for a psychiatric evaluation and for transport to a psychiatric hospital. The resident was escorted out of the building by the police, and the Emergency Medical Technicians (EMTs), to ensure the safety of the other residents in the facility. Discharge paperwork was sent with the EMTs. The resident got onto the stretcher willingly, was taken to the ambulance, and was transported off campus;
-Behaviors Exhibited at 8:15 A.M.: Agitated, delusional, disruptive social interaction, reckless, uncooperative, and verbally aggressive toward others;
-Behaviors Exhibited at 9:15 A.M.: Agitated, anxious, hallucinating, inappropriate, verbally aggressive toward others;
-Behaviors Exhibited at 9:30 A.M.: Delusional, destructive, reckless, and restless;
-Behaviors Exhibited at 10:00 A.M.: Destructive, hostile, inappropriate, and uncooperative.
During an interview on 3/7/24 at 12:30 P.M., the Administrator and Director of Nursing said the resident was admitted to their rehabilitation unit for physical therapy on 2/7/24, after having his/her left shoulder replaced with an artificial shoulder. They later discovered the resident had a history of substance abuse. The facility physician discontinued the resident's oxycodone (a strong narcotic for pain control) on 2/12/24. There were remaining pain control orders for Tramadol and Tylenol. The next morning, the resident wanted his/her oxycodone and became increasingly agitated, aggressive, and erratic, demanding to speak with the physician. The resident tried to throw a chair at staff and broke his/her plastic incentive spirometer (a handheld medical device that measures the volume of your breath), thereby obtaining a small shard of the plastic to use as a weapon. The resident kept saying he/she had his/her own stuff (medications) to take and called a cab to take him/her home. The resident then called the police and his/her ex-spouse to take him/her home. The resident's behavior was erratic and symptomatic of acute psychosis. Five police officers ended up on the scene. The facility physician did a direct, involuntary admission to the psychiatric hospital. The resident was admitted to the hospital.
Review of the resident's hospital behavioral health intake assessment, dated 2/13/24 at 5:00 P.M., showed the resident presented to the hospital from the nursing home's rehabilitation facility for a psychological evaluation. The resident was alert, oriented, and accompanied by an adult offspring. Chart review showed the resident had a history of anxiety, depression, alcohol abuse, and recent left shoulder replacement. Nursing home staff reported to EMS the resident had barricaded him/herself in his/her room and was found in possession of a sharpened piece of plastic. The resident denied having a sharp piece of plastic and said it was a broken spirometer piece with a sharp edge that he/she noticed in the room. Nursing home staff said the resident picked up a chair to throw at staff, which the resident denied. The nursing home was not allowing the resident to return. The hospital assessment showed the resident was agitated, with flat affect and poor eye contact. The resident answered with one or two words unless talking about how the nursing home staff did not give medications to him/her when asked. The resident's family member said the resident was not formally diagnosed with dementia but had similar episodes of agitation and confusion over the past year, seemingly worst after hospitalizations for other medical concerns. The family member said the resident was also ordering medicine off the internet and had some pink pills at his/her house, which he/she wanted to obtain. The family member said the resident had prescriptions for Tramadol and other medications, was not taking Lyrica (a prescription medication for nerve pain) as prescribed, and was not taking his/her antidepressant. The family member said the resident slept all day, was awake all night, and would take six Tylenol P.M. pills, all at once, to sleep. The longer the resident stayed in a healthcare setting, the more uncooperative and worse he/she would get. The family member said the resident was not safe at home. The resident's emergency department physician agreed to admit the resident due to imminent danger to him/herself and others.
Review of the facility's undated discharge form, used for the resident's immediate discharge, showed it did not include the following:
-A title, indicating it was a discharge notice;
-The effective date of discharge;
-The location, which the resident was discharged to;
-Information on how to obtain an appeal form;
-Information on how to obtain assistance with completing the appeal form;
-Information on how to submit the appeal form for a hearing request;
-Information informing the resident he/she could return to the facility if an appeal was filed;
-The correct office address, and email address, of the Long-Term Care Ombudsman's office.
During an interview on 3/13/24 at 3:23 P.M., the Administrator said the location which the resident was discharged to was not applicable because the resident was going to the hospital. The resident was there for therapy and was not in need of long-term care. The information on how to appeal, to stay in the facility, was not applicable because it was not safe to keep the resident in the facility. The Administrator did not know, at the time of the resident's discharge, that the Ombudsman's office address had changed.
MO00231866

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents who lived on the Rehab Unit were served hot foods at appropriate temperatures of at least 120 degrees Fahrenheit (F) at the time of service. Three residents were interviewed about food temperatures and all three said hot foods were frequently too cold (Residents #14, #172 and #173). The census was 148 with 129 in certified beds.
Review of the facility's Meal Temperature policy, dated 1/21/21, showed the following:
-Policy: All food items are evaluated for proper food temperature, taste and appearance prior to meal service. Food and drinks should be palatable, attractive and served at a safe and appetizing temperature, as determined by the type of food, to ensure patients'/residents' satisfaction;
-Procedure:
-When food is transported to a remote serving location such as a household, neighborhood, etc., final cook temperatures are taken and recorded in the kitchen; temperatures are taken and recorded again once transported to service location and prior to serving. If temperatures are not optimal at the receiving location, respond accordingly to correct. Record ending temperatures or at one hour intervals during service;
-Temperatures below or above standards may indicate procedural and/or equipment problems.
1. Review of Resident #14's quarterly Minimum Data Set (MDS) a federally mandated assessment completed by facility staff, dated 9/2/23, showed the resident had severe cognitive impairment.
Observation on 9/25/23 at 1:03 P.M., showed the resident seated at a dining room table with a tray plate containing meat, peas, potatoes, cornbread, and a cup of soup. During an interview, the resident said the food was not good and was cold.
2. Review of Resident #172's admission MDS, dated [DATE], showed the resident was cognitively intact.
During an interview on 9/25/23 at approximately 10:30 A.M., the resident said the food was terrible. It was often served cold. He/She ate meals in his/her room and the meals were often delivered cold.
3. Review of Resident #173's admission MDS, dated [DATE], showed the resident was cognitively intact.
During an interview on 9/25/23 at 11:07 A.M., the resident said the food was okay, but since the unit he/she resided on was served last, food was often cold when served.
4. Observation on 9/26/23 at 1:06 P.M., showed meal trays were delivered to the 1000 unit. A test tray was observed and showed:
-The meal consisted of sausages, potatoes, green beans, potato soup and rolls;
-The sausage measured a temperature at 109 degrees F and was lukewarm to the touch;
-The potatoes measured a temperature at 112.2 degrees F;
-The green beans measured a temperature at 114.2 degrees F;
-The hot roll measured a temperature at 108.3 degrees F;
-The potato soup measured a temperature at 103.4 degrees F and was lukewarm to the touch.
5. Observation on 9/28/23 at 12:50 P.M., showed meal trays were delivered to the 1000 unit. A test tray was observed and showed:
-The meal consisted of glazed chicken, peas, lentil soup and rolls;
-The peas measured a temperature at 112 degrees F;
-The bread measured a temperature at 116 degrees F;
-The lentil soup measured a temperature at 111.5 degrees F and was lukewarm to the touch.
6. Observation on 9/29/23 at 8:13 A.M., showed meal trays were delivered to the 1000 unit. A test tray was observed and showed:
-The meal consisted of oatmeal and eggs;
-The first bowl of oatmeal temperature measured at 109 degrees F and was cold to the touch;
-The second bowl of oatmeal temperature measured at 102 degrees F and was cold to touch;
-The egg temperature measured at 112 degrees F and was lukewarm to touch.
7. During an interview on 9/29/23 at 8:27 A.M. Certified Medication Technician K said food should be delivered to residents at the safe and proper temperature. He/She said if food was not at the proper temperature the food could spoil or not taste good. He/She could not remember what the appropriate temperatures were for cold and hot food.
8. During an interview on 9/29/23 at 8:33 A.M. Registered Nurse L said food should be delivered to residents at a safe and proper temperature. He/She said if food was delivered too cold it was not safe for consumption. He/She said staff were supposed to check the food temperatures before they gave the room tray to residents. He/She estimated hot food should be delivered at 98.6 degrees F.
9. During an interview on 9/29/23 at 8:38 A.M. Dietary Aide (DA) M said food was expected to be delivered to residents at a safe and proper temperature. He/She said hot food should have a temperature of 165 degrees F or higher. Cold food should be at 45 degrees F or lower.
10. During an interview on 9/29/23 at 8:38 A.M. the Dietary Manager said she expected food to be delivered to the residents at the proper temperature. She said once the food left the kitchen, nursing staff were responsible to take food temperatures before residents were given their meal tray to ensure the food was at the proper temperature.
11. During an interview on 9/29/23 at 9:21 A.M. DA N said food was expected to be delivered to residents at the proper temperature. He/ She said hot food should be 140 degrees F or higher and cold food should be 40 degrees F or lower when delivered to residents.
12. During an interview on 9/29/23 at 9:50 A.M. the Administrator said she expected food to be delivered to residents at the proper temperature. She expected staff to follow the facility's policy and procedures to ensure proper food temperatures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow one resident's (Resident #222) wishes of Do Not Resuscitate (DNR, instructs health care providers not to do cardiopulmonary resuscitation (CPR, a lifesaving technique useful in which someone's breathing or heartbeat has stopped) if a patient's breathing or heartbeat has stopped). On [DATE] at 6:00 A.M., the resident was found on the floor, unresponsive and without a pulse. The nurse obtained the wrong chart and performed CPR on the resident for approximately 15 minutes prior to realizing the error. In addition, five out 26 residents reviewed for code status had code status/physician's orders for code status sheets not signed by the physician (Residents #102, #19, #99, #372, and #371). The census was 148 with 129 in certified beds.
Review of the facility's Life Sustaining Treatment policy, last reviewed [DATE], showed:
-Purpose: It is the purpose of this policy to help the facility honor a resident's wishes and comply with federal and state laws concerning the resident's right to make decisions relating to his or her own medical care, including the right to accept, refuse or limit life-sustaining treatment;
-Responsibility: It is the direct responsibility of the nurse responding to the imminent situation requiring the implementation of this policy to know and comply with such policy. The Director of Nursing (DON) is responsible for monitoring the policy. It is the ultimate responsibility of the Administrator to ensure compliance with the policy;
-Policy included:
-The facility recognizes the rights of its residents to make informed decisions about their medical care, including the right to accept, refuse or limit medical treatment, including life-sustaining care, and the right to formulate advance directives;
-It is the policy of the facility to comply with the applicable law and to promote patient self-determination by encouraging the use of advance directives and honoring the treatment preferences expressed by the residents in their advance directives;
-The following are guidelines for requests from the resident or legal representative for withholding or withdrawing life-sustaining treatment;
-When a competent resident, after consultation with the attending physician, voluntarily and knowingly decides that no life-sustaining treatment should be provided, and documents this decision;
-When a resident who can no longer make decisions for him/herself has an advance directive that directs that life-sustaining treatment is to be withheld or withdrawn and the legal representative or surrogate family member document this decision on the CPR/Treatment Directive, form;
-The requests will be honored until the facility receives a written or oral notification from the appropriate decision-maker of a change of the decision, an oral decision must be followed up in writing and a physician order obtained;
-If there is neither an advance directive nor any of the above stated requests, the physician's order will reflect that CPR will be initiated and 911 will be called in the event of a cardiac arrest;
-The physician cannot order no CPR until the appropriate documentation is received from the resident and/or legal representative;
-Practice included:
-Upon admission the resident will be made aware of his/her right to make informed decisions through the information contained in the Resident Handbook and other materials furnished by Social Services and/or the Business Office;
-Should a resident have an advance directive, it will be filed in the front of the resident's medical record;
-In Missouri, a CPR/Treatment Directive order form will be completed according to the advance directive and signed by the physician and the resident or his/her legal representative or surrogate family member. In order to facilitate obtaining a physician order, the form may be faxed for the physician signature or a nurse may take a telephone order;
-NOTE: In Missouri, if the directive indicates the resident has chosen not to be resuscitated (No CPR), an Out of Hospital Do-Not-Resuscitate (OHDNR) form must also be completed. This is the purple form. If a resident has chosen to be resuscitated or not to be resuscitated, staff need to quickly know whether to initiate CPR or not. The CPR/Treatment Directive in the resident's medical record needs to be quickly reviewed if resident is requiring emergent treatment as this directive supersedes other forms of code information if conflicting;
-If there is no advance directive, the CPR/Treatment Directive form will be completed to reflect CPR will be initiated and 911 will be called. If the CPR directive is not filled out with preference, CPR should be initiated;
-The physician's signature on the monthly order will constitute a renewal of the CPR/Treatment Directive. The order will remain in effect unless the decision is rescinded. If this occurs, the physician will immediately be notified and a new CPR/Treatment Directive order will be obtained reflecting the new decision;
-Social Services staff is responsible for reviewing and documenting this review of the CPR Treatment Directive on an annual basis in the medical record and on the back of the CPR/Treatment Directive Form. A new CPR/Treatment Directive only needs to be initiated if their directives change;
-The CPR/Treatment Directive will be maintained in the medical record directly behind the OHDNR form, if applicable. Otherwise, the CPR/Treatment Directive form will be maintained directly behind the face sheet. Be sure only the current CPR/Treatment Directive form is in the medical record.
1. Review of Resident #222's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed:
-admission date [DATE];
-Cognitively intact;
-Diagnoses included Parkinson's disease (movement disorder), metabolic encephalopathy (brain dysfunction), dementia and repeated falls.
Review of the resident's care plan, undated, showed:
-Resident was alert and oriented times 3 to 4;
-No documentation related to code status.
Review of the resident's electronic medical record (EMR), showed no documented signed code status.
Review of the resident's electronic physician order sheet (ePOS), showed an order, dated [DATE], to follow CPR/Treatment Directives with no specific code status indicated.
Review of the resident's Post Fall Evaluation, dated [DATE], showed:
-Fall occurrence date, time of fall: [DATE], 6:00 A.M.;
-Description of fall: Unknown, found on floor;
-Post Fall Evaluation Findings:
-Orientation Assessment: Not oriented to person. Not oriented to place. Not oriented to situation. Not oriented to time;
-Post Fall Injury:
-Injury Type: Laceration to right side of forehead with visible bruising. Noticeable deformity to nose;
-Family member notified;
-Team Meeting Notes: Around 6:00 A.M., resident was found unresponsive by Certified Nurse Aide (CNA). When observing resident's body, the resident had a noticeable laceration to his/her right forehead. There was a small amount of blood. Resident was cool to the touch and his/her skin was pale. Resident was absent of a pulse. Resident's nose was noticeably deformed, crooked to the side. A STAT (immediate response) was called and CPR was rendered and continued after realizing that he/she was a DNR. Paramedics stopped CPR at 7:00 A.M.
Review of the resident's Use of Automated External Defibrillator (AED, portable, life-saving devices used to treat people experiencing sudden cardiac arrest, a medical condition in which the heart stops beating suddenly and unexpectedly) Event Summary Form, dated [DATE], showed:
-Date of event: [DATE];
-Established that patient is a Full Code resident: Yes;
-By whom: Licensed Practical Nurse (LPN) H;
-Was CPR given before the AED arrived: Yes;
-If yes, by whom: LPN F;
-Time AED applied: 6:13 A.M.;
-Were shocks given: No;
-Name of person completing form: LPN F.
Further review of the resident's EMR, showed a handwritten statement from the facility's Corporate Physician, dated [DATE], in which the physician documented a review of the code on resident that occurred on [DATE]. The resident was found unresponsive with no pulse and a noticeable laceration on right forehead due to a recent fall. It was initially thought that the resident was a full code so 911 was called and CPR rendered. After starting CPR, the AED was applied but no shock was given. It was subsequently realized that the resident was not a full code (DNR) and then the paramedics stopped giving CPR and the code was stopped. In my opinion, no code should have been called, no CPR should have been performed. The DNR status was eventually realized and the code was stopped.
Review of the facility's incident report, dated [DATE], showed:
-Date and time of incident: [DATE] at 6:00 A.M.;
-Select the type of incident: Other;
-What was the other issue: Nurse grabbed wrong chart and verified resident code status incorrectly. Resident DNR and nurse initiated and performed full code status measures (CPR). EMS arrived and ended code once current status was verified.
Review of the facility's investigation, showed:
-The resident's hospital discharge summary, printed [DATE], with code status listed as comfort care only - DO NOT Resuscitate, documented under a physician note, dated [DATE];
-A handwritten statement from CNA G, dated [DATE], showed CNA documented the resident was last checked on around 4:00 A.M. He/She was alert and stated that he/she did not want to be changed. CNA G was able to change him/her. Did rounds later and found him/her on the floor, it was around 6:00 A.M. He/She was unresponsive. CNA G notified the nurse immediately. CPR was began;
-A handwritten statement from LPN F dated [DATE], showed LPN F documented around 5:50 A.M., during morning med pass, the resident's CNA informed LPN F that the resident appeared deceased . LPN F went to the nurse's station to grab his/her chart to verify code status. LPN F read full code status. Later on when the paramedics arrived, LPN F realized he/she accidentally grabbed the chart of the resident across the hall. He/She instructed CNA G to call a STAT while LPN F grabbed necessary materials and headed to the room. LPN F, the nursing supervisor, and both assigned CNAs were present for the code. When LPN F entered the room, resident was lying in front of the chairs near his/her nightstand. He/She was lying on his/her right side in a fetal position. He/She was cool to the touch, with a laceration to the right side of his/her forehead. His/Her skin lacked of color. LPN F instructed the CNAs to assist in getting the resident on the board and instructed CNA G to start CPR while LPN F got the AED ready. LPN ended up taking over CPR for the aide while the Nursing Supervisor was able to assist. CPR was administered for approximately 15 minutes before paramedics arrived.
During an interview on [DATE] at 11:22 A.M., the resident's family member said the facility called him/her on the day the resident passed away. The resident's code status was DNR. He/She would have expected staff to honor the resident's wishes by not performing CPR when the resident was found to have no signs of life.
During an interview on [DATE] at 7:44 A.M., LPN F said a resident's code status is documented in the front of the resident's paper chart, which is located at the nurse's station. On [DATE] at approximately 5:15 A.M., CNA G told LPN F the resident was on the floor, dead. LPN F entered the resident's room and saw the resident on his/her side on the floor with blood on the ground. The resident was cold to touch and had no pulse. LPN F went to the nurse's station to get the resident's chart and while he/she was in a state of shock and panic, he/she accidentally grabbed the chart for the resident in the room across the hall. The incorrect chart showed full code, so LPN F started performing compressions on the resident. The AED was used and LPN F and LPN H took turns performing compressions for approximately 20 minutes. When EMS arrived, they told him/her the resident was supposed to be DNR. When LPN F looked at the chart for the physician's phone number, he/she realized he/she had the wrong chart. He/She retrieved the correct chart from the nurse's station and saw the resident's code status form showed he/she was supposed to be DNR.
During an interview on [DATE] at 4:54 P.M., LPN H said on [DATE], he/she was the nurse supervisor on the night shift. Around shift change, between 5:00 A.M. and 6:30 A.M., CNA G said something to alert LPN F and LPN H to go to the resident's room. The nurses responded and found the resident on the floor. It was immediately obvious the resident was deceased . LPN H assessed the resident and the resident did not have a pulse, respirations, or any signs of life. LPN F grabbed the resident's chart while LPN H stayed with the resident. LPN F said the resident was full code and the nurses started CPR. The AED was used and compressions were performed. CPR was attempted for approximately 10 to 15 minutes before EMS arrived. EMS made staff aware that the resident was DNR, not full code.
During an interview with the Administrator, DON, and Corporate Director of Clinical Services (CDCS) on [DATE] at 8:38 A.M., the CDCS said she was the facility's DON in [DATE], when the resident was found unresponsive. The resident was found on the floor and it was assumed he/she had an unwitnessed fall. Someone grabbed the wrong chart and initiated CPR because the chart they looked at said full code. The AED was used. At some point, staff realized they had the wrong chart and the resident was supposed to be DNR. Staff sense of emergency likely contributed to why the wrong chart was retrieved. An in-service was completed with staff to review the facility's Life Sustaining Treatment policy and to ensure staff have the correct chart when a resident is found unresponsive. The resident's paper chart should have been located and searched for a signed code status.
Review of the facility's in-services, showed:
-In [DATE], training topic: Code Status, CPR vs. DNR, Rapid Response;
-15 nurses in attendance, not including LPN F;
-The facility's Life Sustaining Treatment policy attached;
-Supplemental Rights of CPR in-service record, showed on [DATE] and [DATE], the following topics:
-Right chart: Do you have the right chart?;
-Check code status: Are they DNR or full code?;
-Right patient: Visually verified by two staff;
-Team member gets AED if full code.
During an interview on [DATE] at 8:43 A.M., the DON said she looked everywhere through the resident's paper chart and could not find a signed code status.
2. Review of Resident #102's paper chart, showed:
-Diagnoses included coronary artery disease (CAD, a disease caused by plaque buildup in the wall of the arteries that supply blood to the heart), heart failure (a condition that develops when the heart doesn't pump enough blood for the body's needs) and dementia;
-A CPR/Treatment Directive Physician Order (CPR/TDPO) sheet, showed CPR was to be withheld in the event of a medical emergency per the resident's wishes. The document was signed by the resident's representative on [DATE], and was not signed by a physician;
-An OHDNR Order sheet, showed CPR was to be withheld in the event of a medical emergency per the resident's wishes. The document was signed by the resident's representative on [DATE], and was not signed by a physician.
During an interview on [DATE] at 9:37 A.M., the resident's representative said the family and resident had made the decision to change the resident's resuscitation status to DNR this year due to decline in cognitive status and advanced age. The resident's representative had not been notified whether or not the DNR order had been signed by a physician.
3. Review of Resident #19's quarterly MDS, dated [DATE], showed:
-Cognitively intact:
-Diagnoses included high blood pressure, renal insufficiency (partial kidney function failure characterized by less than normal urine excretion), diabetes and high cholesterol.
Review of the resident's paper chart on [DATE] at 7:25 A.M., located on the second floor nurse's station, showed:
-A CPR/TDPO sheet showed:
-Cardiac or respiratory arrest, select status A or B in the event of cardiac arrest. If no option is chosen, CPR protocol will be initiated;
-Option B, no CPR protocol will be initiated was marked;
-The line for the resident's/resident's representative signature showed handwritten: Verbal consent via phone [DATE] at 11:50 A.M. with a family member's name;
-The line for print name of resident/resident representative was signed by the facility Social Worker;
-There was no physician signature;
-An OHDNR sheet, showed:
-The line for resident's/resident's representative signature showed handwritten: Verbal consent via phone [DATE] at 11:50 A.M. and signed by the facility Social Worker, dated [DATE];
-There was no physician signature.
Review of the paper chart on [DATE] at 8:00 A.M., showed the MD signed the CPR/TDPO sheet and the OHDNR on [DATE].
During an interview on [DATE] at 1:58 P.M., the resident said he/she had been at the facility for three and half years and no one had talked with him/her about code status preference. He/she wanted to be revived (CPR).
During an interview on [DATE] at 9:05 A.M. and [DATE] at 11:15 A.M., the Social Worker (SW) said she reviewed a resident's code status upon admission the facility, yearly, and during care plan meetings. After the code status form was completed, it was placed in front of the resident's paper chart until the physician came to the facility. Then, the SW removed the form from the chart for the physician to sign. There was no tracking system or list of sheets that required physician signature. She only went by memory or made a few notes on her desk. If the resident was alert and orientated times four (person, place, time and situation), staff would usually ask the resident what their code status was. If the resident was alert and orientated times two or three, staff would usually ask a family member what the code status was, but it varied case by case. Resident #19 was alert and oriented times three but had some developmental delays, so the SW called the resident's family regarding the resident's code status. If a code status sheet was not signed by the physician, it was nursing staff's decision on how to intervene if the resident was found unresponsive.
4. Review of Resident #99's admission MDS, dated [DATE], showed:
-Moderately impaired cognition;
-Diagnoses included anemia (decrease in number of red blood cells), atrial fibrillation (a-fib, irregular heart rhythm), high blood pressure, renal insufficiency, arthritis and dementia.
Review of the resident's paper chart, located on the second floor nurse's station, on [DATE] at 7:00 A.M., showed:
- A CPR/TDPO sheet, showed:
-Option B, no CPR protocol will be initiated;
-The line for the resident's/resident representative's signature was signed by the family and dated [DATE];
-There was no physician signature;
-The OHDNR order sheet, showed:
-The line for the resident's/resident's representative showed handwritten: Verbal consent via phone [DATE] at 10:15 A.M. and signed by the facility Social Worker, dated [DATE];
-There was no physician signature.
Review of the resident's paper chart on [DATE] at 8:00 A.M., showed:
-The physician signed the CPR/TDPO sheet;
-The OHDNR did not have a physician signature.
5. Review of Resident #372's EMR, showed:
-admitted on [DATE];
-Diagnoses included right shoulder rotator cuff tear, high blood pressure, glaucoma (eye conditions that can cause blindness), diabetes and high cholesterol.
Review of the resident's paper chart, showed:
-An admission Report Sheet, with Code Status as DNR;
-A CPR/TDPO sheet, showed checked No CPR protocol will be initiated, signed by the resident's representative, dated [DATE], not signed by physician;
-A purple OHDNR sheet signed by the resident's representative, not dated and not signed by the physician.
During an interview on [DATE] at 1:33 P.M., the resident said he/she signed DNR sheets upon admission and would like to continue his/her code status preference.
6. Review of Resident #373's EMR, showed:
-admitted on [DATE];
-Diagnoses included altered mental status, high blood pressure and dysphagia (difficulty swallowing).
Review of the resident's paper medical record, showed:
-An admission Report Sheet, with Code Status as Full Code;
-A CPR/TDPO sheet, showed CPR protocol will be initiated, signed by the resident or representative, not dated and not signed by physician.
During an interview on [DATE] at 8:06 A.M., the resident's representative said a Full Code status for the resident was signed, and he/she wanted to continue CPR protocol to be initiated if the resident stopped breathing.
During an interview on [DATE] at 8:44 A.M., LPN E said a resident's code status was filed in their paper charts only, not in the electronic record. Facility staff did not rely on the admission Report Sheet located in the front of a resident's chart because it only contained information from the previous facility from where the resident lived. The information was not updated. The resident or their representative was asked for their code status preference and would sign the CPR/TDPO sheet provided by the facility. If the resident preferred DNR, the purple OHDNR sheet would be added to the CPR/TDPO sheet. The sheets were to be placed in the resident's chart. After the resident signed the sheets, they were placed in the resident's chart. Copies were provided for the physician to sign during their next visit to the facility. LPN E did not know where those copies were placed for the physician to sign. The code status sheets for Residents #372 and #373 were not signed by the physician because the residents were newly admitted to the facility.
7. During an interview on [DATE] at 7:25 A.M. and [DATE] at 8:20 A.M., LPN C said if a resident was unresponsive, he/she would check the resident for signs of life. If the resident had no signs of life, he/she would call for help. He/She knew all the residents' code statuses. If staff did not know a resident's code status, they could check the resident's paper chart. If the resident was a full code, LPN C would grab the crash cart and start CPR. If the resident was a DNR, no CPR would be started. Nursing staff and the SW were responsible for obtaining the resident's code status. Once the form was signed by the resident/resident representative, the form went to the physician folder for the physician to sign the next time they are at the facility. Or the nurse might fax the form to the physician to have them sign and fax it back. Residents needed a physician order for code status. If the resident was alert and oriented times four and the resident said they wanted to be a DNR, but the code status sheet was not signed by the physician, LPN C would not do CPR if the resident coded. He/She had to honor the resident's wishes. If LPN C did not know the resident or the resident's family, he/she would do CPR.
During an interview on [DATE] at 7:36 A.M., LPN I said if a resident was found unresponsive, he/she would stay with the resident and have another employee immediately pull the resident's chart from the nurse's station. A resident's code status was only documented in the resident's paper chart, not the EMR. If a resident's code status sheet was not in the paper chart, staff would assume the resident was full code.
During an interview on [DATE] at 8:20 A.M., LPN I said if a resident who was alert and oriented times four signed a DNR form, but the form was not signed by the physician, he/she would not do CPR if the resident was found unresponsive.
8. During an interview on [DATE] at 8:45 A.M., Nurse Manager D said the code status forms were completed when a resident was admitted . Code status forms were reviewed annually or if the resident or resident representative came to staff and requested a change. If the resident was a full code, the physician did not need to sign the form. If the resident was a DNR, the physician needed to sign the order forms. Staff were responsible to have the physician sign the CPR/TDPO sheet and the OHDNR sheet. These forms were signed by the physician, usually within a few days from when the resident/resident representative signed them. If a resident was found unresponsive, staff would yell out and Nurse Manager D would respond to the code. They would pull the resident's paper chart to check the resident's code status. If the resident was a full code, they would begin CPR and if the resident was a DNR, they would assess the resident and notify the physician and family. If the physician did not sign the code status sheet, staff would follow their policy.
9. During an interview with the Administrator, DON, and CDCS on [DATE] at 8:38 A.M., the CDCS said a resident's code status was listed on a CPR/TDPO sheet, which would be in the front of a resident's paper chart. Paper charts were located at each nurse's station. A resident's code status was not listed in the EMR or any other location. Code status was listed in one place, the paper chart, to ensure less room for error. It was unknown if nursing report sheets indicated a resident's code status. Report sheets were updated by the unit secretary. If a resident was found unresponsive, staff would consult the resident's paper chart and follow the facility's Life Sustaining Treatment policy. Staff would ensure they had the correct paper chart by looking at the name on the outside of the chart, not just the room number. The CPR/TDPO sheet indicated whether a resident was full code or DNR. This document also served as a physician order for code status. All CPR/TDPO sheets needed to be signed by the physician. The CPR/TDPO sheet was provided to residents or their representatives by the nurse upon admission and would be signed by the physician within the timeframe indicated in the Life Sustaining Treatment policy. The SW reviewed code status with residents annually, during care plan conferences and as desired by the resident. If a CPR/TDPO sheet indicated the resident wished to be DNR, but the order was not signed by the physician, staff were expected to follow the policy and treat the resident as full code. If a CPR/TDPO sheet had not been filled out by the resident, it would be expected for staff to treat the resident as full code. Staff were expected to follow the facility's policy for resident code status preference.

Based on interview and record review, the facility failed to follow their Inventory Control of Controlled Substances policy when staff failed to count/document daily controlled substances. 26 controlled substance shift change count sheets (narcotic sheets) were reviewed and issues were found with 18. The census was 148 with 129 in certified beds.
Review of the facility's Inventory Control of Controlled Substances policy, last reviewed 8/2022, showed Community should ensure that incoming and outgoing nurses count all Scheduled II-V controlled substances (a drug or chemical whose manufacture, possession and use is regulated by a government) and Tramadol (medication used to treat pain) daily with both (staff) documenting verification on the Controlled Substance Log.
1. Review of the July 2023 Controlled Substance Shift Change Count sheet for the 2 Rehab Unit, showed 10 out of 31 opportunities had only one staff member's initials.
Review of the July 2023 Controlled Substance Shift Change Count sheet for the 2 Rehab Unit (second sheet), showed 15 out of 31 opportunities had only one staff member's initials.
Review of the July 2023 Controlled Substance Shift Change Count Sheet for the North Unit, showed:
-Three out of 31 opportunities had only one staff member's initials;
-Two out of 31 opportunities had no staff initials.
Review of the July 2023 Controlled Substance Shift Change Count Sheet for the South Unit, showed two out of 31 opportunities had only one staff member's initials;
Review of the July 2023 Controlled Substance Emergency Drug Supply Shift Change Record for the 1 Rehab Unit, showed:
-Seven out of 31 opportunities had only one staff member's initials;
-Six out of 31 opportunities had no staff initials.
Review of the July 2023 Controlled Substance Emergency Drug Supply Shift Change Record for the 1 Rehab Unit (second sheet), showed:
-Seven out of 31 opportunities had only one staff member's initials;
-Six out of 31 opportunities had no staff initials.
2. Review of the August 2023 Controlled Substance Emergency Drug Supply Shift Change Record for the 2 Rehab Unit, showed:
-Eight out of 31 opportunities had only one staff member's initials;
-One out of 31 opportunities had no staff initials.
Review of the August 2023 Controlled Substance Shift Change Count sheet for the 2 Rehab Unit, showed four out of 31 opportunities had only one staff member's initials.
Review of the August 2023 Controlled Substance Shift Change Count Sheet for the 2 Rehab Unit, showed:
-6 out of 31 opportunities had only one staff member's initials;
-Two out of 31 opportunities had no staff initials.
Review of the August 2023 Controlled Substance Shift Change Count Sheet for the North Unit, showed:
-Four out of 31 opportunities had only one staff member's initials;
-Two out of 31 opportunities had no staff initials.
Review of the August 2023 Controlled Substance Shift Change Count Sheet for the South Unit, showed three out of 31 opportunities had only one staff member's initials.
Review of the August 2023 Controlled Substance Emergency Drug Supply Shift Change Record (no location was noted on the form), showed:
-Three out of 31 opportunities had only one staff member's initials;
-Two out of 31 opportunities had no staff initials.
Review of the August 2023 Controlled Substance Emergency Drug Supply Shift Change for the 1 Rehab Unit, showed:
-Five out of 31 opportunities had one staff member's initials;
-Three out of 31 opportunism had no staff initials.
3. Review of the September 2023 Controlled Substance Shift Change Count Sheet for the 2 Rehab Unit, showed:
-Four out of 28 opportunities had only one staff member's initials;
-One out of 28 opportunities had no staff initials.
Review of the September 2023 Controlled Substance Shift Change Count Sheet for 2 Rehab Unit, showed four out of 28 opportunities had only one staff member's initials;
Review of the September 2023 Controlled Substance Shift Change Count Sheet for the Front Hall, showed:
-Six out of 28 opportunities had only one staff member's initials;
-Two out of 28 opportunities had no staff initials.
Review of the September 2023 Controlled Substance Shift Change Count sheet for the back hall, showed five out of 28 opportunities had only one staff member's initials.
Review of the September 2023 Controlled Substance Emergency Drug Supply Shift Change Record (no location was noted on the form), showed:
-Five out of 28 opportunities had only one staff member's initials;
-Three out of 28 opportunities had no staff initials.
4. During an interview on 9/26/23 at 11:01 A.M., Registered Nurse O said he/she would follow the facility's policy for counting controlled substances. Two nurses, one on coming and one off going, would count the controlled substances and sign the narcotic book. If one of the nurse was not available to count, he/she would get another nurse to count and sign the book with him/her.
5. During an interview on 9/29/23 at approximately 7: 50 A.M., Certified Medication Technician (CMT) J said the CMT and nurses count controlled substances at the beginning and end of each shift. He/She counted the number of packages and then they count the number of pills on each card and compare that to the number on the sheet. Once they verified the count was correct they both signed the sheet in the front of the narcotic book. You had to count before you left, and you had to sign the book at the beginning and the end of each shift. If the nurse was not available you had to get another nurse to count with you.
6. During an interview on 9/29/23 at 7:55 A.M. Licensed Practical Nurse (LPN) Q said two nurses counted control substances. One nurse who was leaving and one nurse who was coming on the shift counted at the beginning and at the end of their shifts. The counts were documented on the sheet in front of the narcotic book. If another nurse was not available to count controlled substances he/she would get a supervisor or a manager to count with him/her. A blank on the count sheet meant the count was not done.
7. During an interview on 9/29/23 at 8:03 A.M., Nurse Manager D said the process for staff to count controlled substances was for one staff member, either the nurse or the CMT, from the oncoming shift and one nurse or CMT from the off going shift count the controlled substances and document them on the controlled substance shift change count sheet located in the front of the narcotic book at the change of each shift. If one nurse/CMT was not available to count, the staff member would ask a Nurse Manager or a supervisor to count with them. There was always someone there to count with staff. A blank on the controlled substance shift change sheet could have been because the staff member worked over onto the next shift. The staff member could have worked 12 or 16 hour shifts in place of eight hour shifts.
8. During an interview on 8/29/23 at 8:35 A.M., LPN R said either two nurses or one nurse and one CMT could count controlled substances. They were counted at the beginning and at the end of each shift and documented on the sheet in the front of the narcotic book. Both staff members documented on the sheet. If a nurse or CMT was not available to count with LPN R, he/she would ask a supervisor to count with him/her.
9. During an interview on 8/29/23 at 11:00 A.M. the Director of Nursing said controlled substances only needed to be counted once daily. Staff could count the controlled substances more but not less than daily. She expected staff to follow the facility policy for counting and documenting controlled substances.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 28 opportunities for errors, three errors occurred, resulting in a 10.71% medication error rate (Residents #11, #7 and #272). The sample was 26. The census was 148 with 129 in certified beds.
Review of the facility's Medication Administration-General Guidelines Policy, revised 6/2023, showed:
-Policy: Only a licensed nurse or Certified Medication Technician (CMT) may prepare, administer and/or record the administration of medications. Medications must be administered in accordance with a physician's order (i.e., the right resident, the right medication, the right dosage, the right route and the right time). Medications must always be prepared, administered and recorded by the same nurse/CMT;
-Administration:
-Each resident will have his/her own supply of medications, excluding stock medications;
-Initial on Medication Administration Record (MAR) after each dose is administered;
-After medication pass, check to see that all medications were administered;
-Reorder when three (3) to five (5) day supple remains;
-Reordering and refilling is a daily task for the nurse/CMT at the end of each medication pass. The day shift shall have the primary responsibility for re-ordering medications. Other shifts need to reorder medications that might be given only on their shift and as needed (PRN) medications as needed;
-If the medication is unavailable any time, the Nursing Supervisor should be contacted and may obtain medication from the emergency drug supply or contact the physician to try to obtain an alternate order;
-Medications must be passed within one (1) hour before or after the scheduled time unless specified otherwise;
-General Guidelines:
-There are five (5) storage areas for oral medication:
a. Active working (routine cards);
b. Routine liquids;
c. PRNs;
d. Backup (refills);
e. Refrigerator for medications requiring refrigeration.
1. Review of Residents #11 quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/30/23, showed:
-Diagnoses included high blood pressure and edema (swelling);
-Cognitively intact.
Review of the resident's electronic physician order sheet (ePOS) showed an order dated 3/2/20, for Lasix (water pill) 20 milligram (mg) 1 tablet daily for edema (swelling).
During a Medication administration observation on 9/26/23 at 7:30 A.M., CMT B administered and verified the resident's medications scheduled for 8:00 A.M., five medications administered. Lasix was not one of the medications administered or verified. CMT B failed to administer the resident's ordered Lasix.
During an interview and observation on 9/26/23 at 10:52 A.M., CMT B said medications for the resident were verified and administered this morning. Lasix was not one of the medications administered or verified. He/She pulled the medication routine card out the drawer while saying he/she thought he/she gave it. No pills were missing from the unused card. He/She said he/she did not give it.
During an interview on 9/27/23 at 10:41 A.M., the Director of Nursing (DON) said she would expect staff to follow the five rights for medication administration, the right resident, the right medication, the right route, the right time and the right dose of medication. Staff is expected to document medications accurately. She would expect staff to follow the doctor orders, facility's policy and procedures if a documentation error occur.
2. Review of Resident #7's quarterly MDS, dated [DATE], showed:
-Diagnoses included high blood pressure and chronic obstructive pulmonary disease (COPD, lung disease);
-Cognitively intact.
Review of the resident's ePOS, showed an order dated 12/23/21, for Lisinopril (treats high blood pressure) 20 mg 1 tablet daily.
During observation and interview on 9/26/23 at approximately 7:40 A.M., CMT B administered eight of nine medications ordered. Lisinopril was not administered. He/She said Lisinopril was not available on the medication cart. He/She went to the medication room to check the supply and the medication was not available. CMT B said the medication should be at the facility later today at 12:00 P.M. or 3:00 P.M.
During an Interview on 9/26/23 at 10:50 A.M., CMT B said medication had not come in yet and was not administered. Review of the medication administration record (MAR) with CMT B, showed that the medication was documented as given at 7:42 A.M. He/She looked in the computer on the medication cart and said I must have accidentally pushed the button to say I gave it, I will change it.
During an Interview on 9/28/23 at 07:49 A.M., Licensed Practical Nurse (LPN) C said when medications are not on the medication cart the staff should check the medication room emergency medication dispenser. Staff should notify the charge nurse and they will call the pharmacist and notify the doctor. If the charge nurse is not available the nurse manager will call the pharmacist or check the emergency medication dispenser. The charge nurse should follow up with the nurse manager. Documentation should be located on the MAR. The CMT/nurse should document not available.
During an Interview on 9/28/23 at 07:57 A.M., Nurse Manager D said documentation on the MAR should say not given. A note stating physician was notified should go into the electronic chart. Nurses and CMTs are expected to document that information. The staff is expected to follow policy. There should be training on the medication administration process.
During an Interview on 9/29/23 at 9:41 A.M., with the Administrator and DON, they said when staff administer medications they are expected to follow the facility policy. The emergency medication dispenser is for emergency medications or if staff need medication or items that are not on their cart. Nursing/CMT staff both have access. If a resident does not have a medication on the medication cart the staff is expected to check the emergency medications. The emergency medication dispenser will let you know if the tablets are on hand or not. Currently, the emergency medication dispenser showed ten Lisinopril 10 mg tablets available. Staff is expected to document medications accurately when given and to follow policy. If medication is unavailable staff is expected to follow policy. If a medication documentation error is made staff should follow policy and procedures.
3. Review of Resident #272's admission MDS, dated [DATE], showed:
-Cognitively intact;
-Diagnoses included: diabetes.
Review of the resident's ePOS, dated 9/28/23, showed;
-An order for: Degludec insulin (long acting insulin) flex pen 200 units/milliliter (ml) subcutaneous (under the skin) solution, inject 56 units subcutaneous daily, start date was 9/19/23.
Observation on 9/26/23 at 8:15 A.M., showed Certified Medication Technician (CMT) J, prepared medications for Resident #272. CMT J reached into the top drawer of the medication cart and grabbed a bag with an insulin pen in it. He/She turned the dial on the insulin pen to prime two units of insulin. Then, he/she turned the dial to 56 units of insulin. The surveyor observed the insulin pen and bag and noted it was for a different resident. The name on the insulin pen and on the medication bag label was for Resident #372. CMT J said he/she grabbed the wrong insulin. He/She looked in the drawer and did not see Resident #272's insulin. He/she went to the refrigerator and obtained a new insulin pen for the resident and administered the insulin.
During an interview on 9/27/23 at 10:41 A.M., the DON said she would expect staff to follow the five rights for medication administration, the right resident, the right medication, the right route, the right time and the right dose of medication and she would expect staff to follow physician orders and the facility's policies and procedures.

Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled and stored per acceptable standards of practice. The facility identified five medication rooms, 10 medication carts, five treatment carts and one respiratory cart. Three of five medication rooms, two of five treatment carts, five out of ten medication carts and one of one respiratory carts were checked for medication storage. Issues were found with one medication room when staff failed to date one opened vial of purified protein derivative (PPD, used in skin test to help diagnose silent (latent) tuberculosis (TB) infection) and one treatment cart, when staff failed to date six out of 10 opened insulin pens and one medication cart and when staff failed to date one out of two opened insulin pens and stored one vial of PPD on the medication cart. The census was 148 with 129 in certified beds.
Review of the facility's Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles policy, revised on 10/31/16, showed;
-Once any medication or biological package is opened, facility staff should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened;
-Facility staff may record the calculated expiration date based on date opened on the medication container;
-Facility staff should ensure that medications and biologicals are stored at their appropriate temperatures according to the United States Pharmacopeia guidelines for temperature ranges. Facility Staff should monitor the temperature of vaccines twice a day. Refrigeration temperature ranges: 36° to 46° Fahrenheit (F).
Review of the facility's Insulin Administration and Storage policy, revised 8/2022, showed: The nurse who opens the vial of insulin/insulin pen will be responsible for checking the manufacturer's expiration date and will date the bottle indicating the expiration date once opened. This will be 14 to 42 days after opening for most products or the manufacturer's expiration date, whichever comes first.
Observation and interview on 9/26/23 at 10:45 A.M., showed the second floor medication room refrigerator contained one vial of PPD , opened with no date on the vial or on the box. Licensed Practical Nurse (LPN) C looked at the vial and asked LPN I if he/she knew when the vial was opened. LPN I said the vial was opened yesterday (9/25/23) because there was a new admission. LPN C said the PPD vial was good for 30 days and wrote OD (open date) 9/25/23 and DD (discard date) 10/25/23 on the box.
Observation and interview on 9/26/23 at 10:50 A.M., showed the second floor treatment cart, contained six out of 10 insulin pens with no date. Nurse Manager D for Unit 200 said all the insulin were dated on Friday (9/22/23), and staff must have recently refilled the insulin. Insulin should be dated when it was opened. Whomever opened the insulin was responsible for dating the insulin. The Nurse Manager said the insulin should have been dated when it was opened.
Observation and interview of the first floor front rehab medication cart on 9/26/23 at 11:01 A.M., showed one of two insulin pens without a date. Registered Nurse (RN) O said he/she did not know when the insulin pen was opened. Certified Medication technician (CMT) P said the insulin was in a clear bag yesterday (9/25/23) and he/she thought the insulin pen had a sticker on it. The sticker was not on the insulin today and he/she did not know where the clear bag the insulin was in yesterday was. In the top drawer of the medication cart was one vial of PPD. The directions on the box of PPD showed the medication should be stored between 36 to 46 degrees F. RN O said the PPD was started yesterday. They had three new vials of PPD in the refrigerator yesterday and today there were only two. The PPD should have been stored in the refrigerator and it should have been dated 9/25/23.
During an interview on 9/27/23 at 10:41 A.M., the Director of Nursing said she expected staff to follow the facility's policy for storing PPD vials and dating insulin.

Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 25 opportunities observed, three errors occurred resulting in a 12% error rate (Resident #417). The census was 201 with 164 in certified beds.
Review of the Resident #417's electronic physician order sheet (ePOS), showed:
-An order dated 1/27/20, for amiloride (diuretic) 5 milligram (mg) daily;
-An order dated 1/28/20, for Losartan (used to treat high blood pressure) 100 mg daily;
-An order dated 2/3/20, for prednisone (steroid) 5 mg. Administer one tablet daily.
During a medication administration observation on 2/5/20 at 8:18 A.M., Certified Medication Technician (CMT) B administered medications to the resident. He/she administered prednisone 5 mg, four tablets to equal 20 mg. He/she failed to administer amiloride and Losartan to the resident.
Review of the resident's medication administration record, reviewed on 2/5/20 at 10:50 A.M., showed the resident's morning medications documented as administered at 8:20 A.M. Staff documented the resident's amiloride and Losartan administered at the same time as the other medications administered during the medication administration observation.
During an interview on 2/6/20 at 9:33 A.M., the Director of Nursing said she would expect medications be administered as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow the facility policy and ensure an indwelling urinary catheter (a tube that collects urine from the bladder and leads to a drainage bag) drainage bags remained off the floor for multiple days of the survey. The facility also failed to ensure a catheter drainage bag remained covered and unexposed to the hallway. This affected two of the five residents identified by the facility as having an indwelling urinary catheter (Residents #317 and #155). The census was 201 with 164 in certified beds.
Review of the facility's catheter care policy, revised 4/2019, showed:
-Purpose: To provide guidelines for proper care of the indwelling catheter and drainage bag to prevent complications;
-Responsibility: It is the responsibility of all nursing staff to know and follow the procedure;
-Policy: Catheter care is performed each shift and as needed to keep the catheter clean;
-Catheter care practice:
-Check the catheter drainage and tubing at the beginning of the shift;
-Privacy bags or dignity flap should be used for all urinary drainage bags. Privacy bags should be positioned so the bag does not touch the floor. If the resident is in a low bed, a bath basin may be used to place the drainage or privacy bag.
1. Review of Resident #317's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/23/20, showed:
-Used a urinary catheter;
-Diagnoses included benign prostatic hyperplasia (BPH, enlarged prostate and can cause blocked urinary flow), anxiety, respiratory failure and cancer.
Review of the resident's electronic physician order sheet (ePOS), showed:
-An order dated 1/31/20 for an indwelling urinary catheter size 16 French (FR, size) drain to gravity for BPH and provide catheter care each shift.
Review of the resident's care plan, dated 1/31/20, showed:
-Problem: The resident used a catheter and also has bowel incontinence;
-Interventions: Staff to keep the catheter bag off the floor and below the level of the bladder without dependent loops. Make sure catheter is secured and covered;
-Goal: Staff prevent infection and maintain privacy and dignity when in public area and also remain free of adverse reactions.
During an interview on 2/3/20 at 10:45 A.M., the resident's family member said the resident had been recently readmitted into the facility. The resident currently received hospice services for cancer and had been readmitted to the facility with a catheter. Observation at this time, showed the resident's catheter drainage bag lay directly on the floor, not in a privacy bag and no barrier noted between the floor and the drainage bag.
Further observations of the resident's drainage bag during the survey, showed the drainage bag on the bare floor, not in a privacy bag and no barrier between the drainage bag and the floor on 2/4/20 at 7:36 A.M., 10:44 A.M. and 2:22 P.M., on 2/5/20 at 7:35 A.M. and 10:50 A.M., and on 2/6/20 at 6:45 A.M.
2. Review of Resident #155's ePOS, showed:
-An order dated 9/12/19, for indwelling 16 FR catheter for obstructive uropathy (occluded urinary tract), may change as needed for infection, obstruction or when closed system is compromised;
-An order dated 11/6/19, for daily catheter care at bedtime.
Review of the resident's quarterly MDS, dated [DATE], showed:
-Moderate cognitive impairment;
-Extensive staff assistance needed for eating, toileting and hygiene;
-Used an indwelling catheter;
-Diagnoses of dementia and malnutrition.
Review of the resident's care plan, updated on 1/2/20, showed:
-Problem: The resident has a urinary catheter for obstructive uropathy;
-Goal: Remain free from potential complications related to catheter use;
-Interventions: Ensure that the tubing for the catheter and catheter bag is off the floor, ensure the tubing for the catheter and bag is hanging lower than the bladder. Perform catheter care daily and as needed.
Observations during the survey, showed the catheter drainage bag exposed to the hallway and not in a privacy bag on 2/3/20 at 2:20 P.M. and 3:18 P.M., on 2/4/20 at 12:40 P.M., and on 2/5/20 at 6:40 A.M.
3. During an interview on 2/6/20 at 1:43 P.M., the Director of Nursing said that she expected staff to follow the policy. Catheter drainage bags should be kept in a privacy bag at all times. The drainage bag should be kept off the floor. If the resident is in a low bed, staff should place the drainage bag into a bath basin. If staff allowed the drainage bag to lay on the floor, the risk of infection would increase. Drainage bags should be covered for resident privacy.

Based on observation, interview and record review, the facility failed to ensure staff provided treatment in accordance with professional standards of care, when the facility administered a tube feeding for one resident (Resident #148) while the resident lay flat in the bed. The sample was 32. The census was 201 with 164 in certified beds.
Review of Resident #148 admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/15/20, showed the following:
-The resident had severe cognitive impairment;
-The resident needed extensive to total assistance with grooming, dressing and bathing;
-Nutritional approach was marked for feeding tube;
-Diagnoses included high blood pressure, hemiplegia and hemiparesis (paralysis of the arm, leg and trunk on the same side of the body) following cerebral infarction (stroke) affecting left non-dominant side, dysphasia (deficiency on the generation of speech), dysphagia (swallowing difficulties), apraxia (inability to perform learned movement on command) following cerebral infarction, diabetes, and gastrostomy tube (G-tube, a tube is placed into the abdomen into the stomach to provide nutrition, hydration and medication).
Review of the resident's electronic physician order sheet (ePOS), dated 2/5/20, showed:
-Tube feeding water bolus (water given through the g-tube) 125 milliliters (mL) every four hours;
-Nothing by mouth (NPO);
-Tube feeding, Diabetasource 1.2 (formula for diabetic tube feeding) given by G-tube pump (a pump that delivers fluid at a set rate) give 70 mL an hour/24 hours a day.
Review of the residents comprehensive care plan, in use at time of the survey, showed:
-NPO: Nutrition/hydration risk because of advanced age, difficulty making needs known, inability to take foods orally and reliance on enteral nutrition (G-tube feedings);
-Enteral nutrition is meeting 100% of nutrition goals;
-Please provide with Diabeticsource AC at 70 mL/hour continuous with 125 mL water flush every four hours.
Observation of the resident during the survey, showed the following:
-On 2/6/20 at 7:56 A.M., the resident lay flat in bed. The tube feeding ran at 70 mL. A dry erase board, located inside the resident s room, with NPO, with an arrow pointing to have ice chips and thin liquids, dated 2/5/20 and always keep at 30 degrees in bed, hand written on it;
-On 2/6/20 at 8:10 A.M., the resident continued to lay flat in bed with the tube feeding running.
During an interview on 2/6/20 at 8:15 A.M., the Licensed Practical Nurse (LPN) D said residents who have a G-tube should have the head of bed elevated at 45 degrees when in bed. The resident is elevated at 10 degrees at this time and the resident should be elevated at 45 degrees. LPN D raised the head of the bed to 45 degrees.
During an interview on 2/6/20 at 3:15 P.M., the Director of Nursing (DON) said the resident should be positioned with the head of bed elevated when in bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure resident comprehensive care plans were implemented when staff failed to place fall mats beside a resident's bed and ensure Styrofoam plates were provided for a resident who threw plates, for two residents (Residents #99 and Resident #12) out of 32 sampled residents. The census was 201 with 164 in certified beds.
1. Review of Resident #99's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/4/19, showed:
-Severe cognitive impairment;
-One staff assist for bed mobility, transfers, dressing, toileting and personal hygiene;
-Pain, yes;
-Falls, yes, two or more;
-Diagnoses included stroke.
Review of the resident's care plan, in use during the survey, showed:
-Focus: At risk for falls related to unsteady gait, surgical boot, weakness in legs, and overall increased assistance needed for activities of daily living related to end stage disease. Resident is on hospice, he/she sometimes forgets to ask for assistance and attempts to do things on his/her own;
-Approach: Remind to ask for assistance. Low bed with fall mats on both sides.
Review of the resident's nurse's notes, showed:
-On 1/17/20 at approximately 3:55 A.M., the certified nurse's aide (CNA) assigned to resident reported to this nurse that resident was on the floor. Upon entering resident's room, resident was noted to be lying on the floor in somewhat a fetal position, alongside of the bed and facing the window. Bed in low position, call light attached to resident's gown. Bedside table was located next to bed towards the head of bed. Resident stated he/she rolled over in his/her sleep and rolled out of the bed onto the floor. He/she stated he/she hit his/her head, hematoma (bleed under the skin) noted to right side of forehead. Full head to toe assessment performed, neuro assessment within normal range of resident's baseline and vital signs stable.
Review of the resident's post fall evaluations, showed:
-On 1/17/20 at 4:56 A.M., unwitnessed fall from hi/low bed, at approximately 3:55 A.M., CNA assigned to resident reported the resident was on the floor;
-On 1/24/20 at 10:28 A.M., unwitnessed fall from regular bed, resident found on floor mat upon entering room by CNA. Nurse assessed. No apparent injuries. Resident denies any complaints of pain or discomfort;
-On 1/24/20 at 2:17 P.M., witnessed fall from wheelchair. Team meeting notes: Resident sitting in wheelchair when he/she attempted to reach forward, resulting in his/her falling forward. Resident assisted into bed, bed in low position, safety mats on the floor.
Observation of the resident during the survey, showed:
-On 2/4/20 at 12:50 P.M., the resident lay in bed, a bruise on the right side of his/her face. A fall mat folded between the resident's night stand and his/her bed. No fall mat observed on the floor, either on the right or left side of the resident's bed;
-On 2/4/20 at 1:29 P.M., the resident lay in bed. A fall mat folded between the night stand and his/her bed. No fall mat observed on the floor, either on the right or left side of the resident's bed;
-On 2/6/20 at 3:07 P.M., the resident lay in bed. A fall mat on floor on his/her right side, a second fall mat folded up beside the window. No fall mat on the floor on the resident's left side;
-On 2/7/20 at 8:53 A.M., the resident lay in bed. A fall mat on floor on his/her right side, a second fall mat folded up beside the window. No fall mat on the floor on the resident's left side;
-On 2/7/20 at 12:05 P.M., the resident lay in bed. A fall mat on floor on his/her right side, a second fall mat folded up beside the window. No fall mat on the floor on the resident's left side.
2. Review of Resident #12's quarterly MDS, dated [DATE], showed:
-Resident is rarely/never understood;
-Two staff assist for bed mobility, transfers and dressing;
-One staff assist for eating, toileting and personal hygiene;
-Wheelchair for mobility;
-Behaviors, verbal behavior towards others, 1-3 days a week;
-Behaviors, other than physical, 1-3 days a week;
-Diagnoses included heart failure, high blood pressure, diabetes, dementia, bipolar disorder and asthma.
Review of the resident's care plan, in use during the survey, showed:
-Focus: Moods and behaviors. He/she needs Styrofoam plates, bowls and cups because he/she will throw them when he/she gets agitated. He/she tends to eat with fingers, and he/she will scream out at times. Redirect able at times, if not please leave him/her alone and reproach after some time;
-Approach: Please serve food on Styrofoam dishes to prevent injury to self and others. He/she will do best when placed in a quiet area away from everyone else at meals. Resident will throw his/her food when he/she does not want it, please use plastic ware during meals.
Observation of the resident during the survey, showed:
-On 2/3/20 at 12:23 P.M., he/she was removed from the dining room during lunch after yelling out, put in room, and seated in a wheelchair facing his/her window;
-On 2/3/20 at 12:50 P.M., he/she was seated in his/her wheelchair, inside his/her room, the call light pinned to his/her shirt, which ran across his/her left arm. On the bedside table in front of the resident, a tray with a regular plate. On the plate, a hot dog, fries, and slice of cake. Also on the tray, a plastic cup filled with a red drink. His/her roommate lay in the bed adjacent to the resident;
-On 2/4/20 at 8:14 A.M., he/she lay in his/her bed, the bedside table across his/her lap. On the table, a tray with a regular plate, beside the plate, a silver lid. The resident's roommate lay in the bed adjacent to the resident.
During an interview on 2/7/20 at 8:47 A.M., Certified Medication Technician (CMT) G said the resident ate well this morning. The resident will throw everything, he/she used to throw the hard plates, but dietary brings up Styrofoam plates for his/her safety and the safety of others.
Observation and interview on 2/7/20 at 8:59 A.M., showed Dietary Aide I dodged a kick by the resident as he/she collected empty plates and utensils from the tables. Dietary Aide I said the kitchen didn't send any Styrofoam plates along with the food. The resident needs one. He/she threw his/her drink the minute he/she gave him/her a plastic glass of orange juice this morning.
During an interview on 2/7/20 at 9:18 A.M., Licensed Practical Nurse (LPN) H said the resident does have behaviors. He/she will throw, mainly his/her plates, at mealtime and it is care planned. If he/she throws his/her plate, staff will move him/her by the window and give him/her another plate. Sometimes it's due to over stimulation.
3. During an interview on 2/7/20 at 12:05 P.M., the Director of Nursing said she would expect staff to follow the resident's care plan to ensure safety.

Based on observation, interview and record review, the facility failed to ensure residents were able to self-administer medication only if the interdisciplinary team has determined that this practice is clinically appropriate, for one resident found to have medications left on the dining room table in front of the resident (Resident #73). The census was 201 with 164 in certified beds.
Review of the facility's self-administration of medication policy, revised 8/2018, showed:
-Policy: Medications may be self-administered only after the resident has been evaluated by an interdisciplinary team to determine that the resident can safely self-administer medications and with administrator/executive director approval;
-An evaluation will be completed and documented prior to allowing self-administration of medications, quarterly, with any change of condition or for any route not previously evaluated to be given;
-The evaluation will be documented in the resident's medical record on the form;
-If the evaluation indicates the resident may self-administer medications, the resident's or community member's physician must also give an order allowing the self-administration;
-Self-administration will be addressed in the resident's care plan.
Review of Resident #73's electronic physician order sheet, showed:
-An order dated 11/24/19 for Sitagliptin (Januvia, used to treat diabetes) 25 milligrams (mg) take one tablet daily for diabetes;
-No orders noted for the resident to self-administer medications.
Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/11/19, showed:
-Moderate cognitive impairment;
-No mood or behaviors;
-Diagnoses included dementia.
Review of the residents care plan, updated on 12/24/19, showed the care plan did not address self-administration of medications.
Observations on 2/6/20, showed:
-At 8:00 A.M., the resident sat at the breakfast table. A small pink circular tablet on the table next to his/her glass;
-At 8:23 A.M., a certified nurse aide (CNA) placed the resident's breakfast plate in front of the resident. The CNA slid the tablet over on the table with the plate when he/she placed the plate on the table. The CNA did not notify the nurse of the tablet on the table;
-At 8:25 A.M., Licensed Practical Nurse (LPN) E said the certified medication technician (CMT) should have remained with the resident until the resident took all of his/her medications. Generally the resident takes the medication after eating some food. LPN E obtained a paper medication cup and the resident placed the medication into the cup. LPN E placed the medication into the top drawer of the medication cart. LPN E informed the resident that CMT F would bring the medication back to him/her after he/she had eaten some breakfast. Medications should not be left unless the resident has been assessed and approved to self-administer their own medications. The resident had not been assessed to self-administer and is often confused;
-At 8:34 A.M., CMT F said that the medication on the table was the resident's ordered Januvia. He/she should have remained with the resident to observe that the resident took the medication or brought it back to the resident after he/she had eaten some breakfast.
During an interview on 2/6/20 at 9:30 A.M., the Director of Nursing said that staff should not leave medications. Residents who can self-administer medications receive an evaluation before that resident is allowed to self-administer medications. Leaving medications exposed could allow the risk for other residents to accidentally take that medication.