**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, Resident Identifier (RI) #180's medical record, the facility's policies titled Urine Sample Collection, Antibiotic Stewardship Program, Loeb's Minimum Criteria for Starting Antibiotic Therapy, Revised McGeer Criteria for Infection Surveillance Checklist, and Laboratory Services and Reporting, the facility failed to ensure RI #180 received prompt treatment after the facility's staff identified that he/she was exhibiting signs and symptoms of a Urinary Tract Infection. The facility failed to ensure a system was in place for the proper collection of urinary specimens for culture and sensitivity. Further, the facility did not have a system to ensure ordered antibiotics were administered as expected by the ordering health care provider. On [DATE] the Certified Registered Nurse Practitioner (CRNP) ordered a urinalysis (UA) for RI #180. The urine sample was not collected and sent to the lab until [DATE]. The preliminary lab results were dated [DATE]. On [DATE], the CRNP was notified of the UA results and ordered an antibiotic. The first dose of the antibiotic was not administered until [DATE] at 9:00 PM. RI #180 had dysuria noted on [DATE] and [DATE]. On [DATE] RI #180 was transferred to the emergency room and admitted to the Intensive Care Unit where he/she was treated for Urosepsis and Septic Shock. RI #180 expired at the hospital on [DATE]. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations manual, Appendix PP, 483.25 Quality of Care at a scope and severity of J. On [DATE] at 12:13 PM, the Administrator (ADM) and the Director of Nursing (DON) were provided a copy of the Immediate jeopardy Template and notified of the findings of substandard quality of care at the immediate jeopardy level in the area of Quality of Care, at F 684-Quality of Care. The IJ began on [DATE] and continued until [DATE] when survey team verified onsite that corrective actions had been implemented. On [DATE] the immediate jeopardy was removed, F 684 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This was cited as a result of complaint/report number AL00047090. This affected RI #180, one of four residents sampled for hospitalization. Findings Include: A review of the facility's policy titled Urine Sample Collection with a date implemented 2017 revealed: . Policy: To promote accurate diagnosis and treatment of a resident's medical conditions, staff will obtain urine samples in accordance with established standards of practice. Policy Explanation and Compliance Guidelines: 1. Urine shall be collected for analysis or culture only with a physician's order. Urine will not be routinely cultured. a. Indications for urine culture: i. Presence of flank pain or dysuria (painful urination) ii. Acute hematuria iii. New pelvic discomfort iv. New onset or worsening sepsis without evidence of another source v. New onset urinary frequency or urgency vi. Change in Level of consciousness vii. Increased Confusion . 4. Practice considerations for the different types of urine samples include: . vi. If unable to obtain midstream clean-catch, may obtain a catharized specimen. A review of a facility policy titled Antibiotic Stewardship Program with a date implemented of 2017, revealed: . Policy: It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. Policy Explanation and Compliance Guidelines: . 4. The program includes antibiotic use protocols and a system to monitor antibiotic use. a. Antibiotic use protocols: . iv. The Loeb Minimum Criteria are used to determine whether to treat an infection with antibiotics. vi. Reassessment of empiric antibiotics is conducted after 2-3 days for appropriateness and necessity, factoring in results of diagnostic tests, laboratory reports, and/or changes in the clinical status of the resident. A review of Loeb's Minimum Criteria for Starting Antibiotic Therapy revealed: . Suspected Infection Syndrome Urinary tract infection without catheter Minimum Criteria for Starting Antibiotic Therapy Either one of the following criteria Acute dysuria, OR . A review of Revised McGeer Criteria for Infection Surveillance Checklist revealed: . Table 2 Urinary Tract Infection (UTI) Surveillance Definitions . UTI without indwelling catheter . Must fulfill both 1 AND 2 1. At least one of the following signs or symptoms Acute dysuria or pain, . 2. (greater than or equalt to) 10^2 (100) cfu/mL (Colony Forming Unit per milliliter) of any organism(s) in a specimen collected by an in-and-out catheter . A review of the past medical history last reviewed on [DATE] on 10:43 AM from RI #180's Primary Care Physician (PCP) revealed he/she had a history of Recurrent Urinary Tract Infections (UTIs) and Urinary Incontinence. RI #180 was admitted to the facility on [DATE] with a diagnosis history of Unspecified Protein-Calorie Malnutrition, Type Two Diabetes Mellitus without Complications, and Retention of Urine. A review of RI #180's Minimum Data Set with Assessment Reference Date (ARD) of [DATE] indicated RI #180's Brief Interview for Mental Status (BIMS) was five of 15 which indicated RI #180 was not cognitively intact. RI #180's Functional Abilities for toileting hygiene substantial/maximal assistance. An interview with RI #180's resident representative (RR) family member was conducted on [DATE] at 10:38 AM. RI #180's RR revealed that from the time that RI #180 was admitted the family member had told the nurses that RI #180 would get UTIs frequently. According to the family member staff had been notified of RI #180's pain in back and pain while urinating beginning on [DATE]. RI #180's RR stated he/she asked staff daily if RI #180 had been tested for a UTI. The family member stated staff would give different reasons why the results were not back at that time. The family member stated that they just wanted an antibiotic given if RI #180 needed one since he/she had a history of UTIs. The complainant stated the family had not been invited to attend a baseline care plan to express their concerns about RI #180's history of UTIs. A nurses note on [DATE] at 5:06 PM noted by the Unit Coordinator/Licensed Practical Nurse (UCLPN) stated .Reported by CNA that urinary output is less today has odor and blood (tinged) and guest (is) more confused. New orders received to obtain UA C&S (Urinalysis Culture and Sensitivity) to rule out bladder infection. A review of RI #180's written Physician's Orders revealed an untimed telephone order dated [DATE] for UA CFS(Urinalysis Culture for Sensitivity) telephone order. RI #180's urinalysis report documented the draw date of [DATE] at 6:30 AM and the received date [DATE] at 5:00 PM. The urinalysis report had date issued of [DATE] at 8:42 PM. The results indicated that RI #180's sample had abnormal results for 100 uL (microliter) of Leukocytes. The reference range for Leukocytes was Negative. The Microscopic Exam, Urine had abnormal results for Urine WBC 20-30/HPF (pus cells per high power field) and Urine Bacteria 2+/HPF. The reference range for Urine WBC was 0-5/HPF and the reference range for Urine WBC was None/HPF. The results included: .NOTE NEW CRITERIA: Culture indicated and ordered if any one of these criteria are met: 1. Positive for .Leukocytes .3. WBC greater than 10 . A review of RI #180's written Physician's Orders revealed a written order dated [DATE] for Levaquin 250 milligrams (MG) by mouth daily for five days. The order did not indicate the time the order was written or given. The order was signed by the CRNP. A review of the Medication Administration Record (MAR) for RI #180 revealed an order for Levofloxacin 250 MG, one tablet by mouth for five days for UTI. The MAR indicated the initial dose of the Levaquin 250 MG was not administered until [DATE] at 09:00 PM. The medication was administered on [DATE] at 09:00 PM and [DATE] at 09:00 PM. A review of the Certified Registered Nurse Practitioner (CRNP) notes for RI #180 for date of service [DATE] documented: .Chief Complaint/ Nature of Presenting Problem: . We did do a UA for (complaint of) dysuria .History of Present Illness: . Patient has been (complaining of) dysuria. We did obtain a UA. I was notified over the weekend of the results. I did start (him/her) on Levaquin. ICD (International Classification of Disease) Codes: .Dysuria . Acute cystitis . The note was electronically signed on [DATE] by the CRNP. A review of RI #180's Urine Culture and Sensitivity documented that RI #180's urine contained greater than 100,000 CFU/mL of Enterococcus faecalis (Isolate 1). The report indicated the date issued was [DATE] at 8:12 AM. The CRNP notes for RI #180 for date of service of [DATE] documented: .Chief Complaint/ Nature of Presenting Problem: . (He/She) does have a UTI and has been on Levaquin. (His/Her) Sensitivity has returned . History of Present Illness: . Patient has been c/o (complaining of) dysuria. I did start (him/her) on Levaquin low dose for 5 days . (He/She) continues to have c/o (complaint of) dysuria. I will increase the dose to see if this helps with (his/her) symptoms . The note was electronically signed on [DATE] by the CRNP. Further review of RI #180's written Physician's Orders revealed a written order dated [DATE] to Increase Levaquin to 500 (MG) (by mouth daily for five days) for cystitis and continued c/o (complaint of) dysuria. The order did not indicate the time the order was written or given. The order was signed by the CRNP. Further review of RI #180's MAR revealed an order for Levofloxacin 500 MG, one tablet by mouth for five days with Stop Date: [DATE]. The medication was electronically documented as administered for four days, [DATE], [DATE], [DATE], and [DATE]. The [DATE] dose was hand initialed by Licensed Practical Nurse (LPN) #13. A review of the hospital's History and Physical Reports for RI #180 with an admission date of [DATE] at 07:04 AM revealed: . History of Present Illness . In the ED, patient had a UA concerning for UTI, high anion gap metabolic acidosis with elevated lactate, AKI (acute kidney injury) with creatinine 1.7 from baseline of 0.7 elevated troponin . leukocytosis at 18,000 . hypoxia to 82 on room air . cardiology was consulted, bedside echo (echocardiogram) revealed EF (ejection fraction) approximately 20% . Cardiology suspects type II NSTEMI (Non ST elevation myocardial infarction (heart attack)) in the setting of UTI and sepsis. admitted to the ICU [DATE] . urosepsis and septic shock . An interview was conducted on [DATE] at 5:05 PM with the UCLPN. She stated that the physician or CRNP would need to be notified if unable to collect the lab within twenty-four hours. The UCLPN stated the order was received on [DATE] from the CRNP and collected on [DATE]. The UCLPN stated that the ordering provider should be notified each shift when staff were unable to obtain a urine sample for a lab. According to the UCLPN an order for Levaquin 250 mg was ordered [DATE], but she was unable to say the time it was ordered since there was not a time on the order. The UCLPN stated the first dose was documented as given on [DATE] at 09:00 PM and it should have been given on [DATE]. On [DATE] at 12:37 PM an interview was conducted with CNA #22. She stated urine samples were usually collected immediately when the nurse let the CNA know that the sample was needed. She further stated if the sample was unable to be obtained, the sample would be obtained by a straight catheterization. CNA #22 stated she let the nurses know when the urine was in the hat in the toilet after the resident has gone to the bathroom. CNA #22 stated she did not collect the urine sample on [DATE] during her shift, because it had been contaminated with stool. CNA #22 stated that when RI #180 first arrived at the facility she did not need much assistance. CNA #22 stated that he/she needed assistance with showers and to blow dry his/her hair. CNA #22 stated RI #180 would let her know when he/she would have to go to the bathroom. Further the CNA #22 said, during the last week of RI #180's stay he/she was using his/her brief to go to the bathroom. On [DATE] at 10:36 AM an interview was conducted with the LPN #24. She stated the physician should be notified after three attempts to obtain a urine on a shift, but she did not recall the policy. On [DATE] at 10:35 AM an interview was conducted with the LPN #14. She stated that an order for RI #180 for a UA was ordered on [DATE]. She stated that she did not attempt a clean catch urine for RI #180, but the CNA did on [DATE]. She stated she was only aware of one time that the CNA attempted to obtain a urinalysis for RI #180 on [DATE]. LPN #14 stated she attempted a straight catheter one time on [DATE] to obtain a urine sample but was unable to get urine return. LPN #14 stated the urine should be collected as soon as possible after receiving the order for the urinalysis. On [DATE] at 4:33 PM an interview was conducted with the Infection Preventionist (IP) RN/ADON. The IP said the facility's policy was that a urine specimen for urinalysis should be collected within 24 hours. The IP said it was the facility's policy that the urine specimen be collected by lab within 48 hours. The IP was asked, when an order was written for urinalysis, when should the urine be collected. The IP responded, immediately. The IP said if staff were unable to obtain first attempt by clean catch, then the nurse would obtain a straight catheter specimen. The IP stated that when an antibiotic for UTI was ordered, it should be started within 24 hours unless a now order was ordered. The IP said the risk of not administering an antibiotic within 24 hours or the next day would be worsening of infection. The IP stated the facility did not keep up with a number of UTIs but maintained a map that was color coded by infections. The IP stated that she counted the color for UTIs for each month to calculate the number of UTIs that were diagnosed and treated in house. She stated in [DATE] there were 12 in house UTIs; February 2024 there were 7 in house UTIs; [DATE] there were 16 in house UTIs; [DATE] there were 5 in house UTIs; [DATE] there were 16 in house UTIs; [DATE] there were 5 in house UTIs; and the [DATE] had not been calculated at that time. An interview with the DON was conducted on [DATE] at 11:55 AM. The DON said when a UA was ordered it should be collected as quick as possible so it could be addressed if needed. The DON said a straight catheter should be attempted within a day if the urine specimen could not be collected by clean-catch. The DON said according to the policy the sample should be collected via straight catheter if unable to collect as clean catch specimen. The DON said once the specimen was collected the UA resulted within a few hours or a day at the most and the urine culture resulted at 72 hours. The DON said a UA that was positive for UTI would not necessarily be called to the doctor or CRNP. The DON stated the nurse that received the call from the lab, would notify the physician of a critical lab result. The DON said the faxed results were placed in the charts and flagged to be reviewed by the physician or the CRNP. The DON stated that only critical labs and nurses' judgement were called to the CRNP and or the physician. She stated if the UA was positive for a UTI the facility staff waited until on the final Culture and Sensitivity (C&S) report before notifying the CRNP or the physician. The DON further stated the CRNP and physician would not want to start antibiotics unless there was fever or dysuria and would want to wait until the final C&S report. The DON stated the CRNP or physician would just review the next time they would be in the facility. The DON was asked about the timeline of events regarding the treatment of RI #180's UTI. The DON stated the UCLPN reported to the CRNP that RI #180 had decreased urinary output, blood-tinged urine, and urine odor. The DON stated the CRNP ordered a UA and C&S. The DON said after unsuccessful attempts to collect a clean-catch urine specimen, the facility tried a straight catheter on [DATE]. The DON said there was no urine obtained when the straight catheter was attempted on [DATE]. According to the DON the urine specimen was collected on [DATE] at 6:30 AM by straight catheter. The DON stated that she would have liked the urine to have been collected sooner. The DON stated RI #180 was found on the floor on [DATE] around 5:00 PM by LPN #24. The DON said LPN #24 notified the CRNP and received new orders for a UA and C&S. The DON said LPN #16 sent the preliminary results from the UA that was ordered on [DATE] to the CRNP on [DATE] at 11:50 PM. The DON stated that it was at that time the CRNP ordered the Levaquin 250 milligrams for five days. According to the DON the antibiotics were started on [DATE] at 9:00 PM. The DON stated on [DATE] the CRNP increased the dose of the Levaquin. On [DATE] at 10:16 AM an interview with the CRNP was conducted. She stated the UA was ordered on [DATE] and the antibiotic was ordered on [DATE]. The CRNP stated she would want to be notified on the day staff attempted to collected urine if unable to obtain the specimen. The CRNP stated she was not notified but should have been notified on [DATE] when a straight catheter was attempted on RI #180 and no urine output was collected. The CRNP stated the antibiotics should have been started at least by [DATE] when she ordered the UA on [DATE]. The CRNP stated that she expected the antibiotics to start the day she ordered them. A phone interview with the Medical Director (MD) was conducted on [DATE] at 9:44 AM. The MD stated that when the CRNP ordered a UA and Culture and Sensitivity (C&S) on [DATE] for RI #180 he would have expected it to be collected within twenty-four hours. The MD would have expected the facility staff to call when they were unable to obtain the urine specimen within twenty-four hours. According to the MD the facility staff should have followed policy and obtained the urine for RI #180 by straight catheter when it was unable to be obtained by clean catch. The MD stated that antibiotics could have been started on [DATE] depending on the situation and according to the McGreer's Criteria. ******************************************************************************************************************** On [DATE] at 03:41 PM, the facility submitted an acceptable Removal Plan for F684 which documented: 1. Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome The Administrator or designee notified the facility Medical Director of the incident on [DATE]. On [DATE], the Director of Nursing (DON) or designee used a verification checklist that includes the following: a. Date/time the result was received b. Date/time when the results were reported to provider All abnormal urinalysis (UA) results for residents admitted [DATE] (date UA was ordered for RI #180), who are still a resident in this facility were reviewed, to ensure that all results were reported to the provider appropriately. The total number of UA results reviewed was: eight (8). Seven (7) of the UA's were determined to have been reported timely to the provider. One (1) was determined to have not been reported to the provider according to the facility's revised Laboratory Services and Reporting policy that was updated on [DATE]. Going forward, the Nurse Practitioner will receive emails directly from the lab, to allow electronic review of all lab results, regardless of provider. On [DATE], the resident's medical record was reviewed and, although the lab work wasn't reported according to the facility's revised Laboratory Services and Reporting policy, the patient still received timely treatment and recovered from their infection with no adverse outcome. The broad-spectrum antibiotic prescribed, prior to receiving the final culture and sensitivity was not deemed effective against their particular infection and once the final culture and sensitivity was received, the MD changed the antibiotic to one that the patient's infection was susceptible to. On [DATE], the DON or designee used a verification checklist that includes the following: c. Date/time an order was written (if an order was written) d. Date/time the medication was first administered e. Date/time the UA was ordered f. Date/time the UA was collected All abnormal urinalysis (UA) results for residents admitted since [DATE]m 2024 (date UA was ordered for RI #180), who are still a resident I this facility were reviewed, to ensure that all residents received prompt treatment. The total number of UA results reviewed was: eight (8). Six (6) of the UA's reviewed were determined to have had their first dose of antibiotic administered timely, after being ordered. Two (2) of the UA's reviewed were not prescribed an antibiotic. Six (6) of the UA's were determined to have been collected timely. Two (2) of the UA's were determined to have been collected slightly outside of the acceptable time frame, based on facility's revised Urine Sample Collection policy. to ensure timely collection of urine samples in the future. Both resident records were reviewed, and although the samples were collected slightly outside of the acceptable time frame, based on facility's revised Urine Sample Collection policy, both patients were still treated timely and recovered from their UTI's with no adverse outcomes. On [DATE], two (2) LPNs were provided one-on-one education, by the DON or designee, on the facility's revised Urine Sample Collection policy, to ensure timely collection of urine samples in the future. 2. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. On [DATE], the Urine Sample Collection Policy, were revised by the Administrator, DON, and ADON. Urine Sample Collection Policy Section 4-vi. was revised to say, If unable to obtain midstream clean -catch on first attempt, may obtain a catheterized, It previous said, if unable to obtain midstream clean-catch, may obtain a catheterized specimen. Section 6 was revised to say, Notify physician if unable to obtain a urine sample within 12 hours. It previously said, Notify physician of results, and file results in the resident's medical record. On [DATE], DON or designee spoke with medical director and received the following instructions regarding when a medication should be given, to be considered timelym If a medication is ordered in response to results of the UA, the medication should be started within 24 hours of receiving the order, unless otherwise indicated (i.e. STAT or NOW doses). Or unless a specific date/time is given to start the medication. This was added as section 7 of this policy. The DON or designee educated all facility nurses that perform urine collections on facility's revised Urine Sample Collection Policy on [DATE]. From [DATE]-[DATE] the DON or designee will continue to utilize verification checklist at least twice per week, to ensure all residents receive prompt treatment. On [DATE], the DON or designee spoke with facility Medical Director and CRNP regarding process change for prompt notification of lab results. After conversation, the DON or designee arranged for the contract laboratory to email results of all lab work results (regardless of which provider ordered the lab work) to CRNP for electronic review. All critical labs should also be called to provider immediately. In addition to an electronic copy being emailed to provider, the physical copy will be flagged o the physical chart, for provider to review upon next visit to the facility. *************************************************************************************** The Immediate Jeopardy was removed as of [DATE] and the scope and severity was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and review of facility policy titled Quality Assessment and Assurance the facility's Quality Assessment and Assurance Committee (QAAC), the facility's Quality Improvement Performance Improvement (QAPI) committee, failed to thoroughly review all factors related to Resident Identifier (RI) #180's hospitalization on [DATE]. The facility did not identify the delay in treatment that resulted from the facility's failure to promptly obtain RI #180's urine specimen, promptly notify the Certified Registered Nurse Practitioner (CRNP) of RI #180's urinalysis (UA) results, and failure to administer RI #180's antibiotic timely. The facility's QAAC further failed to systemically address the factors that resulted in delay in treatment. On [DATE] RI #180 was noted to have decreased urinary output, urine odor, blood-tinged urine, and increased confusion. The QAAC had reviewed RI #180's incident report after a fall on [DATE] and identified the immediate action needed was treat Urinary Tract Infection (UTI). On [DATE] and [DATE] RI #180 was noted to have dysuria. On [DATE] RI #180 was transferred to the emergency room and admitted to the Intensive Care Unit where he/she was treated for Urosepsis and Septic Shock. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations manual, Appendix PP, 483.75 Quality Assurance and Performance Improvement at a scope and severity of J. On [DATE] at 12:13 PM, the Administrator (ADM) and the Director of Nursing (DON) were provided a copy of the Immediate Jeopardy Template and notified of the findings of substandard quality of care at the immediate jeopardy level in the area of Quality of Care, at F867- QAPI/QAA Improvement Activities. The IJ began on [DATE] and continued until [DATE] when survey team verified onsite that corrective actions had been implemented. On [DATE] the immediate jeopardy was removed, F 867 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This was cited as a result of complaint/report number AL00047090. The facility further failed to ensure 12 of 12 Skills Validation Perineal Care forms were completed to include the observed person's signature and the date of the observation. The Skills Validation Perineal Care forms were a component of a performance improvement project related to UTIs Findings Include: Cross-Reference F 684 and F 690. A review of the facility's policy titled Quality Assessment and Assurance with a date implemented 2016 revealed: . Policy: This facility will maintain a Quality Assessment and Assurance (QAA) Committee to identify quality issues and develop appropriate plans of action to correct quality deficiencies through an interdisciplinary approach. Policy Explanation and Compliance Guidelines: . 4. The committee will: c. Identify and respond to quality deficiencies throughout the facility. d. Develop and implement corrective plans of action and monitor to ensure performance goals or targets are achieved and sustained. RI #180 was admitted to the facility on [DATE] with a diagnosis history of Unspecified Protein-Calorie Malnutrition, Type Two Diabetes Mellitus without Complications, and Retention of Urine. An interview with RI #180's family member was conducted on [DATE] at 10:38 AM. The family member revealed that from the time that RI #180 was admitted the family member had told the nurses that RI #180 would get UTIs frequently. According to the family member staff had been notified of RI #180's pain in back and pain while urinating beginning on [DATE]. The family member stated he/she asked staff daily if RI #180 had been tested for a UTI. The family member stated they would give different reasons why the results were not back at that time. The family member stated that they just wanted an antibiotic given if he/she needed one since he/she had a history of UTIs. A nurses note on [DATE] at 5:06 PM noted by the Unit Coordinator/Licensed Practical Nurse (UCLPN) stated . Reported by CNA that urinary output is less today has odor and blood (tinged) and guest (is) more confused. New orders received to obtain UA C&S (Urinalysis with Culture and Sensitivity) to rule out bladder infection. A review of RI #180's written Physician's Orders on [DATE] an untimed order for UA CFS (Urinalysis with Culture for Sensitivity) via telephone order the CRNP. RI #180's urinalysis (UA) results documented the draw date of [DATE] at 6:30 AM and the received date [DATE] at 5:00 PM. The UA final report was dated [DATE] at 8:42 PM. A review of a facility report dated [DATE] at 5:37 PM titled Resident Incident Report for RI #180 revealed the incident type was a fall. The report indicated risk factors possible related to the incident was B&B (bowel and bladder) Urgency. The Immediate Post-Incident Action was Treat UTI / INCREASED CONFUSION. A review of RI #180's written Physician's Orders revealed a written untimed order dated [DATE] for Levaquin 250 milligrams (MG) by mouth daily for five days. The order was signed by the CRNP. A review of the Medication Administration Record (MAR) for RI #180 revealed an order for Levofloxacin (Levaquin) 250 MG, one tablet by mouth for five days for UTI. The MAR indicated the initial dose of the levofloxacin 250 MG was not administered until [DATE] at 09:00 PM. A review of the CRNP notes for RI #180 for date of service [DATE] stated one of the chief complaints as dysuria as a reason for the ordering of the urinalysis. The CRNP notes for RI #180 for date of service of [DATE] revealed RI #180 continued to have dysuria and the CRNP indicated she would increase the dose of Levaquin. A review of the hospital's History and Physical Reports for RI #180 with an admission date of [DATE] at 07:04 AM revealed RI #180 was admitted to the Intensive Care Unit (ICU) on [DATE] with diagnoses that included Sepsis due to UTI and Septic Shock. A review of the hospital's Discharge Documentation revealed RI #180 expired on [DATE]. The documentation included that RI #180 was admitted to the intensive care unit with Urosepsis on [DATE]. A review of a facility report titled Infection Report-Basic labeled with Quality Assurance Q.A.P.I Document signed by RN/IP on [DATE] for RI #180 documented: . Infection Category: Urinary First Symptom Onset: [DATE] Infection Source: It is likely infection developed in the facility . Related Diagnosis: Enterococcus . Final Disposition: hospitalized . Sign/Symptom/Condition . Blood in urine . Note . Foul, blood tinged, decreased UOP (Urine Output) .Onset [DATE] . Interventions Antibiotic-Yes . Levaquin .Started [DATE] . Further review of the report revealed a handwritten note that stated Reviewed in QAPI. No Concern. Hosp. (hospitalization) unavoidable. Return anticipated. A review of a facility report titled Infection Report Follow Up labeled with Quality Assurance Q.A.P.I Document signed by RN/IP on [DATE] for RI #180 documented: . Infection Category: Urinary First Symptom Onset: [DATE] Infection Source: It is likely infection developed in the facility . Reviewed by Infection Control Committee: Yes . A review of a facility report labeled with Quality Assurance Q.A.P.I Document documented: Readmissions <30 days Short Stay . RI #180 . Septic Shock . Unavoidable . There were no dates on the report to indicate when RI #180 was transferred or when the report was reviewed. On [DATE] at 8:40 AM the ADM stated that all the documentation for the QAPI meetings concerning RI #180 was given to the surveyor. On [DATE] at 11:55 AM an interview was conducted with the Director of Nursing (DON). The DON said the QA Committee did not identify any concerns with the treatment of RI #180's UTI. On [DATE] at 4:33 PM an interview was conducted with the Infection Preventionist (IP) RN/ADON. The IP said the facility's policy was that a urine specimen for urinalysis should be collected within 24 hours. The IP said it was the facility's policy that the urine specimen be collected by lab within 48 hours. The IP was asked, when an order was written for urinalysis, when should the urine be collected. The IP responded, immediately. The IP said if staff were unable to obtain first attempt by clean catch, then the nurse would obtain a straight catheter specimen. The IP stated that when an antibiotic for UTI was ordered, it should be started within 24 hours unless a now order was ordered. The IP said the risk of not administering an antibiotic within 24 hours or the next day would be worsening of infection. The IP stated the QAPI committee came up with a plan of action each month to decrease the number of UTIs in the facility. The IP stated the facility did not keep up with a number of UTIs but maintained a map that was color coded by infections. The IP stated that she counted the color for UTIs for each month to calculate the number of UTIs that were diagnosed and treated in house. She stated in [DATE] there were 12 in house UTIs; February 2024 there were 7 in house UTIs; [DATE] there were 16 in house UTIs; [DATE] there were 5 in house UTIs; [DATE] there were 16 in house UTIs; [DATE] there were 5 in house UTIs; and the [DATE] had not been calculated at that time. The IP stated that the facility had increased oral hydration, hand washing surveillance, and perineal care check offs. On [DATE] at 5:48 PM an interview with the ADM was conducted. The ADM stated he oversaw the QAPI committee and was also a member. The ADM stated that the QAPI committee worked on a couple of different Performance Improvement Projects (PIPs) during [DATE] including UTI due to the flagging on the CASPER report for UTIs. The actions that were put in place at that time were hydration rounds and perineal care observations. The facility's Validation Checklist Perineal Care forms were reviewed as evidence of the facility's UTI PIP. There were 12 forms and zero were signed by the staff who performed the care and zero included the date. One of the 12 forms was labeled with RI #180's name and was dated 01/2024. All 12 of the Validation Checklist Perineal Care form's documentation indicated no concerns were identified during the observations of perineal care. A follow-up interview with the ADM was conducted on [DATE] at 8:40 AM. The ADM stated that there was documentation about RI #180 brought to QAPI and the information was provided to the surveyor. The ADM then stated there was no other information for RI #180 from the QAPI committee, the PIP subcommittee and any other QA Meeting not provided to the surveyor that he was aware. The ADM stated the PIP project started on [DATE] as a result of the CASPER report and the QAPI meeting was on the same day. The ADM stated the first perineal check list form was dated [DATE]. The ADM stated he did not know why there was not a specific date on the form and further stated he did not know why the nurse being observed did not sign the checklist. The ADM stated RI #180's name was documented on the top of a checklist. The ADM was asked, when was RI #180 discharged . The ADM said RI #180's discharge date was [DATE]. The ADM stated that there were 12 perineal checklist forms and none of the 12 checklist forms had completed dates. The ADM stated that there were 8 of the 12 perineal checklist forms with the observer's signature and 0 of the 12 signatures from the person being observed. *************************************************************************************** On [DATE] at 06:48 PM, the facility submitted an acceptable Removal Plan for F 867 which documented: 1. Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. The Administrator or designee notified the facility Medical Director of the incident on [DATE]. On [DATE], the Director of Nursing (DON), Administrator and Assistant Director of Nursing (ADON) reviewed all Quality Assurance (QA) Committee meeting minutes for [DATE] through [DATE], as well as reviewing rehospitalization records for months where no QAPI meeting was held. A Root Cause Analysis (RCA) was conducted for all (3) rehospitalizations related to urinary tract infection (UTI) to determine if further investigation/action was needed. One (1) RCA produced no action items. No areas for needed improvement were identified. Two (2) RCA's did produce action items. On [DATE], the Laboratory Services and Reporting Policy was revised by the Administrator, DON, and ADON. Section 7 was revised to say, Immediately notify the ordering physician, or nurse practitioner of critical finding. Previous version stated, Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of critical laboratory results. nSection 8 was added to say, Nurse practitioner will be notified of resulted labs for review electronically and nurse will place physical copy in chart for review at the providers next visit to the facility. This includes all lab results, regardless of which provider ordered the lab work. The DON or designee educated all seven (7) RNs and thirteen (13) LPNs that inform providers of lab results, on facility's revised Laboratory Services and Reporting policy on [DATE]. This includes nurses from every shift and every rotation, including weekends. On [DATE], the DON or designee spoke with facility Medical Director and CRNP regarding process change for prompt notification of lab results. After conversation, the DON or designee arranged for the contract laboratory to email results of all lab work results (regardless of which provider ordered the lab work) to CRNP for electronic review. All critical labs should also be called to provider immediately. In addition to an electronic copy being emailed to provider, the physical copy will be flagged on the physical chart, for provider to review upon next visit to the facility. On [DATE], the Urine Sample Collection Policy, were revised by the Administrator, DON, and Assistant Director of Nursing (ADON). Urine Sample Collection Policy Section 4-vi. was revised to say, If unable to obtain midstream clean-catch on first attempt, may obtain aa catheterized specimen. It previous said, If unable to obtain midstream clean-catch, may obtain a catheterized specimen. Section 6 was revised to say, Notify physician if unable to obtain a urine sample within 12 hours. It previously said, Notify physician of results, and file results in the resident's medical record. On 08/20 2024, DON or designee spoke with medical director and received the following instructions regarding when a medication should be given, to be considered timely, If a medication is ordered in response to results of the UA, the medication should be started within 24 hours of receiving the order, unless otherwise indicated (i.e. STAT or NOW doses). Or unless a specific date/time is given to start the medication. This was added as section 7 of this policy. The DON or designee educated all facility nurses that perform urine collections on facility's revised Urine Sample Collection Policy on [DATE]. From [DATE] to 1 [DATE], the DON or designee will continue to utilize verification checklist at least twice per week, to ensure all residents receive prompt treatment. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: [DATE]) On [DATE], the Quality Assessment and Assurance Policy was revised by the Administrator and DON. On [DATE], Section 4.d. was revised to say, Develop and implement corrective plans of action to include contributing factors, and monitor to ensure performance goals or targets are achieved and sustained. Prior version stated, Develop and implement corrective plans of action, and monitor to ensure performance goals or targets are achieved and sustained. On [DATE], section 4.f. was added. Section 4.f. states, Utilize Root Cause Analysis Tools, which may include, The 5 Why's, Fishbone, Timeline, or Plan, Do, Study, Act (PDSA) when assessing contributing factors. On [DATE], the Administrator completed an education course through Relias Online Training, titled The Use of Root Cause Analysis. This course discussed what an RCA is and how to use it. On [DATE], after completion of the RCA training listed above, the Administrator educated the QA Committee on F-867 Quality Assessment and Assurance, facility's revised Quality Assessment and Assurance Policy, and how to conduct an RCA. QA Committee members educated included: Director of Nursing, Medical Director, Governing Body, Assistant Director of Nursing, (3) LPNs, RN MDS Coordinator, SW, Social Services Assistant, LPN MDS Coordinator, Dietician, and Business office Manager. *************************************************************************************** The Immediate Jeopardy was removed as of [DATE] and the scope and severity was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.