**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free from neglect for one of 40 sampled resident's (Resident 56) when Resident 56 experienced a choking episode while eating a meal unsupervised in his room in bed on 11/29/18 and staff did not recognize the emergent situation and delayed calling emergency services or 9-1-1. Resident 56 was diagnosed with Progressive Supranuclear Palsy (PSP - a brain disorder that affects the ability to swallow and affects the ability to walk with a steady gait, balance and speech) on 4/18/18. Resident 56's diagnosis of PSP was not communicated to the Primary Care Physician and Interdisciplinary team (IDT- a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the patient). Based on this new diagnosis and high risk for choking there was no updated care plan and no intervention in place. Resident 56 had multiple teeth extractions and there was no documented assessment performed by Licensed Nurses after Resident 56 returned from his dental appointments. Resident 56's multiple teeth extractions could have placed the resident at a higher risk of choking affecting his chewing and swallowing ability. These facts were not communicated to the Speech Pathologist for a swallow evaluation to be done. These failures resulted in Resident 56 not receiving the care needed for a diagnosis of PSP, such as swallow evaluation, possible supervision during meals, modified meals and other services required for PSP. The facility did not respond timely to an emergent situation and the delay in response led to Resident 56's death. Because of the actual harm to Resident 56 that resulted in a choking episode which led to Resident 56 's death, an IJ situation was called on 1/3/19 at 3:29 p.m. with the Administrator and Director of Operations in attendance. The facility submitted an Action Plan to address the IJ situation which included providing education to all staff members on how to recognize and respond to a life threatening emergency which included calling 911. The Licensed Nurses were also provided in-service education on assessment and documentation when a resident returns from an appointment, has a new diagnosis that required special needs or supervision and a change in condition. The Action Plan was accepted on 1/3/19 at 6:47 p.m. The interventions to address the IJ situation on the Action Plan were fully implemented and the IJ was removed on 1/4/19 at 12:23 p.m. Findings: Resident 56's face sheet (a document containing resident profile information) indicated Resident 56 was [AGE] years of age, admitted to the facility on [DATE] with diagnoses which included dysphagia (difficulty in swallowing) and muscle weakness. Resident 56's Minimum Data Set assessment (MDS) (a resident assessment tool used to identify resident cognitive and physical function) assessment, dated 10/4/18 indicated the following for Resident 56: Brief Interview for Mental Status (BIMS- assessment of cognitive status for memory and judgement) score of 9 of 15 points (moderate cognitive impairment)required supervision (oversight, encouragement or cueing) with setup assistance for meals and had no problems or difficulty with swallowing. On 12/5/18 at 8:30 a.m., during an interview, Certified Nursing Assistant (CNA) 1 stated, I have been working in the facility for 17 years. I took care of [Resident 56] for 1 year. He eats breakfast in his room. I open the lid of his tray and he would feed himself. That's all I do for him and he will eat by himself, then I would get his tray back [once resident was finished with his meal]. CNA 1 stated on 11/29/18 while in the room giving Resident 56's roommate his breakfast tray, he heard Resident 56 cough. CNA 1 stated, I went over [to Resident 56], he was sitting upright, he just nodded, he didn't say anything. I told the charge nurse [Resident 56] might be aspirating [breathing foreign objects into airways]. That was the only time I heard [Resident 56] cough like that. On 12/5/18 at 9:16 a.m., during an interview, Licensed Nurse (LN) 2 stated, A CNA came to me [on 11/29/18] and told me [Resident 56] might be aspirating. [Resident 56] didn't talk. I told him to lift up his head, I looked into his mouth and I saw a white drool mixed with food. I ran out to the nurses' station [calling out] that I need help [Resident 56] is choking. I called [Name of Ambulance Company] at around 7:25 a.m. [11/29/18] that I need an emergency transport, a resident is choking. I told them to send an ambulance with lights and sirens. I need emergency transfer now. LN 2 pointed at a paper written with the name and number of the ambulance company located at the nurses station and stated that was the number she used to call for the ambulance. LN 2 stated, I came back to the nurses station and [the time] was 7:55 a.m. I was angry. Where are [the paramedics]. I see them out there parked at the front door [located across the street from the facility]. I asked them are you guys the lights and siren guys and he said yeah that's how busy we are. I told them I think our patient just passed away and they said what room . I don't understand what took them so long. They could have saved him. They are well equipped. They didn't even come with the lights and sirens on. I would have heard it but I didn't hear it. I never have to send a resident on a real emergency. Usually it's planned and [paramedics] respond right away but this time, I don't know why they didn't come right away. Review of Resident 56's progress note dated 11/29/18 indicated, . This writer [LN 2] was notified at 0725 [a.m.] by CNA [1] that [Resident 56] may be possibly choking on breakfast, immediately went to assess resident and [Resident 56] was found sitting up in bed with a tray in front of him containing a freshly served breakfast that included a partially eaten tortilla. Resident pulse at 65, SpO2 sat (oxygen saturation- level of oxygen in the blood) is only 65% on RA [room air], asked resident if he was choking and no response was given, had resident sit more upright and looked in his mouth and could see nothing, immediately went to nurses station to get help from NOC [night nurse], returned to resident with NOC nurse and he [NOC nurse] immediately began to do abdominal thrusts after quick assessment and attempting a finger sweep with no success because resident would not open his mouth and partially clenching his teeth, after NOC nurse gave approximately 4 abd [abdomen] trust [thrusts]with no success [LN 1] ran back to nurses station to call for emergency assistance from [name of Ambulance Company] . dispatcher states that she will send ambulance with lights and sirens due to patient's inability to breathe . at 7:45 [LN 1] went back to desk and called resident's emergency contact . and notified them of situation [choking] . returned to resident's bedside, abd thrust still are ineffective . however resident still has strong pulse 65-68 and Sp02 in 60's, resident suddenly went limp, cyanotic [turned blue in color] and without a pulse at [7:55 a.m.] . Resident 56's progress note dated 11/29/18 at 8 a.m., indicated [name of Ambulance Company] arrived at [approximately] 0758 [a.m.] . resident was no longer breathing . time of death announced [sic] at [7:55 a.m., by [RN] . On 12/5/18 at 3:06 p.m., during an interview, Resident 17 stated she was Resident 56's sister. Resident 17 stated, I just don't understand, they knew he had problems with swallowing. He needed to have supervision while eating. Somebody should have been there watching him. Nobody supervised him. They just put his tray and leave. My sister comes in on Monday, Wednesday and Friday. We eat lunch together. When we eat together, he coughs a lot that's why he needed some supervision. My sister was not here every day to watch for him. Somebody with that problem shouldn't be left alone in the room while eating. We shouldn't have to be mourning his death if they would have supervised him. On 12/5/18 at 3:46 p.m., during a concurrent interview and record review, the Speech Pathologist (SP) reviewed Resident 56's speech therapy notes and plan of care dated 4/10/17 which indicated the facility referred Resident 56 to SP for a swallow evaluation due to reports from caregivers of Resident 56 having swallowing difficulties during meals. The SP stated he performed the initial swallow evaluation on 4/10/17 and documented Resident 56 was having difficulty masticating [chewing] foods, and was observed with occasional coughing during meals. The SP stated Resident 56 and the family report intermittent [swallowing] difficulty. The SP stated Resident 56 was at risk for aspiration on liquids and required intermittent supervision. The SP stated, He [Resident 56] was admitted on mechanical soft diet (is a diet that includes soft and easy to chew foods for people who have difficulty chewing and swallowing), honey thick liquids. When I discharged him [on 5/5/17], he did not require cueing and supervision with mechanical soft texture. He was safe to eat by himself. I told him to take small sips, small bites and he was able to demonstrate it safely. The SP note dated 5/8/17 indicated, The [Resident 56] wishes to remain on current mechanical soft texture diet with nectar thick liquids to minimize risk of aspiration . Precautions: .Aspiration . [Resident 56] and family report intermittent [swallowing] difficulty]. The SP stated it was a team effort that involved Licensed Nurses and CNA's to observe him and supervise him while eating. The SP stated, [The facility] would have to let me know if [Resident 56] had any problems and would make a referral for me to do another swallow [evaluation]. SP stated the facility did not request a second referral for Resident 56 to receive a swallowing evaluation. On 12/5/18 at 4:26 p.m., during a telephone interview, Family Member (FM) 1 stated she took Resident 56 to an appointment with Neurologist (Neuro- brain and spinal cord Medical Doctor [Neuro MD]) on 4/18/18 and Resident 56 was diagnosed with PSP. FM 1 stated she took Resident 56 to the neuro MD because Resident 56 began to have difficulty speaking and was falling frequently. FM 1 stated Resident 56's voice was, Very soft spoken that you could hardly hear his voice or understand him. FM 1 stated she was concerned and wanted to know what was wrong with him. FM 1 stated she wanted to know if Resident 56 had Parkinson disease (a progressive disease of the nervous system marked by tremor, muscular stiffness, and slow, rough movement). FM 1 stated, [Resident 56] got diagnosed last April [2018] with Progressive Supranuclear Palsy. It was paralysis in the muscles. It affected his speech, walking and swallowing. The [Neuro MD] told me it's a progressive disease. FM 1 stated she comes to the facility every Monday, Wednesday and Friday to visit Resident 56 and Resident 17 and they would have lunch together. FM 1 stated, One time, we had lunch and something got stuck in his throat. I took [Resident 56] out to the nurses' station and told the nurse something got stuck in his throat. I told a [Licensed Nurse] and she just gave him a pudding. I cut [Resident 56's] food in small pieces when I am there. He needs supervision while eating. He coughs up a lot . I wouldn't want it to happen to anybody else. Review of Resident 56's clinical record fax to physician dated 6/13/17, indicated, [Attention] . [Name of PCP] . Problem, [Resident 56] and [FM] want [Resident 56] referred to Neurology. [FM] states [Resident 56] has slurred speech, swallowing problems (on thickened liquids) . gait imbalance . The clinical record indicated Resident 56's PCP ordered a referral to a Neuro MD. On 12/6/18 at 9:10 a.m., during an interview, CNA 2 stated she had been working in the facility for 26 years and took care of Resident 56. CNA 2 stated Resident 56 was observed to decline for the past months. CNA 2 stated Resident 56's voice changed to a very low tone and was at times difficult to understand. CNA 2 stated Resident 56 was becoming weaker and began to fall more often. CNA 2 stated she was unaware if he had swallowing issues because she would only set-up the meal tray for Resident 56 to eat his meal in his room and was not present while Resident 56 was eating. CNA 2 stated Resident 56 was not supervised during his meals. On 12/6/18 at 9:47 a.m., during a concurrent interview and record review, LN 4 reviewed Resident 56's Neuro MD progress notes dated 4/18/18 indicating, . Had PSP (Progressive Supranuclear Palsy) with degeneration . need to be monitored closely . LN 4 stated she was the LN assigned to Resident 56 when he returned from his appointment with the Neuro MD. LN 4 stated Resident 56 returned with a doctor progress note indicating Resident 56 was newly diagnosed with PSP. LN 4 stated, I just gave the document to medical records and it would be filed [away from the clinical record] by medical records. LN 4 stated she did not know what PSP meant for Resident 56's care and did not inform the Unit Manager (UM), Director of Nursing (DON) or the IDT team about the new diagnosis. LN 4 stated she should have informed the UM and DON in order to communicate and plan Resident 56's care and needs especially with a new diagnosis that she was not familiar with. LN 4 reviewed Resident 56's clinical record and was not able to find a care plan for his new diagnosis of PSP and how to address his care needs. LN 4 stated, I have never done a care plan. It should be care planned so the nursing team would communicate and take care of his needs. It should also be [added] in his diagnosis but I don't see it included in his diagnoses. When I received the document after his appointment I should have documented it [in the clinical record]. I just wrote no new orders and no new diagnosis. I should not have done that. It made it look like I didn't do it. I didn't put it in the electronic health care record (EHR). I should have put it (in the EHR). That is what we were trained as nurses. LN 4 stated Resident 56's Primary Care Physician (PCP) should have been informed of his new diagnosis but she did not communicate this to him. LN 4 stated, If we noticed that residents are having problems with swallowing we get a referral for a speech therapist [evaluation]. He had no problems with eating and swallowing. Sometimes I see him when I pass meds [medications] and he was okay. The facility document titled, Job Description LVN undated, indicated, . As LVN . you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties . Assist in developing methods for coordinating nursing services with other patient services to ensure the continuity of the patients' total regimen of care . Participate in the development of a written plan of care (preliminary and comprehensive) for each patient that identifies the problems/needs of the patient, indicates the care to be given, goals to be accomplished, and which professional service is responsible for each element of care . On 12/6/18 at 9:59 a.m., during a concurrent interview and record review, the UM reviewed Resident 56's Neuro MD progress notes dated 4/18/18 indicating, . Had PSP (Progressive Supranuclear Palsy) with degeneration . need to be monitored closely . The UM stated she was not aware of Resident 56's new diagnosis of PSP when he went to his Neuro appointment. The UM stated, It should have been communicated with all staff. It was not care planned and it should have been care planned. If I was the one doing the care plan, I would put it under ADL's [Activities of Daily Living] and to monitor for decreased ADL functions such as difficulty in swallowing, to monitor how he eats, decreased in mobility function and to monitor for falls. [Resident 56] does not have a progressive disease like Parkinson's [progressive nervous system disorder that affects movement] before but now that he has a diagnosis of a progressive disease with degeneration, it should have been communicated with staff in order to plan care and anticipate the residents' needs. The UM stated the SP and PCP should have been notified about his newly diagnosed condition but was not informed by the nursing staff. On 12/6/18 at 10:05 a.m., during a concurrent interview and record review, the DON reviewed Resident 56's Neuro MD progress notes dated 4/18/18 and indicated, . Had PSP (Progressive Supranuclear Palsy) with degeneration . need to be monitored closely . The DON stated she was not familiar with PSP or what it meant for Resident 56's care needs. The DON stated, I did not know that [Resident 56] had that diagnosis. The healthcare team should have been notified about the diagnosis. If it got worst, we would have to send him back to the doctor. A referral to Speech [Pathologist] should have been made with the new diagnosis. It is important to monitor his swallowing if it got worse. The DON reviewed Resident 56's clinical record and was unable to find a care plan addressing his needs with his new diagnosed condition of PSP. The DON was unable to find Resident 56's PSP diagnosis added to his list of diagnoses. The DON stated, It should be included in the diagnosis and it should be care planned to better plan for his care especially with a new diagnosis. The supervision [how he eats and level of assistance when eating] for [Resident 56] might have been different if the facility was aware of the new diagnosed condition. The DON reviewed the Neuro progress note with the PSP diagnosis and stated LN 4 was aware of the diagnosis and failed to communicate the condition to all facility team members. On 12/6/18 at 11:44 a.m., during a telephone interview, the SP stated he was not aware of Resident 56's diagnosis of PSP. The SP stated, That's the first time I've heard of that diagnosis. Unfortunately I wasn't aware. It would have warranted a [speech therapy] screen . The SP stated a speech therapy screening was not requested by the facility. On 12/6/18 at 1:39 p.m., during a telephone interview, the PCP stated the new diagnosis of PSP for Resident 56 was not communicated to him by the nursing staff. The PCP stated, I'm looking at [internet search engine name] right now for the meaning of PSP. It means the resident will have swallowing problems . [The facility] has my direct number. They can call me anytime but I was not informed about the new diagnosis. It's a progressive disease so all the symptoms he was having will get worse over time [swallowing problems]. The nurses need to monitor his swallowing, the food and diet texture is a big thing . On 12/7/18 at 8:46 a.m., during a telephone interview, the Neuro MD stated, I saw [Resident 56] last April 2018 and I diagnosed him with PSP. It means the patient cannot swallow, [he] will fall more. It's like a death sentence for the patient. With a swallow eval [evaluation] it may prolong his life . The facility should have known he had PSP. I wrote monitoring but [the facility] has their own speech therapist. They should have made a referral with the speech therapist when they saw the diagnosis that he had PSP. A speech evaluation should have been made. The resident needs supervision with eating and walking because [he] will have more difficulty with swallowing and walking as the disease progresses. It's a simple job they need to do. They need to look at the diagnosis and find out what the best care to give the patient. That's why nursing homes are there to provide the best care for the patient. They should not just file the paper with the diagnosis. They should read it and find out about it and what it means to the patient's care. That's what nursing care is for, to be able to provide a better care for the patient and their needs. [The facility] has a speech therapist that should work with him. Professional reference titled, Progressive Supranuclear Palsy (PSP) information undated, (found at www.movementdisorders.ufhealth.org) indicated, . Treating speech and swallow impairments is equally important . Choking or swallow difficulty is very common in PSP and another potential hazard. Aspiration of food, liquids or saliva can result in death. As such, formal swallow evaluation is strongly recommended and should include regular follow-up exams . On 12/7/18 at 9:14 a.m., during an interview, LN 5 stated she has been working in the facility for 6 years. LN 5 stated, If [residents] are choking or having a stroke, I start the Heimlich maneuver . I would call 911 first because it's an emergency situation. I never had to send somebody out on an emergency. The most recent one I sent out was a resident had a [Urinary Tract Infection- infection of the bladder] so I called [Name of Ambulance Company] but if it's an emergency I would call 911. On 12/7/18 at 9:25 a.m., during an interview, LN 1 stated she would call 911 in a life and death situation such as when a resident was choking. LN 1 stated she would call the [name of Ambulance Company] for non-threatening situations. On 12/7/18 9:49 a.m., during an interview, CNA 3 stated, I notify the nurse if I came across a resident that needs emergency attention, and after that the nurse takes over. I would call 911 for an emergency situation . On 12/7/18 10:04 a.m., during an interview, CNA 4 stated, For emergency situation, I call code blue from the nurses station. The nurses will do whatever they need to do for the resident and if delegated to me to call the ambulance, I will call 911. We have a different ambulance [phone number] for non-emergent situation. I will call 911 whether outside, home or in the facility for emergency situation. On 12/7/18 at 10:01 a.m., during a telephone interview, LN 2 stated, We call [Name of Ambulance Company] for everything, for emergency and non-emergency . I will not call 911. That's what [licensed nurses] were trained when I got hired and that's what I did. On 12/7/18 at 9:35 a.m., during an interview, the CNO stated, For both emergency and non-emergency, nurses are supposed to call [Name of Ambulance Company]. If it is an emergency, we specify lights and sirens. It will not make any difference if we call 911 because there's only one Ambulance Company in this area. The CNO stated new hires and current staff are given in-service training for unusual occurrence such as fall prevention program, skin integrity and choking. On 12/7/18 at 9:45 a.m., during an interview, the DON stated, .If I am in that situation, I could have handled it differently. I would have called 911 directly since they will come immediately and 911 would have dispatched the fire department to respond competently in an emergency situation. The DON stated the facility does not have a specific policy for responding in an emergency situation. The DON stated it was included in the LN's Basic Life Support (BLS) training that they knew how to respond to an emergency like choking and how to perform the Heimlich maneuver. On 12/7/18 9:55 a.m., during a concurrent interview and record review, the Director of Staff Development (DSD) stated the LN's are in-serviced annually on how to respond to an emergency situation like choking prevention. The DSD was not able to provide a specific policy on how the facility responds to an emergency situation like choking. The DSD stated the facility does not have a specific policy on how to respond when a resident was choking. The DSD stated LN's are supposed to call 911 for an emergency situation. The DSD provided a facility document titled, CPR [Cardiopulmonary Resuscitation- an emergency life-saving procedure performed when someone's breathing or heartbeat has stopped] undated, indicated . First Aid for the Choking Victim: The Heimlich maneuver .[the manual application of sudden upward pressure on the upper abdomen of a choking victim to force a foreign object from the trachea] Choking is caused by an obstructed airway and is one of the leading causes of death. Everyone should know how to help a person who is choking, and as medical professionals, all CNAs are required to know how to assist someone with an obstructed airway caused by a foreign body . It is sensible to have someone call 911. The Heimlich maneuver may be successful. But it may not work and it is much, much better to have emergency personnel on the way then wait until the person loses consciousness and then call for help . Always call 911 or have someone call for help . The DSD stated she goes over this document when she performs her annual in-service training on choking with the Licensed Nurses. On 12/7/18 at 10:16 a.m., during an interview, LN 6 stated, If it's an emergency, I would immediately call 911. If it's a non-emergency situation, I would assess the resident and I would call the PCP. If the PCP says to send resident out then I would call the ambulance which is [Name of Ambulance Company] but if they are having a heart attack or choking, I would definitely call 911 because it's an emergency. The nurses on the floor trained me what to do in case of an emergency situation and they told me to call 911. On 12/7/18 at 10:43 a.m., during a telephone interview, [Ambulance Company] representative stated, [The facility] usually gets a hold of us through 911 or by calling us directly. Sometimes it depends on the situation . but I would think if it's a real emergency situation [staff] would call 911 as far as I know. On 12/7/18 at 12:16 p.m., during a concurrent interview and record review, LN 7 opened a facility binder located at the nurse's station and pointed at the [Name of Ambulance Company] number and stated, I would call [name of Ambulance Company] for any emergency situation. I was trained on orientation to call direct line [name of Ambulance Company] for all emergencies. On 12/10/18 at 9:40 a.m., during an interview, the DSD stated she would call 911 for an emergency situation such as when a resident was choking. The DSD stated she would call [Name of Ambulance Company] for non-emergency situations such as when a resident will be transferred out of the facility to General Acute Care Hospital (GACH) for a procedure. On 12/10/18 at 9:50 a.m., during an interview, LN 8 stated she would call 911 for every emergency situation such as when a resident was choking or having chest pain. LN 8 stated she would call [Name of Ambulance Company] for non-emergency situations and if residents were stable enough to be transferred to GACH for an evaluation. LN 8 stated, The difference between calling 911 and the [name of Ambulance Company] is that, 911 can dispatch an ambulance that is available right away. On 12/10/18 at 10:41 a.m., during an interview, LN 2 stated she was not sure if anybody checked to see if the ambulance arrived to the facility while Resident 56 was still choking. LN 2 stated she did not call the paramedics to ask if they were on the way to the facility. On 12/10/18 at 10:53 a.m., during an interview, the DON stated nobody from the facility staff checked to see if the ambulance arrived at the facility while Resident 56 was still choking. The DON stated, Someone should have called [the ambulance to [ask] when they are arriving to the facility]. The [facility staff] should call 911 . On 12/27/18 at 9:17 a.m., during a telephone interview, [Ambulance Company] Compliance Officer stated, If the facility needs emergency transport, they should call 911. They should not be calling for the ambulance number. The ambulance number is different from 911. The Ambulance Compliance Officer stated 911 was used for emergency situations and the ambulance direct phone number was used for non-emergency situations. On 1/3/19 at 8:20 a.m., during a telephone interview, FM 1 stated, [Resident 56] was having a lot of problems with speech, swallowing and walking. That's why I wanted him seen by a neurologist. [The facility staff] were saying [Resident 56] was high functioning. I was trying to get my brother more help. FM stated Resident 56 was admitted to the facility on [DATE] FM stated, [Resident 56's] voice was not clear enough. I have to tell him to speak louder and he told me he couldn't. I requested another appointment to a neurologist and the reason for the referral was his speech problem so he could communicate better and other things that needs to be addressed like swallowing. On 1/3/19 at 9:28 a.m., during a concurrent interview and record review at the nurse's station, LN 4 reviewed the appointment calendar and stated Resident 56 went to dental appointments on 4/18/18, 5/4/18, 5/23/18, 6/5/18, 6/15/18, 7/19/18, 7/24/18, 9/17/18 and 11/21/18. LN 4 stated, I don't know why [Resident 56] went to the dentist. LN 4 stated she was not aware Resident 56 had tooth extractions whenever he would go to his dental appointments or what procedure was performed by the dentist on Resident 56. LN 4 stated, [Resident 56] has never had any tooth extractions, not that I am aware of. LN 4 reviewed Resident 56's progress notes in the computer and was unable to find documented assessment for the reason Resident 56 went to multiple dental appointments. LN 4 stated, It should be documented in the progress notes. It should have been documented when the [dental] appointment was made so [Licensed Nurses] knew why [Resident 56] was going to the [dentist]. It should be documented in case it doesn't get passed on [to the next shift]. LN 4 stated it was important Licensed Nurses assessed and documented in the nurse's progress notes every time Resident 56 went to his dental appointment and after Resident 56 comes back from his dental appointment to ensure continuity of care and provide his care needs. LN 4 stated Resident 56 has a low tone voice and it was difficult for staff to understand him at times. LN 4 stated, . In the morning, [Resident 56's] voice would be louder, it varies, but that would be his usual [tone of voice]. LN 4 stated, the facility would call the PCP to get an order for a referral to SP but a referral to SP was not made. LN 4 stated, It should have been referred to the [SP]. [Resident 56] should have been evaluated [by SP]. LN 4 stated she did not inform the PCP on Resident 56's change of voice. LN 4 stated, For me [Resident 56] has always been that way [difficult to understand speech]. On 1/3/19 at 10:24 a.m., during a telephone interview, FM stated Resident 56 was having dental pain and had tooth extractions. FM stated, I do not know how many teeth [the dentist] pulled. He was complaining about tooth pain for about a year and the dentist was working with him for one year. I do not remember how many teeth [were extracted]. The facility should have notes from the dentist. On 1/3/19 at 12:03 p.m., during a concurrent interview and record review, the DON reviewed Resident 56's dental consultation notes dated 1/11/18, indicated, . Treatment (Tx) Recommendation . # (number) 27 [tooth] sharp edge . # 27 painful- cuts tongue [with] sharp edge . The DON stated the dental consultation notes should have been given to the Licensed Nurse for a follow up after the dentist evaluated Resident 56. The DON was unable to find a documented nurse's assessment or follow up in Resident 56's clinical record. The DON stated, It would be painful for a resident when they are eating. If you have a cut in the tongue, it makes [the resident] not want to eat. It will hurt more with spices [on the food] . On 1/3/19 at 12:09 p.m., during a concurrent interview and record review, the DON reviewed Resident 56's dental consultation notes dated 3/23/18, indicated, . Tx Recommendation . [Extraction] # 21 [tooth] . The DON was unable to find documented nurse's assessment in Resident 56's cli[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assess one of 40 sampled residents (Resident 70) for the risk of entrapment (resident caught, trapped, or entangled in the space in or about the bed and side rail) from bed (side) rails (adjustable metal or rigid plastic bars that attach to the bed), prior to installation and failed to ensure safety standards were met for the installation of bed rails when Resident 70 was observed with four bed rails up and his legs entrapped between the gap of the bed and side rails almost touching the ground . The Guidance for Industry and FDA Staff: Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, issued on 3/10/06, indicated that entrapment may occur in flat or articulated (raised) bed positions. To reduce the risk of head entrapment, rail perimeter openings should not be greater than four and three quarter inch. To reduce the risk of neck entrapment the gap between the mattress and under the rail should be less than four and three quarter inches. The recommendation also indicated the dimension limits for the open space within the perimeter of the rail should be small enough to prevent the head from entering. The recommended space should be less than four and three-quarter inches . This failure resulted in bed (side) rail entrapment for Resident 70 (bed user's legs were entrapped within openings of the two side rails and between the bed mattress) and place Resident 70 at potential risk for serious harm, injury or death. Because of the serious potential harm related to the use of side rails used without proper assessment of the size of the bed, the weight of the resident, and without an intervention to prevent entrapment an Immediate Jeopardy (IJ) situation was called on 12/19/18 at 1:45 p.m. with the Administrator, Director of Nursing, Chief Nursing Officer and Director of Operations. Findings: Resident 70's Order Summary Report dated 4/19/18 indicated, Admit to [facility] on 4/19/2018 under care of [physician name] for skilled nursing services with the diagnoses of [deconditioning secondary to multiple CVA's - cerebral vascular accident (poor blood flow to brain results in cell death)] .all meds [medications] via [by way of] peg-tube . (Percutaneous Esophageal Tube-surgically placed for administration of medications or feeding). Resident 70's Progress Notes undated, indicated, [Resident 70] was admitted on [DATE] to room [number of room] via stretcher from [Acute Care Hospital] with a diagnosis of deconditioning secondary to multiple CVA .Resident was oriented to the facility including the use of the call light and bed controls [bed with four side rails] . Pt [patient] A&O x2 (alert and oriented to person and time), able to make needs known, calm and cooperative with staff and care pt is 1-2 person assist . Resident 70's physician order dated 4/20/18, indicated, [Resident 70] May use Side rails for assist in mobility, repositioning, and in assist with ADL (activities of daily living) care. On 12/7/18 at 8:30 a.m., during an observation, Resident 70 was in his bed lying on his right side with his legs over the side of the bed. The bed had four side rails in the up position and Resident 70's legs were dangling off the bed entrapped in the gap between the right upper side rail and the right lower side rail. The call light cord was looped on a hook on the wall at the head of the bed and out of reach from Resident 70. During the observation Resident 70 was alone in his room with no staff available to provide assistance to Resident 70. On 12/7/18 at 8:31 a.m., during a concurrent observation and interview, Licensed Nurse (LN) 5 observed the position of Resident 70's legs dangling off the bed entrapped in the gap between the bed and upper and lower side rails on the right side. LN 5 immediately attempted to repositioned Resident 70 so his legs were on the bed and no longer entrapped in the gap between the upper and lower side rails. LN 5 then called CNA 8 to assist in repositioning Resident 70 up on the bed because she was unable to reposition his without another staff member's assistance and attempted to lower the side rails. LN 5 was unable to lower the side rail on the lower left side of the bed and left the lower left side rail in the up position. The side rail on the lower right side was lowered by the LN 5 with ease. LN 5 stated the call light was not where it should be. On 12/7/18 at 9:45 a.m., during a concurrent observation and interview in Resident 70's room, Resident 70 laid in bed with three side rails up. LN 5 stated there were three side rails up and only the right lower side rail was down. LN 5 stated, I'm pretty sure the right bottom side rail was up [during the 8:31 a.m. observation]. On 12/7/18 at 9:48 a.m., during a concurrent observation and interview in Resident 70's room, Resident 70 laid in bed, resting and there were three side rails in the up position (right and left upper and left lower). Certified Nursing Assistant (CNA) 8 stated he had worked with Resident 70 for several months and was assigned to Resident 70 since 6 a.m. on 12/7/18. CNA 8 stated, We [Facility staff] were told not to use the bottom side rails and I don't know how they got in the upper position. I overlooked that four side rails were up. CNA 8 stated he did not know why the call light cord was on the wall and out of the reach of Resident 70. On 12/7/18 at 10:00 a.m., during an interview, LN 5 stated she understood there was an order to use only the upper right and upper left side rails. LN 5 stated she did not know who put the lower side rails in the up position. On 12/10/18 at 10:55 a.m., during an interview, the Director of Nursing (DON) stated, Yes, all four side rails would be considered a restraint. It could be for safety, but the consent does not include [consent to use] all four side rails. On 12/17/18 at 1:36 p.m., during a concurrent interview and record review, the UM reviewed Resident 70's progress note dated 11/15/18 at 5:35 p.m. for Resident 70's fall number 7 which indicated .Residents RT [right] arm was caught between the right side rail and the bed . The IDT Summary dated 11/15/18 at 10:00 a.m. indicated, The IDT discussed resident and current safety/fall interventions. BIMS 0 .on the falling star program .has daily showers, new clock provided .and a white board to let resident know when his showers will be .cd player in room to play music to calm resident . resident has alarms and will stay in place at this time . The UM stated the environment should have been checked for potential hazards. The UM stated no education was provided on measuring the gap between side rails and mattress. The UM stated a side rail assessment should had been done after the fall when Resident 70's arm was caught in between the side rail and the mattress and that was not done. On 12/17/18 at 4:55 p.m., during a concurrent interview and record review, the DON stated a side rails assessment was completed on 4/19/18 but did not include alternative measures tried prior to the decision to use side rails or a risk of entrapment assessment. The DON reviewed side rail informed consent and stated the informed consent had documented risk of Resident 70 side rail entrapment. The DON stated, The CNAs and nurses are responsible to see that a bed assessment is completed. The bed already came with side rails. He is dead weight; he is non-ambulatory; he came as a LTC [Long Term Care] resident. A Hoyer lift [mechanical lift to assist a resident to transfer who is unable to assist in self transfer] is used due to dead weight [115.8 pounds]. The DON stated a reassessment of the side rails was not done in July and started reassessment in October. The DON stated no one admitted who put up the lower side rails. The DON emphasized staff were aware they were not to put all four rails in the up position. The DON stated Resident 70 could have injured himself while the four rails were up. The DON stated, [Resident 70] could be at risk for entrapment, but with all the side rails up he could still get through. The DON stated, We do not consider this (meaning side rails up) a restraint if used for mobility. The DON stated there was no monitoring plan to make sure the use of the side rails was safe. Resident 70's Resident Bed Rail Consent Form dated 4/19/18, indicated, . Mobility Assist .Can enable [Resident 70] to independently reposition self in bed, or to assist caregivers to reposition him/herself in bed, from side to side, move closer to the head of the bed, or to move from a lying to sitting to lying position .Medical Safety .can be a safety measure identified in the resident's care plan by preventing [Resident 70] from slipping or rolling out of bed due to seizures .It is the policy of this facility to use bed rails only after evaluation and care planning deemed it is appropriate to treat the resident's medical symptoms and assist the resident in maintaining his/her highest practicable physical and psychosocial wellbeing .Recommendations .Type of rail (s) . 1/4 partial rail, left upper, right upper . Frequency . Rail(s) are to be used at all times when [Resident 70] is in bed . Bed rail (s) are to be released PRN [as needed] to allow the resident to move in and out of bed, exercising his/her extremities . Benefits [versus] Risk indicated, . Area of concern . [Resident 70] side rails . Benefits .Security-feel safe, mobility assist from side to side, move from a lying to sitting to lying position, help with transferring, medical safety . Risks related to Noncompliance [sic] . skin tears, possible Fall [with] injury, bruising, strangulation, suffocation, caught between rail [and] mattress . Review of the clinical record indicated Resident 70 did not have a seizure diagnosis. UM confirmed that Resident 70 did not have documented diagnosis of seizures. On 12/17/18 at 4:52 p.m., during a concurrent interview and record review, the DON stated side rails were ordered on 4/20/18 and a side rail consent was obtained on 4/19/18 and side rails were in use as of 4/19/18 [day of admission]. Fall risk assessment dated [DATE] indicated Resident 70 was a Moderate risk for falling. The DON stated there was no documentation for side rail alternative for least restrictive intervention used before side rails were implemented. The DON stated, All staff is responsible to assess if the side rails are working properly and will notify maintenance if there is something wrong with the side rails. The DON stated the side rails were determined necessary for Resident 70 by an assessment and speaking with RP (responsible person). The DON was unable to find documentation of a seizure diagnosis. The DON stated a Hoyer lift (hydraulically operated device used to enable caregiver to transfer a resident from the bed to wheelchair) was the safest way to transfer Resident 70 because he could not bear weight or help with transfer from bed to chair. The DON stated the process to wean residents off from side rail use was for nurses to reassess [for side rail need] every three months. The DON stated the side rails would not impede Resident 70 from doing anything. The DON stated resident was able to move out of bed and had been found on the floor multiple times. The DON stated, I can't tell you why the four side rails were up. The nurses didn't tell me. They should not have been up. The DON stated the risk for entrapment and injury was high with four side rails up. The DON stated Resident 70 was able to move himself out of his bed which increased the risk of entrapment when the four side rails were in the up position. On 12/18/18 at 9:20 during an interview, the Director of Rehabilitation (DOR) stated, Resident 70 had frequent falls and used a motion alarm to alert the staff when resident was attempting to get out of his bed. DOR stated the motion is activated When a resident has a fall, it sets off an alarm. The DOR reviewed resident 70 clinical record and stated, With that many falls [10 since June 2018] he [Resident 70] should be in our study [for QAPI - quality assurance prevention and intervention] and should be reviewed for intervention. We should be asking the questions how to keep him safe. The DOR stated the facility does not involve her department with assessments for side rail safety. (DOR) stated she had been working for 17 years with the facility and the DON or ADM would let her know if someone had a mobility decline, falls or a need for therapy services. The DOR stated Resident 70 was not referred to receive therapy services each time he had a fall and would benefit from these services with his safety risk. The DOR stated the process of referral depended upon the nurses to inform the therapy department of the need and change of condition. On 12/18/18 at 10:26 a.m., during a concurrent interview and record review with the DON and ADM, the DON stated she was unable to find documentation of the incident [dated 12/7/18 when Resident 70 was observed dangling off the bed with his legs between the side rails]. The ADM stated, We have called it a mistake. On 12/18/18 at 12:00 p.m., during a concurrent interview and record review, the Social Service Assistant (SSA) stated she had worked at the facility for one year and had taken the lead position one week ago. The SSA stated the side rail assessment was not addressed in IDT meetings and it would require another IDT (interdisciplinary team - a group of healthcare providers from different fields who work together or toward the same goal to provide the best care or best patient outcomes) meeting to assess for the need of the side rails. The SSA reviewed the records and was unable to find documented evidence where Resident 70 had been referred to RNA (restorative nursing therapy services) or PT (Physical Therapy) because of his climbing out of bed and falling. The SSA stated she knew staff had been performing one on one supervision for resident 70 because of his high risk of falling but the one on one was only performed on as needed bases. The SSA stated she was not involved with the assessment or when the decision was made to place Resident 70 on a one on one supervision. The SSA stated, I am still learning his needs. I do IDT notes and always attend IDT meetings. On 12/18/18 at 3:29 p.m., during a concurrent interview and record review, the Director of Staff Development (DSD) stated she was not involved in any assessment of side rails and had no knowledge of any alternative or reassessment of side rails. The DSD stated, If I'm not present during the IDT meeting there is no way for me to get the information that was discussed. The DSD stated Resident 70 would have benefited from a restorative nurse assistant (RNA) program to provide range of motion exercise for Resident 70. The DSD stated, The side rails pose more of a threat or a hazard to him if the staff was not present. The DSD stated keeping the side rails up was not preventing Resident 70 from falling Because he was still falling, even with the side rails. On 12/18/18 at 5:18 p.m., during a telephone interview, the family member (FM) stated, At the time [Resident 70] was admitted , the consent for side rails was not filled out when they gave it to me. They told me to sign it and they would fill it in later. The FM stated she did not want the side rails all the time and was told the side rails were going to be on the right side of the bed to help with his mobility. FM stated the facility did not attempt alternatives prior to implementing the side rails on the day of admission. On 12/18/18 at 5:45 p.m., during a concurrent observation and interview, the DON stated she did not know how the right lower side rail worked. The DON stated, Usually the CNAs know better. The DON called for a CNA who had difficulty finding the release lever and putting the lower rails up or down. On 12/19/18 at 8:05 a.m., during an interview in the ADM's office, the ADM stated it was a mistake for the staff to have used the bottom two side rails on 12/7/18. The ADM stated the lower two side rails should have already been removed, just like all the rest of the beds in the facility. The ADM stated the maintenance staff had removed the lower side rails on Resident 70's bed on 12/18/18. The ADM stated she did not know why Resident 70's bed had four side rails and it appeared his bed had been missed when they checked all the beds for removal of lower end side rails. The ADM stated there was no way to know if the lower side rails had been used before the observation of Resident 70 dangling off the bed with his legs between the side rails. On 12/19/18 at 9:19 a.m., during a telephone interview, LN 5 stated on the day of 12/7/18 the two upper side rails were up and the right lower side rail was up on Resident 70's bed. LN 5 stated the lower left side rail was up and even with the bed mattress. LN 5 stated, I didn't even know where the lever was to put it down. LN 5 stated the left lower side rails remained in the up position because she did not know how to release the side rail. LN 5 stated her understanding was that a restraint was something that prevented movement and she did not consider the side rails as a risk for Resident 70 because Resident 70 could move in bed. On 12/19/18 at 9:23 a.m., during a telephone interview, CNA 8 stated, I'm pretty sure all four side rails were up [on 12/7/18] . I was a little late that day, and I was rushing . CNA 8 stated that all four side rails would be considered a restraint according to nursing home regulations. On 12/19/18 at 11:05 a.m., during a concurrent interview and record review, the DON stated she was unable to find documentation of the incident where Resident 70 was dangling off the bed with his legs between the side rails on 12/7/18. The DON stated the only way to identify delayed injuries as a result of the incident dated 12/7/18 was for the nurses to document. The DON stated, The nurse does weekly skin assessments and would see if there had been [delayed] bruising. The DON stated she had asked the Chief Nurse Executive (CNE) if there should be documentation and was told by the CNE she would not view it as a fall so no documentation was necessary. The facility policy and procedure titled, Physical Restraints, dated, 11/24/17, indicated, .physical restraints are to be only when there is a physician's order .the 'restraint' is based on the effect .of restricting freedom of movement or normal access to one's body .Alarms that prevent the resident the freedom to move around, or cause fear in the resident who attempts to move independently, are considered restraints . The facility policy and procedure titled, Fall Program dated 11/24/17, indicated .a licensed nurse is to complete the Fall Risk Assessment .upon admission to determine the resident's risk factors associated with the potential for falls .is to then be completed .after any actual fall .The higher a resident's risk for falls is, the more individualized interventions should be considered .Bed in low position .Medication review by the pharmacist. Eliminate or reduce medications when appropriate .Restorative program to improve mobility, lower extremity strengthening and/or coordination .