**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure medical supervision of the care for one of three sampled residents (Resident 399), who was newly admitted to the facility and had diagnosis of diabetes mellitus (DM - is a disorder in which the body does not produce enough or respond normally to insulin [a hormone that controls the amount of sugar in the blood], causing blood sugar (glucose) levels to be abnormally high). Attending Physician 1 (MD 1), who was a new doctor for Resident 399 at the facility, did not perform a thorough review of Resident 399's discharge documents from General Acute Care Hospital 1 (GACH 1) including diagnoses and medications to meet the resident's diabetic care upon Resident 399's admission to the facility on [DATE]. Resident 399 did not receive the needed insulin for a total of 11 consecutive days (12/26/2023 to 1/6/20224). As a result, on 1/3/2024, Resident 399's blood sugar (BS) level was 475 milligrams per deciliter (mg/dL - unit of measure) abnormally high (normal fasting [not eating for at least eight hours] BS level is below 100 mg/dL and normal BS level at random time is below 200 mg/dL) and Resident 399 did not receive any medication intervention including insulin. On 1/6/2024, Resident 399 required transfer to GACH 2 emergency room (ER) with extremely high BS levels leading to polyuria (frequent urination) and altered mental status ([AMS] - change in mental function characterized by confusion, disorientation, disordered perceptions) requiring hospitalization. On 2/8/2024 at 3:34 p.m., the California Department of Public Health (CDPH) while conducting the investigation of a complaint about quality of care during the facility's annual recertification survey, identified an Immediate Jeopardy (IJ - a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) under 42 CFR §483.30 Physician Services. The Administrator (ADM) and the Director of Nursing (DON) were notified on 2/8/2024 at 11:18 a.m. of the IJ situation from the facility's failure to ensure Resident 399 was free from any significant medication error. On 2/9/2024 at 4:51 p.m., the IJ situation was removed in the presence of the DON and the Director of Staff Development (DSD), while onsite, after verifying and confirming through observation, interview, and record review the implementation of the facility's submitted and accepted IJ Removal Plan (includes all actions the facility has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely). The acceptable IJ Removal Plan included the following summarized actions: 1. On 2/8/2024, LVN 1 was provided in-service (training intended for staff actively engaged in the practice) on medication reconciliation by reviewing the hospital transfer medication list/another facility medication list/home medication list of the resident and verifying with the admitting physician which medications to continue and which ones to discontinue. Any medication(s) not to be continued at the facility will be documented in the resident's clinical chart. In-service to LVN 1 was also provided on Diabetes Clinical Protocol and Reporting of Test Results policy. 2. On 2/8/2024 and 2/9/2024, MD 1 was provided in-service on the facility's medication reconciliation process for newly admitted residents and facility's policies on diabetes care and test results. 3. On 2/8/2024, the DON and the licensed nurses reviewed all residents admitted to the facility in the last 30 days (between 1/7/2024 and 2/7/2024) for medication reconciliation discrepancies and elevated BS results without any insulin order, without interventions and/or without communication with the physician. No other residents were identified to be affected by the same deficient practice. 4. On 2/8/2024, the facility's Medical Director ((Med Dir 1), the DON, the Quality Assurance (QA) Nurse Consultants, and the DSD started conducting in-service training to all licensed nurses on Diabetes Clinical Protocol, Significant Medication Errors policy, Reporting Test Results policy, reconciliation of hospital medication transfer list, review of BS levels greater than 450 mg/dl with no MD medication order or intervention requiring immediate communication with the physician or the Medical Director if necessary. 5. On 2/9/2024, the QA Nurse Consultants started conducting in-service training to all licensed nurses on faxing the admission medication list along with the facility's admission medication orders to the Pharmacist Consultant (PC) to complete the Interim Medication Regimen Review (IMRR) within 72 hours of a resident's admission to the facility. 6. On 2/9/2024, Med Dir 1 started conducting in-services to residents' attending physicians (MD) on the facility's medication reconciliation, diabetes care and test results policies, and elevated BS levels for follow-up and interventions as indicated. 7. The DON, the nursing supervisors, and the Minimum Data Set (MDS) nurses will review daily the BS level test results to validate communication with MD for new orders or interventions. For BS levels greater than 450 mg/dL without interventions or orders from MD, the DON, nursing supervisor or designee will immediately contact Medical Director. 8. The DON, the nursing supervisor, and the MDS nurses will review within 24 to 72 hours from residents' admission the reconciliation of medications for compliance. 9. The DON, the nursing supervisors, and the MDS nurses will review the fasting BS results during the daily (Monday to Friday) clinical team conference to ensure the MD is informed and interventions are started/implemented. 10. The weekend nursing supervisor will review the fasting BS results and will be responsible to ensure the MD is informed and interventions are started/implemented. 11. The Medical Director will review monthly residents with diagnosis of DM for BS test results and medications with the DON or designee and will make recommendations as appropriate. 12. The Interdisciplinary team (IDT, a group of healthcare professionals from different disciplines involved in the care of the residents) conferences with resident/resident representatives will be held to read the medication list out loud by going through the hospital transfer medication list and the medication orders list in PointClickCare (PCC, electronic health record) and document in the care conference notes the acknowledgement/understanding of the resident/resident representatives. 13. On 2/9/2024, the DSD and the QA Nurse Consultants initiated the knowledge competency with the licensed nurses about medication reconciliation, Diabetes Care Protocol, BS greater than 450 mg/dl with no MD order. 14. The DSD will incorporate medication reconciliation knowledge competency in the orientation program for licensed nurses annually and as needed. 15. The DSD and/or the DON will provide quarterly in-service to licensed nurses on medication reconciliation on admission, Diabetes Care Protocol, reporting labs to MD and to Medical Director for BS greater than 450 mg/dl without MD order or intervention, and faxing the medication list along with the facility's medication admission order to the PC who completes the IMRR within 72 hours of resident admission to the facility. 16. The DON will communicate trends or concerns related to medication reconciliation, Diabetic Care Protocol for abnormal BS results, BS greater than 450 md/dL with no order or intervention by MD, and outcomes of the PC IMMR report of new admits to the Quality Assessment and Assurance (QA&A) committee monthly. The QA&A committee will continue to review for 3 consecutive months or until such time that the deficiency has been proven to be resolved. Cross reference F760 Findings: A review of Resident 399's admission Record (Face Sheet) indicated Resident 399 was admitted to the facility from GACH 1 on 12/26/2023 with diagnoses including DM. A review of Resident 399's Discharge Summary packet from GACH 1 sent with Resident 399 indicated the following: 1) Diagnosis of DM 2) A1C (a test indicating average BS levels for the last 3 months) level of 6.8% and 7% on 12/22/2023. 3) On insulin at home 4) Diabetic diet 5) Discharge medications included insulin glargine 25 units subcutaneous (SQ, injection under the skin) twice a day. A review of Resident 399's Physician Orders on admission [DATE]) did not include an order for insulin glargine as indicated in GACH 1 discharge medication list. A review of Resident 399's Care Plan, dated 12/26/2023, indicated the resident had DM and the interventions included giving medications as ordered by doctor and monitoring and documenting side effects and effectiveness. A review of Resident 399's laboratory test results, with collection date of 1/3/2024, indicated a BS level result of 475 mg/dL on 1/3/2024 and the communication note dated 1/4/2023, by LVN 1 to MD 1 indicated MD 1 did not give any new order (to lower Resident 399's BS level). A review of Resident 399's licensed nurses Progress Notes, dated 1/5/2024, indicated Registered Nurse 1 (RN 1) informed MD 1 about Resident 399's frequent urination. A review of Resident 399's Physician Discharge Note, dated 1/6/2024 at 11:50 a.m., indicated Resident 399 was discharged to GACH 2 by MD 1 due to AMS. A review of Resident 399's Situation, Background, Assessment Recommendation (SBAR, communication form between members of the health care team caring for the resident), dated 1/6/2024 and timed at 1 p.m. by LVN 2 indicated Resident 399 confusion increased and MD 1 and Resident 399's family was notified. A review of Resident 399's Physician Orders dated 1/6/2024 and timed at 3:04 p.m. indicated to administer Resident 399 insulin Humalog (fast-acting insulin) per sliding scale (dosing plan whereby the amount of insulin administered depends on the BS level). A review of Resident 399's GACH 2 ER admission record indicated the resident was admitted on [DATE] at 4:04 p.m. with extremely high BS levels, AMS and polyuria. On 1/6/2024 at 4:17 p.m., Resident 399's BS level was greater than 600 mg/dL; at 4:32 p.m., the BS level was 861 mg/dL; at 8:07 p.m., the BS level was 581 mg/dL; at 9:07 p.m., the BS level was 581 mg/dL. At 11:22 p.m., Resident 399's urine glucose level was greater than 1000 mg/dL and Resident 399 was having seizures (convulsions, burst of abnormal electrical signals in one or more parts of the brain that interrupt normal signals). During an interview on 2/7/2024 at 10:34 a.m., MD 1 stated he reviews and completes resident admission medication orders from the hospital discharge summary orders. MD 1 stated he had reviewed Resident 399's GACH 1 discharge summary, and no DM diagnosis or order for insulin were included. During an interview on 2/7/2024 at 10:44 a.m., LVN 1 stated registered nurses (RN) are responsible for admitting new residents to the facility and addressing discrepancies between the hospital discharge orders and current orders. LVN 1 stated for residents with DM, diabetic interventions should include BS control through diabetic diet, oral medications and/or insulin injections. LVN 1 stated residents with DM and history of insulin use at home or in the hospital should continue insulin upon admission to the facility. LVN 1 stated not continuing insulin can cause hyperglycemia (elevated BS levels) with symptoms of confusion, shakiness, loss of consciousness, polyuria, and in severe cases lead to death. During an interview on 2/7/2024 at 10:50 a.m., Registered Nurse 1/Assistant Director of Nursing (RN 1/ADON) stated for new resident admissions the facility receives paperwork from the discharging hospital including a medication list. RN 1/ADON stated the admitting nurse calls the MD to review the medication list which the MD would continue. RN 1/ADON stated Resident 399 was admitted to the facility on [DATE] and during the admission process the insulin order for glargine was not read to MD 1. RN 1/ADON stated Resident 399 was diabetic and LVN 1 and MD 1 should have identified the lack of medication for DM. RN 1/ADON stated LVN 1 and MD 1 failed to complete appropriate medication reconciliation when not ordering insulin and BS checks for Resident 399. During an interview on 2/7/2024 at 10:51 a.m., RN 3 stated the admitting nurse, usually an RN, admits new residents to the facility. RN 3 stated new residents arrive to the facility with packet of paperwork, and the admitting RN reviews the resident's medication reconciliation list from the discharging hospital with another RN. RN 3 stated the MD reviews the hospital discharge summary orders for diagnosis and medication list to determine which medications to continue or discontinue. During an interview on 2/7/2024 at 11:23 a.m., LVN 1 stated the discharge packet from the hospital is reviewed for new residents admitted to the facility. LVN 1 stated she verified Resident 399's medication orders for Resident 399 with MD 1. LVN 1 stated she later noticed insulin was not ordered but did not follow-up with MD 1 or Nurse Practitioner 1 (NP 1) about the insulin orders for Resident 399. During an interview on 2/7/2024 at 1:18 p.m., the PC stated residents with diagnosis of DM and a care plan for DM should have orders for antidiabetic (to treat diabetes) medications. The PC stated missing 11 days of insulin administration for residents with history of insulin use from home or hospital can lead to AMS, polyuria, and BS levels greater than 500 mg/dL requiring hospitalizations. During an interview on 2/7/2024 at 1:30 p.m., MD 1 stated he did not receive communication from the facility on 1/4/2024 for Resident 399's BS level of 475 mg/dL. MD 1 stated without completing a thorough assessment of a resident or having ruled out factors such as certain medications, urine infections, etc., elevated BS for DM patients may potentially result from not receiving insulin. During an interview on 2/7/2024 at 2:31 p.m., NP 1 stated that a medication reconciliation review is done with the nurses and MD. NP 1 stated that during interdisciplinary team (IDT) conference with the family, missed medications can be identified. NP 1 stated a DM care plan indicating to monitor for side effects and effectiveness indicates there is an order for antidiabetic medication. NP 1 stated BS level of 475 mg/dL is considered high and can lead to fatigue, loss of vision, weakness, polyuria and may require hospitalization. During an interview on 2/7/2024 at 3:22 p.m., LVN 1 stated she contacted MD 1 on 1/4/2024 for Resident 399's BS level of 475 mg/dL and that Resident 399 has DM. LVN 1 stated MD 1 gave no new orders. During an interview on 2/7/2024 at 5:39 p.m., Med Dir 1 acknowledged the failure of MD 1 and LVN 1 not completing a thorough medication reconciliation for Resident 399 resulting in the resident missing insulin glargine for 11 days and subsequently requiring hospitalization. Med Dir 1 stated missing 11 days of insulin for a resident with DM can lead to hyperglycemia, coma, death, and hospitalization, and for Resident 399 the incomplete medication reconciliation led to the omission of 11 days of insulin administration resulting in Resident 399 experiencing AMS and polyuria requiring hospitalization. During an interview on 2/8/2024 at 1:07 p.m., Med Dir 2 (GACH 2 ER Medical Director) stated omitting 11 days of insulin glargine administration was a contributing factor for Resident 399's severe hyperglycemia. During an interview on 2/8/2024 at 1:25 p.m., Doctor of Osteopathy 1 (DO 1) stated he reviewed Resident 399's discharge summary packet from GACH 1 and stated based on the discharge medication list, he would have continued the insulin glargine, upon admission to the facility since Resident 399 had DM. DO 1 also stated he would have intervened with orders for a BS level of 475 mg/dl. DO 1 stated omitting 11 days of insulin administration was a contributing factor for Resident 399's hyperglycemia and the continued hyperglycemia from the insulin omissions led to Resident 399's hospitalization. During an interview and record review on 2/8/2024 at 1:36 p.m., Med Dir 1 stated the discharge summary packet from GACH 1 for Resident 399 and confirmed the packet indicated a diagnosis of DM, diabetic diet, A1C of 6.8 percent (%) and 7%, and an order for insulin glargine 25 units twice a day. Med Dir 1 stated these are indicators that Resident 399 had DM and should have been on antidiabetic medications. Med Dir 1 stated MD 1 should have reviewed the discharge summary packet from GACH 1 for Resident 399 and continued the insulin glargine upon admission to the facility. Med Dir 1 also stated the DM care plan developed on 12/26/2023 for Resident 399 included Diabetes medications as ordered by doctor. Monitor/document for side effects (unwanted effects from medications) and effectiveness. Med Dir 1 stated the facility did not follow or modify Resident 399's care plan if it was not applicable. Med Dir 1 stated several system failures including medication reconciliation not thoroughly reviewed, DM care plan not followed or modified, BS level of 475 mg/dl with no intervention, all causing harm to Resident 399 by the omission of 11 days of insulin glargine administration resulting in hyperglycemia, AMS, polyuria, and ultimately requiring hospitalization. Med Dir 1 stated it is the responsibility of the MD to ensure their residents are thoroughly assessed for diagnosis and medication orders and test results are properly addressed. Med Dir 1 stated going forward to implement a protocol for basic interventions for BS greater than 450 mg/dl and for Med Dir 1 to be notified when licensed nurses are unable to reach MD. During an interview on 2/8/2024 at 4:34 p.m., LVN 1 stated that when MD 1 did not give any orders for Resident 399's BS level of 475 mg/dL on 1/4/2024, she was concerned and flagged the chart for MD 1 to see it on the next visit to the facility. LVN 1 stated she did not know when MD 1 would visit Resident 399. LVN 1 stated she did not notify a supervisor or the DON about Resident 399's elevated BS level on 1/4/2024 and MD 1's the lack of orders or interventions. During an interview on 2/9/2024 at 4 p.m., the DON stated there are clear system failures and the facility needs to have more robust system put in place to prevent these deficiencies. The DON stated there needs to be better clinical judgment from licensed staff to emphasize the importance of continuing medications to MDs and to have more detailed documentation in the resident's chart. The DON stated licensed staff should also communicate to supervisors when they do not feel comfortable not having MD orders for appropriate resident care. The DON stated this was an eye-opening experience of having focus on processes that are clearly deficient in the facility. The DON stated she sees the immediacy of these deficient practices and why the facility needed to have immediate actions taken to prevent further harm to its residents. A review of the facility's policy and procedures (P&P) titled, Reconciliation of Medications on Admission, dated July 2017, indicated The purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission or readmission to the facility. Preparation 1. Gather the information needed to reconcile the medication list: a. Discharge summary from referring facility b. admission order sheet c. All prescription and supplement information obtained from the resident/family during the medication history; and d. Most recent MAR, if this is a readmission. General Guidelines 1. Medication reconciliation is the process of following post-discharge medications by creating an accurate list of both prescription and over the counter medications that includes the drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omissions at transition points in care. 2. Medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption, in the correct dosages and routes, during the admission/transfer process. 3. Medication reconciliation helps to ensure that medications, routes, and dosages have been accurately communicated to the Attending Physician and care team. Steps in the Procedure 4. Review the list carefully to determine if there are discrepancies/conflicts 5. If there are discrepancy or conflict in the medications .determine the most appropriate action to resolve the discrepancy. 6. Document findings and actions Documentation 1. Document the medication discrepancy on the medication reconciliation form. 2. Document what actions were taken by the nurse to resolve the discrepancy. A review of the facility's P&P titled admission Assessment and Follow Up: Role of the License Nurse, dated September 2012, indicated The purpose of this procedure is to gather information about the resident's physical, emotions, cognitive, and psychosocial condition upon admission for the purposes of managing the resident, initiating the care plan, and completing the required assessment instruments, including the Minimum Data Set (MDS, a standardized assessment and care screening tool). 7. Conduct an admission assessment, including: c. A list of active medical diagnoses d. Current medications and treatments 11. Reconcile the list of medications from the medication history, admitting orders, the previous MAR (if available,) and the discharge summary from the previous institution, according to established procedures. 12. Contact the attending physician to communicate and review the findings of the initial assessment and any other pertinent information and obtain admission orders that are based on these findings. A review of the facility's P&P titled Medication Errors, dated April 2023, the P&P indicated: 5. A 'medication error' is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of professional(s) providing services. 7. The IDT reviews the resident's medication regimen for efficacy and actual or potential medication-related problems on an ongoing basis. A review of the facility's P&P titled Diabetes - Clinical Protocol, dated November 2020, the P&P indicated: Assessment and Recognition 1. As part of initial assessment, the physician will help identify individuals with elevated BS, impaired glucose tolerance, or confirmed diabetes . 2. For residents who meet the criteria for diabetes testing, the physician will order pertinent screening; for example, A1C, fasting plasma glucose, or 2-hour plasma glucose with oral glucose load. 3. For residents with confirmed diabetes, the nurse shall assess and document/report the following during the initial assessment: a. Dose and time of most recent anti-hyperglycemic given b. All other current medications c. Residents BS history of 48 hours d. Usual patterns of BS over recent months e. Recent labs Treatment/Management 1. Based on the preceding assessment .the Physician will order appropriate intervention, which may include: c. oral hypoglycemia agents; and /or d. insulin Monitoring and Follow-Up 1. The Physician will follow up on any acute episodes associated with a significant sustained change in BS . 2. As indicated, the Physician will order appropriate lab tests (for example, periodic finger sticks or A1C) and adjust treatments based on these results and other parameters a. Examples of blood glucose monitoring . 1) For the resident receiving insulin who is well controlled: monitor blood glucose levels twice a day if on insulin .; monitor 3 to 4 times a day if on intensive insulin therapy or sliding scale insulin; . Monitor A1C on admission .or when diabetes is diagnosed, and every 6 months thereafter . 4. The Physician will order desired parameters for monitoring and reporting information related to BS management. A review of the facility's P&P titled Care Plans, Comprehensive Person-Centered, dated December 2016, the P&P indicated that: 1. The IDT, in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 8. The comprehensive, person-centered care plan will: b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physician, mental, and psychosocial well-being. g. Incorporate identified problem areas k. Reflect treatment goals . 1. Reflect currently recognized standards of practice for problem areas and conditions. 10. b. The resident's physician (or primary healthcare provider) is integral to this process. 11. Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. A review of the facility's P&P titled Physician Services, dated February 2021, indicated that The medical care of each resident is supervised by a licensed physician. 2. Once a resident is admitted , orders for the resident's immediate care and needs can be provided by a physician, physician assistant, nurse practitioner, or clinical nurse specialist. 3. Supervising the medical care of the resident includes (but is not limited to): a. Participating in the resident's assessment and care planning b. Monitoring changes in the resident's medical status; c. Providing consultation or treatment when called by the facility; d. Prescribing medications and therapy; h. Overseeing a relevant plan of care for the resident. A review of the facility's P&P titled Test Results, dated April 2007, indicated: 1. Results of laboratory, .tests shall be reported in writing to the resident's attending physician or to the facility. 2. .the attending physician shall be promptly notified of the results.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B. A review of Resident 70's admission Record indicated the facility admitted the resident on 9/28/2023 and readmitted the resident on 12/22/2023, with diagnoses including, type 2 diabetes mellitus (a disease that occurs when the blood glucose, also called blood sugar, is too high) with diabetic neuropathy (nerve damage caused by diabetes) and type 2 diabetes mellitus with foot ulcer (an open sore on the foot). A review of Resident 70's History and Physical (H&P), dated 12/15/2023, indicated the resident had the capacity to understand and make decisions. A review of Resident 70's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/31/2023, indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident was on a high-risk drug class hypoglycemic medication (a group of drugs used to reduce the amount of sugar in the blood) insulin. A review of Resident 70's Order Summary Report, dated 12/22/2023, indicated an order for insulin glargine solution 100 unit per milliliters (unit/ml, a unit of fluid volume). Inject 10 unit subcutaneously (sq, administering medications beneath the skin) at bedtime for diabetes. A review of Resident 70's Location of Administration Report on 10/2023 indicated Lantus sq Solution 100 unit/ml was administered on: -10/13/2023 at 6:44 p.m. on the Abdomen- Left Upper Quadrant (Abdomen - LUQ) -10/14/2023 at 9:16 a.m. on the Abdomen - LUQ -10/25/2023 at 8:23 p.m. on the Abdomen - Right Lower Quadrant (Abdomen-RLQ) -10/26/2023 at 8:10 p.m. on the Abdomen - RLQ -10/27/2023 at 8:14 p.m. on the Abdomen - LUQ -10/28/2023 at 8:27 p.m. on the Abdomen - LUQ A review of Resident 70's Care Plan titled, The resident has diabetes mellitus on insulin glargine 10 units every night (QHS), last revised on 2/7/2024, indicated an intervention of diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Insulin glargine solution 100 unit/ml inject 10 unit subcutaneously at bedtime. Rotate injection sites. During an interview and record review on 2/8/2024, at 8:16 a.m., with Registered Nurse 1/Assistant Director of Nursing (RN 1/ADON), reviewed with RN 1/ADON Resident 70's Location of Administration for 10/2023. RN 1/ADON stated there were multiple instances the administration of insulin administration was not rotated. RN 1/ADON stated it was important to rotate insulin administration site to prevent skin issues such as lipodystrophy. A review of the facility's recent policy and procedure titled, Insulin Administration, last reviewed on 6/29/2023, indicated injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). A review of the facility's Patient Information for Lantus (LAN-tus) (insulin glargine injection) for subcutaneous use, 100 Units/ml (U-100), approved on 7/2015, indicated to change (rotate) injection sites within the area you choose with each those. Do not use the exact spot for each injection. 2. A review of Resident 85's admission Record indicated the facility admitted the resident on 11/23/2023 and readmitted the resident on 11/29/2023, with diagnoses including type 2 diabetes mellitus with foot ulcer and type 2 diabetes mellitus with diabetic chronic kidney disease (a type of kidney disease caused by diabetes). A review of Resident 85's H&P, dated 11/23/2023, indicated the resident had the capacity to understand and make decisions. A review of Resident 85's MDS, dated [DATE], indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident was on a high-risk drug class hypoglycemic medication insulin. A review of Resident 85's Order Summary Report indicated at order for: - Insulin lispro injection solution 100 unit/ml (Insulin Lispro). Inject as per sliding scale (the increasing administration of the premeal insulin dose based on the blood sugar level before the meal): if 0 - 149 = 0 units; 150 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401+ = 12 units If blood glucose (BG, also called blood sugar ) above 400 give dose and call provider., subcutaneously before meals and at bedtime for diabetes mellitus (DM) on 11/23/2023. - Lantus SoloStar subcutaneous solution pen-injector 100 unit/ml (insulin glargine). Inject 8 unit subcutaneously at bedtime for DM on 1/7/2024. A review of Resident 85's Care Plan titled, Resident 85 has diabetes mellitus, last revised on 11/25/2023, indicated an intervention to inject as per sliding scale: if 0 - 149 = 0 units; 150 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401+ = 12 units If BG above 400 give dose and call provider., subcutaneously before meals and at bedtime. Rotate injection sites. A review of Resident 85's Location of Administration Report on 11/2023 to 2/2024, indicated insulin was administered subcutaneously on: - Insulin glargine subcutaneous solution 100 unit/ml 11/24/2023 at 8:44 p.m. on the Arm - left 11/25/2023 at 8:22 p.m. on the Arm - left 11/29/2023 at 8:25 p.m. on the Arm - left 11/30/2023 at 9:42 p.m. on the Arm - left - Insulin lispro injection solution 100 unit/ml 11/24/2023 at 4:04 p.m. on the Abdomen- Left Lower Quadrant (Abdomen - LLQ) 11/24/2023 at 8:42 p.m. on the Abdomen - LLQ 11/25/2023 at 8:16 p.m. on the Arm - left 11/29/2023 at 11:36 a.m. on the Arm - left 12/02/2023 at 9:50 p.m. on the Arm - right 12/03/2023 at 12:08 p.m. on the Arm - right 12/04/2023 at 5:44 a.m. on the Arm - right 12/10/2023 at 12:09 p.m. on the Abdomen - LLQ 12/10/2023 at 9:27 p.m. on the Abdomen - LLQ 12/16/2023 at 6:46 a.m. on the Arm - left 12/16/2023 at 12:18 p.m. on the Arm - left 12/18/2023 at 11:47 a.m. on the Abdomen - LUQ 12/19/2023 at 11:56 a.m. on the Abdomen - LUQ 1/09/2024 at 11:23 a.m. on the Abdomen - LUQ 1/10/2024 at 11:44 a.m. on the Abdomen - LUQ 1/22/2024 at 12:21 p.m. on the Abdomen - LUQ 1/23/2024 at 11:01 a.m. on the Abdomen - LUQ 1/24/2024 at 06:22 a.m. on the Abdomen- Right Upper Quadrant (Abdomen - RUQ) 1/24/2024 at 11:19 a.m. on the Abdomen - RUQ 1/29/2024 at 4:46 p.m. on the Abdomen - LLQ 1/29/2024 at 9:45 p.m. on the Abdomen - LLQ 1/30/2024 at 06:03 a.m. on the Arm - left 1/30/2024 at 12:29 p.m. on the Arm - left 2/04/2024 at 9:50 p.m. on the Arm - left 2/05/2024 at 6:20 a.m. on the Arm - left - Lantus SoloStar subcutaneous solution pen-injector 100 unit/ml 02/03/2024 at 9:23 p.m. on the Arm - left 02/04/2024 at 9:50 p.m. on the Arm - left During an interview and record review on 8:26 a.m., with RN 1/ADON, reviewed with RN 1/ADON Resident 85's Location of Administration of insulin from 11/2023 to 2/2024. RN 1/ADON stated there were multiple repeated administration sites of insulin on the Location of Administration Report. RN 1/ADON stated the insulin administration sites should be rotated to prevent skin issues and lipodystrophy. RN 1/ADON stated not following the manufacturer's recommendation of administering the medication was considered a medication error. A review of the facility's recent policy and procedure titled, Medication Errors, last reviewed on 6/29/2023, indicated a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturers specifications, or accepted professional standards and principles of the professional(s) providing the services. A review of the facility's recent policy and procedure titled, Insulin Administration, last reviewed on 6/29/2023, indicated injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). A review of the facility's Highlights of Prescribing Information, revised in 3/2023, indicated HUMALOG administered by subcutaneous injection (under your skin) should be given in the abdominal wall, thigh (upper leg), upper arm, or buttocks. Injection sites should be rotated within the same region from one injection to the next to reduce the risk of lipodystrophy. Based on interview and record review, the facility failed to: A. Ensure one of three sampled residents (Resident 399), who was newly admitted to the facility and had diagnosis of diabetes mellitus (DM - is a disorder in which the body does not produce enough or respond normally to insulin [a hormone that controls the amount of sugar in the blood], causing blood sugar (glucose) levels to be abnormally high), was free from medication error (any error [of commission or omission] that occurs at any point in the medication use process). Upon Resident 399's admission to the facility on [DATE], Attending Physician 1 (MD 1) and Licensed Vocational Nurse 1 (LVN 1) did not perform medication reconciliation (formal process for creating the most complete and accurate list possible of a resident's current medications and comparing the list to those in the resident's record or medication orders) and an order for the medication administration of insulin glargine (long-acting insulin [covers insulin needs for about one full day]) for twice a day was not verified with MD 1 and not transcribed into the facility's medication admission orders. Resident 399 did not receive the needed insulin for a total of 11 consecutive days (12/26/2023 to 1/6/20224). As a result, on 1/3/2024, Resident 399's blood sugar (BS) level was 475 milligrams per deciliter (mg/dL - unit of measure) abnormally high (normal fasting [not eating for at least eight hours] BS level is below 100 mg/dL and normal BS level at random time is below 200 mg/dL) and Resident 399 did not receive any medication intervention including insulin. On 1/6/2024, Resident 399 required transfer to General Acute Care Hospital 2 (GACH 2) emergency room (ER) with extremely high BS levels leading to polyuria (frequent urination) and altered mental status ([AMS] - change in mental function characterized by confusion, disorientation, disordered perceptions) requiring hospitalization. On 2/8/2024 at 11:18 a.m., the California Department of Public Health (CDPH) while conducting the investigation of a complaint about quality of care during the facility's annual recertification survey, identified an Immediate Jeopardy (IJ - a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) under 42 CFR §483.45(f)(2) Residents are Free of any Significant Medication Errors. The Administrator (ADM) and the Director of Nursing (DON) were notified on 2/8/2024 at 11:18 a.m. of the IJ situation from the facility's failure to ensure Resident 399 was free from any significant medication error. On 2/9/2024 at 4:51 p.m., the IJ situation was removed in the presence of the DON and the Director of Staff Development (DSD), while onsite, after verifying and confirming through observation, interview, and record review the implementation of the facility's submitted and accepted IJ Removal Plan (includes all actions the facility has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely). The acceptable IJ Removal Plan included the following summarized actions: 1. On 2/8/2024, LVN 1 was provided in-service (training intended for staff actively engaged in the practice) on medication reconciliation by reviewing the hospital transfer medication list/another facility medication list/home medication list of the resident and verifying with the admitting physician which medications to continue and which ones to discontinue. Any medication(s) not to be continued at the facility will be documented in the resident's clinical chart. In-service to LVN 1 was also provided on Diabetes Clinical Protocol and Reporting of Test Results policy. 2. On 2/8/2024 and 2/9/2024, MD 1 was provided in-service on the facility's medication reconciliation process for newly admitted residents and facility's policies on diabetes care and test results. 3. On 2/8/2024, the DON and the licensed nurses reviewed all residents admitted to the facility in the last 30 days (between 1/7/2024 and 2/7/2024) for medication reconciliation discrepancies and elevated BS results without any insulin order, without interventions and/or without communication with the physician. No other residents were identified to be affected by the same deficient practice. 4. On 2/8/2024, the facility's Medical Director ((Med Dir 1), the DON, the Quality Assurance (QA) Nurse Consultants, and the DSD started conducting in-service training to all licensed nurses on Diabetes Clinical Protocol, Significant Medication Errors policy, Reporting Test Results policy, reconciliation of hospital medication transfer list, review of BS levels greater than 450 mg/dl with no MD medication order or intervention requiring immediate communication with the physician or the Medical Director if necessary. 5. On 2/9/2024, the QA Nurse Consultants started conducting in-service training to all licensed nurses on faxing the admission medication list along with the facility's admission medication orders to the Pharmacist Consultant (PC) to complete the Interim Medication Regimen Review (IMRR) within 72 hours of a resident's admission to the facility. 6. On 2/9/2024, Med Dir 1 started conducting in-services to residents' attending physicians (MD) on the facility's medication reconciliation, diabetes care and test results policies, and elevated BS levels for follow-up and interventions as indicated. 7. The DON, the nursing supervisors, and the Minimum Data Set (MDS) nurses will review daily the BS level test results to validate communication with MD for new orders or interventions. For BS levels greater than 450 mg/dL without interventions or orders from MD, the DON, nursing supervisor or designee will immediately contact Medical Director. 8. The DON, the nursing supervisor, and the MDS nurses will review within 24 to 72 hours from residents' admission the reconciliation of medications for compliance. 9. The DON, the nursing supervisors, and the MDS nurses will review the fasting BS results during the daily (Monday to Friday) clinical team conference to ensure the MD is informed and interventions are started/implemented. 10. The weekend nursing supervisor will review the fasting BS results and will be responsible to ensure the MD is informed and interventions are started/implemented. 11. The Medical Director will review monthly residents with diagnosis of DM for BS test results and medications with the DON or designee and will make recommendations as appropriate. 12. The Interdisciplinary team (IDT, a group of healthcare professionals from different disciplines involved in the care of the residents) conferences with resident/resident representatives will be held to read the medication list out loud by going through the hospital transfer medication list and the medication orders list in PointClickCare (PCC, electronic health record) and document in the care conference notes the acknowledgement/understanding of the resident/resident representatives. 13. On 2/9/2024, the DSD and the QA Nurse Consultants initiated the knowledge competency with the licensed nurses about medication reconciliation, Diabetes Care Protocol, BS greater than 450 mg/dl with no MD order. 14. The DSD will incorporate medication reconciliation knowledge competency in the orientation program for licensed nurses annually and as needed. 15. The DSD and/or the DON will provide quarterly in-service to licensed nurses on medication reconciliation on admission, Diabetes Care Protocol, reporting labs to MD and to Medical Director for BS greater than 450 mg/dl without MD order or intervention, and faxing the medication list along with the facility's medication admission order to the PC who completes the IMRR within 72 hours of resident admission to the facility. 16. The DON will communicate trends or concerns related to medication reconciliation, Diabetic Care Protocol for abnormal BS results, BS greater than 450 md/dL with no order or intervention by MD, and outcomes of the PC IMMR report of new admits to the Quality Assessment and Assurance (QA&A) committee monthly. The QA&A committee will continue to review for 3 consecutive months or until such time that the deficiency has been proven to be resolved. Cross reference F710 B. Ensure residents were free of any significant medication errors by failing to: 1. Rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) administration sites of insulin (a hormone that lowers the level of sugar in the blood) to one out of five sampled residents (Resident 70) investigated under unnecessary medications. 2. Rotate subcutaneous administration sites of insulin to one out of one sampled resident (Resident 85) investigated under insulin. The deficient practice had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (a rare disease that occurs when a protein called amyloid builds up in organs). Cross reference F658 Findings: A. A review of Resident 399's admission Record (Face Sheet) indicated Resident 399 was admitted to the facility from GACH 1 on 12/26/2023 with diagnoses including DM. A review of Resident 399's Discharge Summary packet from GACH 1 sent with Resident 399 indicated the following: 1) Diagnosis of DM 2) A1C (a test indicating average BS levels for the last 3 months) level of 6.8% and 7% on 12/22/2023. 3) On insulin at home 4) Diabetic diet 5) Discharge medications included insulin glargine 25 units subcutaneous (SQ, injection under the skin) twice a day. A review of Resident 399's Physician Orders on admission [DATE]) did not include an order for insulin glargine as indicated in GACH 1 discharge medication list. A review of Resident 399's Care Plan, dated 12/26/2023, indicated the resident had DM and the interventions included giving medications as ordered by doctor and monitoring and documenting side effects and effectiveness. A review of Resident 399's laboratory test results, with collection date of 1/3/2024, indicated a BS level result of 475 mg/dL on 1/3/2024 and the communication note dated 1/4/2023, by LVN 1 to MD 1 indicated MD 1 did not give any new order (to lower Resident 399's BS level). A review of Resident 399's licensed nurses Progress Notes, dated 1/5/2024, indicated Registered Nurse 1/Assistant Director of Nursing (RN 1/ADON) informed MD 1 about Resident 399's frequent urination. A review of Resident 399's Physician Discharge Note, dated 1/6/2024 at 11:50 a.m., indicated Resident 399 was discharged to GACH 2 by MD 1 due to AMS. A review of Resident 399's Situation, Background, Assessment Recommendation (SBAR, communication form between members of the health care team caring for the resident), dated 1/6/2024 and timed at 1 p.m. by LVN 2 indicated Resident 399 confusion increased and MD 1 and Resident 399's family were notified. A review of Resident 399's Physician Orders dated 1/6/2024 and timed at 3:04 p.m. indicated to administer Resident 399 insulin Humalog (fast-acting insulin) per sliding scale (dosing plan whereby the amount of insulin administered depends on the BS level). A review of Resident 399's GACH 2 ER admission record indicated the resident was admitted on [DATE] at 4:04 p.m. with extremely high BS levels, AMS, and polyuria. On 1/6/2024 at 4:17 p.m., Resident 399's BS level was greater than 600 mg/dL; at 4:32 p.m., the BS level was 861 mg/dL; at 8:07 p.m., the BS level was 581 mg/dL; at 9:07 p.m., the BS level was 581 mg/dL. At 11:22 p.m., Resident 399's urine glucose level was greater than 1000 mg/dL and Resident 399 was having seizures (convulsions, burst of abnormal electrical signals in one or more parts of the brain that interrupt normal signals). During an interview on 2/7/2024 at 10:34 a.m., MD 1 stated he reviews and completes resident admission medication orders from the hospital discharge summary orders. MD 1 stated he had reviewed Resident 399's GACH 1 discharge summary, and no DM diagnosis or order for insulin were included. During an interview on 2/7/2024 at 10:44 a.m., LVN 1 stated registered nurses (RN) are responsible for admitting new residents to the facility and addressing discrepancies between the hospital discharge orders and current orders. LVN 1 stated for residents with DM, diabetic interventions should include BS control through diabetic diet, oral medications and/or insulin injections. LVN 1 stated residents with DM and history of insulin use at home or in the hospital should continue insulin upon admission to the facility. LVN 1 stated not continuing insulin can cause hyperglycemia (elevated BS levels) with symptoms of confusion, shakiness, loss of consciousness, polyuria, and in severe cases lead to death. During an interview on 2/7/2024 at 10:50 a.m., RN 1/ADON stated for new resident admissions the facility receives paperwork from the discharging hospital including a medication list. RN 1/ADON stated the admitting nurse calls the MD to review the medication list which the MD would continue. RN 1/ADON stated Resident 399 was admitted to the facility on [DATE] and during the admission process the insulin order for glargine was not read to MD 1. RN 1/ADON stated Resident 399 was diabetic and LVN 1 and MD 1 should have identified the lack of medication for DM. RN 1/ADON stated LVN 1 and MD 1 failed to complete appropriate medication reconciliation when not ordering insulin and BS checks for Resident 399. During an interview on 2/7/2024 at 10:51 a.m., RN 3 stated the admitting nurse, usually an RN, admits new residents to the facility. RN 3 stated new residents arrive to the facility with packet of paperwork, and the admitting RN reviews the resident's medication reconciliation list from the discharging hospital with another RN. RN 3 stated the MD reviews the hospital discharge summary orders for diagnosis and medication list to determine which medications to continue or discontinue. During an interview on 2/7/2024 at 11:23 a.m., LVN 1 stated the discharge packet from the hospital is reviewed for new residents admitted to the facility. LVN 1 stated she verified Resident 399's medication orders for Resident 399 with MD 1. LVN 1 stated she later noticed insulin was not ordered but did not follow-up with MD 1 or Nurse Practitioner 1 (NP 1) about the insulin orders for Resident 399. During an interview on 2/7/2024 at 1:18 p.m., the PC stated residents with diagnosis of DM and a care plan for DM should have orders for antidiabetic (to treat diabetes) medications. The PC stated missing 11 days of insulin administration for residents with history of insulin use from home or hospital can lead to AMS, polyuria, and BS levels greater than 500 mg/dL requiring hospitalizations. During an interview on 2/7/2024 at 1:30 p.m., MD 1 stated he did not receive communication from the facility on 1/4/2024 for Resident 399's BS level of 475 mg/dL. MD 1 stated without completing a thorough assessment of a resident or having ruled out factors such as certain medications, urine infections, etc., elevated BS for DM patients may potentially result from not receiving insulin. During an interview on 2/7/2024 at 2:31 p.m., NP 1 stated that a medication reconciliation review is done with the nurses and MD. NP 1 stated that during interdisciplinary team (IDT) conference with the family, missed medications can be identified. NP 1 stated a DM care plan indicating to monitor for side effects and effectiveness indicates there is an order for antidiabetic medication. NP 1 stated BS level of 475 mg/dL is considered high and can lead to fatigue, loss of vision, weakness, polyuria and may require hospitalization. During an interview on 2/7/2024 at 3:22 p.m., LVN 1 stated she contacted MD 1 on 1/4/2024 for Resident 399's BS level of 475 mg/dL and that Resident 399 has DM. LVN 1 stated MD 1 gave no new orders. During an interview on 2/7/2024 at 5:39 p.m., Med Dir 1 acknowledged the failure of MD 1 and LVN 1 not completing a thorough medication reconciliation for Resident 399 resulting in the resident missing insulin glargine for 11 days and subsequently requiring hospitalization. Med Dir 1 stated missing 11 days of insulin for a resident with DM can lead to hyperglycemia, coma, death, and hospitalization, and for Resident 399 the incomplete medication reconciliation led to the omission of 11 days of insulin administration resulting in Resident 399 experiencing AMS and polyuria requiring hospitalization. During an interview on 2/8/2024 at 1:07 p.m., Med Dir 2 (GACH 2 ER Medical Director) stated omitting 11 days of insulin glargine administration was a contributing factor for Resident 399's severe hyperglycemia. During an interview on 2/8/2024 at 1:25 p.m., Doctor of Osteopathy 1 (DO 1) stated he reviewed Resident 399's discharge summary packet from GACH 1 and stated based on the discharge medication list, he would have continued the insulin glargine, upon admission to the facility since Resident 399 had DM. DO 1 also stated he would have intervened with orders for a BS level of 475 mg/dl. DO 1 stated omitting 11 days of insulin administration was a contributing factor for Resident 399's hyperglycemia and the continued hyperglycemia from the insulin omissions led to Resident 399's hospitalization. During an interview and record review on 2/8/2024 at 1:36 p.m., Med Dir 1 stated the discharge summary packet from GACH 1 for Resident 399 and confirmed the packet indicated a diagnosis of DM, diabetic diet, A1C of 6.8 percent (%) and 7%, and an order for insulin glargine 25 units twice a day. Med Dir 1 stated these are indicators that Resident 399 had DM and should have been on antidiabetic medications. Med Dir 1 stated MD 1 should have reviewed the discharge summary packet from GACH 1 for Resident 399 and continued the insulin glargine upon admission to the facility. Med Dir 1 also stated the DM care plan developed on 12/26/2023 for Resident 399 included Diabetes medications as ordered by doctor. Monitor/document for side effects (unwanted effects from medications) and effectiveness. Med Dir 1 stated the facility did not follow or modify Resident 399's care plan if it was not applicable. Med Dir 1 stated several system failures including medication reconciliation not thoroughly reviewed, DM care plan not followed or modified, BS level of 475 mg/dl with no intervention, all causing harm to Resident 399 by the omission of 11 days of insulin glargine administration resulting in hyperglycemia, AMS, polyuria, and ultimately requiring hospitalization. Med Dir 1 stated it is the responsibility of the MD to ensure their residents are thoroughly assessed for diagnosis and medication orders and test results are properly addressed. Med Dir 1 stated going forward to implement a protocol for basic interventions for BS greater than 450 mg/dl and for Med Dir 1 to be notified when licensed nurses are unable to reach MD. During an interview on 2/8/2024 at 4:34 p.m., LVN 1 stated that when MD 1 did not give any orders for Resident 399's BS level of 475 mg/dL on 1/4/2024, she was concerned and flagged the chart for MD 1 to see it on the next visit to the facility. LVN 1 stated she did not know when MD 1 would visit Resident 399. LVN 1 stated she did not notify a supervisor or the DON about Resident 399's elevated BS level on 1/4/2024 and MD 1's the lack of orders or interventions. During an interview on 2/9/2024 at 4 p.m., the DON stated there are clear system failures and the facility needs to have more robust system put in place to prevent these deficiencies. The DON stated there needs to be better clinical judgment from licensed staff to emphasize the importance of continuing medications to MDs and to have more detailed documentation in the resident's chart. The DON stated licensed staff should also communicate to supervisors when they do not feel comfortable not having MD orders for appropriate resident care. The DON stated this was an eye-opening experience of having focus on processes that are clearly deficient in the facility. The DON stated she sees the immediacy of these deficient practices and why the facility needed to have immediate actions taken to prevent further harm to its residents. A review of the facility's policy and procedures (P&P) titled, Reconciliation of Medications on Admission, dated July 2017, indicated The purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission or readmission to the facility. Preparation 1. Gather the information needed to reconcile the medication list: a. Discharge summary from referring facility b. admission order sheet c. All prescription and supplement information obtained from the resident/family during the medication history; and d. Most recent MAR, if this is a readmission. General Guidelines 1. Medication reconciliation is the process of following post-discharge medications by creating an accurate list of both prescription and over the counter medications that includes the drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omissions at transition points in care. 2. Medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption, in the correct dosages and routes, during the admission/transfer process. 3. Medication reconciliation helps to ensure that medications, routes, and dosages have been accurately communicated to the Attending Physician and care team. Steps in the Procedure 4. Review the list carefully to determine if there are discrepancies/conflicts 5. If there are discrepancy or conflict in the medications .determine the most appropriate action to resolve the discrepancy. 6. Document findings and actions Documentation 1. Document the medication discrepancy on the medication reconciliation form. 2. Document what actions were taken by the nurse to resolve the discrepancy. A review of the facility's P&P titled admission Assessment and Follow Up: Role of the License Nurse, dated September 2012, indicated The purpose of this procedure is to gather information a[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide immediate emergency care including cardiopulmonary resuscitation (CPR- emergency procedure used to restart a person's heartbeat and breathing after one or both have stopped) for one of two sampled residents (Resident 73) who was found unresponsive (when a person is at least unconscious[abnormal state in which a person exhibits a complete, or near-complete, inability to maintain an awareness of self and environment], and possibly dead or dying) on [DATE] at 10:40 p.m. This deficient practice resulted in Resident 73's death on [DATE] at 10:45 p.m. On [DATE] at 4:11 p.m., the State Survey Agency (SSA) identified an Immediate Jeopardy (IJ, a situation in which the facility's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) situation under 42CFR §483.24(a)(3) Personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives. The Administrator (ADM) and the Director of Nursing (DON) were notified of the IJ situation from the facility's failure to provide CPR immediately to Resident 73 when found unresponsive. On [DATE] at 5:08 p.m., the IJ situation was removed in the presence of the Administrator and DON, while onsite, and after verifying through observation, interview, and record review the implementation of the facility's submitted and accepted IJ Removal Plan. The IJ removal plan included the following summarized actions which were initiated on [DATE] and ongoing until completed on [DATE]: 1. On [DATE], the Director of Nursing (DON) and a certified CPR Instructor (a third-party vendor) conducted an in-service and return demonstration to all nursing staff, including Certified Nursing Assistant 3 (CNA 3) and Licensed Vocational Nurse 1 (LVN 1), on the timeliness of initiating emergency care, including CPR. 2. On [DATE], the Director of Staff Development (DSD) checked employee records of CPR certification training to all direct care staff nurses in the facility. 3. The DON and CPR Instructor re-trained all nursing staff on initiating emergency care including CPR immediately upon assessment. 4. The DON and CPR instructor in-serviced all nursing staff on the required assessment to initiate CPR immediately. 5. The DSD administered a competency test on emergency care, including CPR, to all nursing staff. 6. The DON and Administrator reviewed and updated the facility's policy and procedure for emergency care to include but not limited to CPR procedures. The policy was brought forth to the Quality Assurance (QA) Committee on [DATE] for review and approval. 7. A root cause analysis was initiated on [DATE] and completed on [DATE]. 8. A second crash cart will be made available at Nurses Station 2 by the Maintenance Supervisor and reviewed by the DON on [DATE]. 9. The Administrator and DON developed a crash cart policy and procedure on [DATE] and will be brought forth to the QA committee for review and approval. 10. At the direction of the QA Performance Improvement (QAPI) committee, the Director of Nurses and/or designee shall review as necessary those residents that required emergency care including CPR to determine the timeliness of when emergency care was provided including CPR. The review of record will be recorded on a tracking log to determine the timeliness of when emergency was initiated. The results of the audits will be presented to the QA committee by the DON at a minimum of quarterly for further action planning and monitoring as necessary. Finding: A review of Resident 73's admission Record indicated the facility admitted Resident 73 on [DATE] and readmitted on [DATE], with diagnoses including malignant neoplasm (term for a cancerous tumor) of unspecified ovary (pair of female glands), acute respiratory failure (a serious condition that makes it difficult to breathe on your own) with hypoxia (low levels of oxygen in your body tissues) and hypotension (abnormally low blood pressure). A review of Resident 73's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated [DATE], indicated Resident 73 had the ability to make herself understood and understand others. A review of Resident 73's Physician's Orders for Life Sustaining Treatment (POLST- portable medical orders that communicate patient wishes for end-of-life intervention to health care facilities and providers, including emergency medical services, dated [DATE], indicated to attempt resuscitation/CPR and full treatment. A review of Resident 73's nursing Progress Notes, dated [DATE] and timed at 11:52 p.m., indicated that on [DATE] at 10:40 p.m. CNA 3 reported to Licensed Vocational Nurse 1 (LVN 1) Resident 73 was not responsive. LVN 1 was unable to get vital signs (measurements of the body's most basic functions such as body temperature, heart [pulse] rate, respiration rate [rate of breathing], and blood pressure [pressure of circulating blood against the walls of blood vessels]). LVN 1 could not feel Resident 73's pulse. The nursing Progress Note indicated that at 10:45 p.m. (five minutes after Resident 73 was found without vital signs), LVN 1 and LVN 2 initiated CPR and called paramedics (health professionals certified to perform advanced life support procedures) through 911 (a phone number to contact the emergency services). The progress notes indicated Resident 73 was pronounced dead at 10:45 p.m. and paramedics and sheriff (law enforcement) arrived at 11:07 p.m. On [DATE] at 1:26 p.m., during an interview with the DON and concurrent review of Resident 73's POLST, the DON stated Resident 73 wished to be resuscitated. The DON stated on [DATE], there was a delay of five minutes in starting CPR on Resident 73 (from 10:40 p.m. to 10:45 p.m.). The DON stated CNA 3 was trained in CPR and could have started CPR immediately. On [DATE] at 2:33 p.m., during an interview, CNA 3 stated that on [DATE] at past 10 p.m., she stopped by to see Resident 73, who was in bed, and noted her to be pale (loss of color from the skin). CNA 3 stated she left Resident 73's room to notify LVN 1. CNA 3 stated she was CPR certified but had not performed CPR before and was not comfortable doing it and that was the reason she did not initiate CPR on Resident 73. CNA 3 stated she should have not left Resident 73 and instead she should have yelled for help and start CPR. On [DATE] at 3:29 p.m., during an interview, LVN 1 stated CNA 3 came to the nurses' station and reported she believed Resident 73 was dead. LVN 1 stated she went into Resident 73's room and observed Resident 73 was pale and was not breathing. LVN 1 stated Resident 73's room was less than a minute from the nurses' station. LVN 1 stated it took about 3 minutes for her to reposition the resident, check for brachial (artery) pulse (heartbeat felt in the anterior aspect of the elbow), carotid (artery) pulse (heartbeat felt in on either side of the front of the neck just below the angle of the jaw), and wrist (radial artery) pulse. LVN 1 stated LVN 2 came inside Resident 73's room and she asked LVN 2 to help checking Resident 73's condition. LVN 1 stated she did not want to be the one to say that Resident 73 was dead and needed someone else to verify. LVN 1 stated LVN 2 tried to take Resident 73's blood pressure manually but could not hear anything using the stethoscope (a medical instrument used to listen to blood pressure sounds). LVN 1 stated LVN 2 started chest compressions (the act of applying pressure to someone's chest to help blood flow through the heart in an emergency situation) and LVN 1 called paramedics. LVN 1 stated there was a delay in starting CPR for about four to five minutes. On [DATE] at 2:24 p.m., during an interview, Resident 73's Primary Physician (PP 1) PP 1 stated he was not the one to call the time of Resident 73's death. On [DATE] at 11:04 a.m., during an interview, LVN 1 stated she had a CPR training and learned that an unresponsive resident requires one pulse check and if there is no pulse one should start CPR right away. LVN 1 stated she checked several areas for Resident 73's heart rate and CPR initiation was delayed which could have potentially caused Resident 73's death. On [DATE] at 2:19 p.m., during an interview, the DON stated when a resident is unresponsive, staff should stay with the resident, yell for help, check for pulse and rising and falling of chest, and start CPR if the resident has no heartbeats and is not breathing. The DON stated that the five-minute delay in giving CPR to Resident 73 could have caused Resident 73's death. When asked, the DON was able to give the facility's policies and procedures on Emergency Care and Cardiopulmonary Resuscitation but was not able to give any other policies and procedures related to giving emergency care to residents such as Crash Carts (a cart stocked with emergency medical equipment, supplies, and drugs for use by medical personnel especially during efforts to resuscitate a patient experiencing cardiac arrest) and Code Blue (a declaration of or a state of medical emergency and call for medical personnel and equipment to attempt to revive a patient from unconsciousness especially when in cardiac arrest or respiratory distress or failure). A review of facility's policy and procedures titled, Emergency Care, revised on [DATE], indicated it was the policy of the facility to provide emergency care which included, but not limited to CPR and / or calling 911 for transfer to an acute care facility for more definitive treatment. The policy indicated that when paramedics arrive, the resident's care is transferred to the paramedics. The following is the procedure: 1. Notify the physician and report changes in condition pursuant to policy. 2. Provide emergency care as necessary. 4. Calling 911 is at the discretion of the charge nurse base on his/her professional judgment. 5. Follow CPR . guidelines as indicated. A review of facility's policy and procedures titled, Cardiopulmonary Resuscitation (CPR), revised on [DATE], indicated to ensure ventilation and establish circulation on a resident with absence of respirations and pulse until emergency personnel arrives. Giving CPR: 1. Check the scene for safety, form an initial impression and use personal protective equipment (PPE). 2. If the person appears unresponsive, check for responsiveness, breathing, life-threatening bleeding or other life-threatening conditions using shout-tap-shout. 3. If the person does not respond and is not breathing or only gasping, call 9-1-1 and get equipment, or tell someone to do so. 4. Place the person on their back on a firm, flat surface. 5. Give 30 chest compressions. 6. Give two breaths. 7. Continue giving sets of 30 chest compressions and two breaths. Use an automated external defibrillator (AED - it is a sophisticated, yet easy-to-use, medical device that can analyze the heart's rhythm and, if necessary, deliver an electrical shock, or defibrillation, to help the heart re-establish an effective rhythm) as soon as one is available.