**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure, residents did not develop an adverse effect (an undesired effect of a medication or other type of treatment) due to receiving antipsychotic medications used to treat mental health conditions like schizophrenia (a serious mental disorder in which people interpret reality abnormally), bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs and lows), Seroquel, Risperdal and Ativan and for two of 18 sampled residents (Resident 18 and Resident 25). The facility failed to: 1. Ensure Resident 25, who had a physician's order to discontinue administration of Seroquel 25 milligrams ([mg]- a unit of measure of weight) dated 5/14/2024, was not administered Seroquel for an additional 20 days, a total of 20 extra doses from 5/14/2024 to 6/4/2024. 2. Ensure the licensed nurses monitored Resident 25 for psychotropic medication adverse effects including Seroquel and Depakote Sprinkles. 3. Ensure licensed staff followed the facility's policy and procedure (P&P) titled, Use of Psychotropic Medication, which indicated residents are not given psychotropic medication unless the medication is necessary to treat a specific condition and ensure Resident 25 was not prescribed Seroquel. 4. Ensure Resident 18 did not receive Risperdal and Ativan without indication for use and without a consent to receive this medication for one month from 5/9/2024 to 6/11/2024. These deficient practices resulted in: 1. Resident 25 having increased confusion, becoming lethargic (sluggish) and difficult to arouse with low blood pressure 96/59 Blood pressure reference range is 120/80. On 6/5/2024 at 9:16 a.m. Emergency medical services (EMS) were called, and Resident 25 was transferred to a general acute care hospital (GACH). Upon arrival to the GACH's emergency room (ER) Resident 25 was hypoxic (abnormally low level of oxygen) upon arrival with a high blood sugar of 209 milligrams per deciliter (mg/dL [unit of measure of volume]). Blood sugar reference range is 70 to 99 mg/dL. Resident 25 was admitted to the GACH from 6/5/2024 to 6/11/2024 for evaluation and treatment. 2. Resident 18 was unnecessarily placed at risk for experiencing the adverse effect of Risperdal and Ativan. Findings: A. During a review of Resident 25's admission Record, the admission Record indicated Resident 25 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (disrupted blood flow to the brain caused by issues with the blood vessels that supply it), hemiplegia (severe weakness on one side of the body), hemiparesis (one sided weakness without complete paralysis), dementia (a group of symptoms that affects memory and thinking) without behavioral disturbance (aggression, anxiety) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 25's Minimum Data Set ([MDS] a standardized assessment and care-screening tool), dated 4/15/2024, the MDS indicated Resident 25 did not exhibit behaviors such as hallucinating, delusions, or physical (hitting, biting) and verbal (screaming at others) behaviors. The MDS indicated Resident 25 was moderately depressed. The MDS indicated Resident 25 required maximal assistance from staff for transferring from chair to bed, rolling in bed left and right and required moderate assistance for toileting, bathing, and dressing. During a review of the History and Physical (H&P) dated 4/14/2024, the H&P indicated Resident 25 did not have the capacity to make medical decisions. During a review of the psychiatrist's (a medical practitioner that specializes in the diagnosis and treatment of mental illness) note dated 5/14/2024, the psychiatrist's note indicated Resident 25 had a diagnosis of anxiety and treatment for anxiety and psychosis and had episodes of disruptive behaviors or behaviors that interfere with activities of daily living, restlessness, and constant attempts to get out of bed, was difficult to redirect, easily frustrated and agitated, constantly fidgeting and unable to keep still, inability to relax, frequent shakes and tremors, and had persistent sad facial expressions. The Psychiatrist's note indicated to start Depakote Sprinkles (medication used to treat bipolar disorder) 25 mg twice a day, Lexapro (medication used to treat depression) 10 mg once a day, and to continue Ativan (medication used for anxiety and insomnia) 0.5 mg every six hours as needed for 14 days then re-evaluate. The Psychiatrist's note indicated to discontinue Seroquel on 5/14/2024. During a review of the Order Summary Report (Physician's Orders) dated 6/6/2024, the Order Summary Report indicated Resident 25 had the following physician's orders: 1. Lexapro oral tablet 10 mg one time a day for depression manifested by (m/b) low interest in activities of daily living (ADL's) ordered on 5/15/24. 2. Monitor for episodes of depression m/b low interest in ADL's, tally by hashmark every shift for Lexapro ordered on 5/21/2024. 3. Depakote Sprinkles delayed release oral capsule 125 mg by mouth two times a day for dementia m/b constantly getting up ordered on 5/14/2024. 4. Seroquel 25 mg by mouth at bedtime for depression manifested by(M/B) verbalization of feeling sadness. During a review of Resident 25's Medication Administration Record (MAR) for May 2024, the MAR indicated there was an order for Seroquel 25 mg one tablet by mouth at bedtime for depression manifested by verbalization of feeling of sadness to start on 5/2/2024 with a discontinue date of 6/4/2024. The MAR indicated Resident 25 had been receiving Seroquel 25 mg from 5/15/2024 until 6/3/2024, after it was discontinued. During a review of the Medication Administration Record (MAR) for the month of June 2024, there was no documentation to indicate Resident 25 was monitored for adverse effects of Seroquel including anticholinergic effects (dry mouth, constipation, urinary retention, bowel obstruction, dilated pupils, blurred vision, increased heart rate, and decreased sweating), akathisia ( feeling of muscle quivering, restlessness, and inability to sit still, sometimes a side effect of antipsychotic or antidepressant medication), parkinsonism (brain conditions that cause slowed movements, rigidity (stiffness) and tremors), neuroleptic malignant syndrome ([NMS] a life-threatening idiosyncratic (having strange or unusual habits, ways of behaving, or features) reaction to antipsychotic drugs characterized by fever, altered mental status, muscle rigidity, and autonomic dysfunction) tardive dyskinesia (condition affecting the nervous system, often caused by long-term use of some psychiatric drugs) and excessive sedation (a state of calm or sleep). During an observation on 6/4/2024 at 7:41 a.m. Resident 25 was observed sleeping in bed. During an interview on 6/5/2024 at 7:40 a.m. in Resident 25's room, the Licensed Vocational Nurse (LVN7) stated that the resident was always very sleepy and was hard to wake him up. During a concurrent observation and interview on 6/5/2024 at 8:10 a.m., in Resident 25's room, a Certified Nurse Assistant (CNA 6) stated she was not sure why Resident 25 has been getting very sleepy every day and she did not give him breakfast because CNA 6 could hardly keep the resident awake. During an interview on 6/6/2024, at 11:15 a.m., the Registered Nurse Supervisor (RNS 1) stated that it was the responsibility of the nurses to carry out doctor's orders. During a concurrent interview and record review of the Order Summary Report on 6/10/2024 at 9:54 a.m. with RNS 1, RNS 1 stated that was the only order for monitoring the side effects of taking psychotropic medication. RNS 1 stated Resident 25 was supposed to have an order to monitor Resident 18 for adverse effects of Seroquel when the medication was ordered. During an interview on 6/10/2024 at 2:12p.m., with the Psychiatrist's Physician Assistant (PPA 1), the PPA 1 stated on 5/14/2024 Resident 25's Seroquel was discontinued, and the resident was started on Depakote, which is a mood stabilizer, for his behavior. PPA 1 stated he tries to avoid using antipsychotics medications, such as Seroquel, for residents with dementia (the loss of cognitive functioning - thinking, remembering, and reasoning) unless the resident is having psychosis with delusions (believing things that are not actually true) such as the resident thinking the facility is trying to poison their food and would weigh the risks and benefits of putting them on antipsychotic medication but it would depend on the resident. PPA 1 stated if a medication is not necessary, he would discontinue it. PPA 1 stated antipsychotic medications are not necessary for behaviors such as confusion as it is not a sign and symptom of psychosis like delusions and hallucinations. PPA 1 stated if the resident is confused due to dementia, a mood stabilizer such as Depakote is more appropriate. During a concurrent interview and record review on 6/11/2024 at 12:49 p.m., PPA 1 stated the order for Seroquel 25 mg on the May MAR should have been discontinued effective 5/14/2024 but was missed and he (PPA 1) should have placed an order to discontinue this medication. PPA 1 stated for residents with dementia who are trying to get out of bed unassisted, Depakote is a better medication to manage the behavior than antipsychotics such as Seroquel. A review of an article titled Drugs and Supplements-Seroquel from the nationally recognized Mayo Clinic; indicated that Seroquel may increase the amount of sugar in the blood. High blood sugar levels associated with Seroquel can, in some cases, be extreme and lead to a precipitous (sudden) drop in blood pH (chemical balance in the blood that is necessary for normal body function), ketoacidosis (dangerous imbalance of chemicals in the blood), and coma (where a person is unresponsive and cannot be woken), or death. https://www.mayoclinic.org/drugs-supplements/quetiapine-oral-route/precautions A review of an article titled, Antipsychotic use in dementia: a systematic review of benefits and risks from meta-analyses from the nationally recognized National Institute of Health ([NIH]- the [NAME] medical research agency), indicated use of antipsychotic medications in residents with dementia is limited, due to its significant adverse effects. The NIH indicated antipsychotics should be used as a last resort. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4994396 During a concurrent interview with the Director of Nursing (DON) on 6/11/2024 at 4:45 p.m. and a record review of the Behavioral Management note (group of staff that meets monthly consisting of Social Service Designee (SSD), MDS nurse, Activities Director, Dietician and Pharmacy Consultant) dated 5/14/2024, the DON stated that it was documented on the Behavioral Management note to discontinue the Seroquel 25 mg on 5/14/2024, but it was not carried out or followed up on. On 6/11/2024 at 4:48 p.m., during a concurrent interview and review of Resident 25's MAR for June 2024 with the DON, the DON stated the physician's order to discontinue Seroquel on 5/14/2024 was not carried over to the MAR. During a review of PPA 1's note dated 5/14/2024, PPA' 1s note indicated Resident 25 was reported to be very sleepy and that it could have been the Seroquel's adverse effect that was not monitored. During a review of the Change of Condition ([COC]- internal document) form dated 6/5/2024, the COC indicated Resident 25 was observed very difficult to arouse, a deep sternal (bone in the middle of the chest) rub (a lifesaving painful technique used to get a response from an unresponsive person) was initiated on Resident 25, but the resident was unresponsive and appeared very lethargic with low blood pressure 96/59. Blood pressure reference range is 120/80. During a review of Resident 35's GACH emergency record (ER) notes dated 6/5/2024, the record indicated Resident 25 was admitted due to increased confusion, immediately falls back to sleep, obviously weak and lethargic. During a review of the facility's P&P titled, Dementia Care, revised 12/19/2022, the P&P indicated it is the policy of this facility to provide the appropriate treatment and services to every resident who displays signs of, or diagnosed with dementia, to meet his or her highest practicable physical, mental, and psychosocial well-being. Care and services will be person-centered and reflect each resident's individual goals while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety. Individualized, non-pharmacological approaches to care will be utilized, to include meaningful activities aimed at enhancing the resident's well-being. During a review of the facility's P&P titled, Use of Psychotropic Medication, revised 12/19/2022, the P&P indicated residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). The indications for initiating, withdrawing, or withholding medication(s), as well as the use of non-pharmacological approaches, will be determined by assessing the resident's underlying condition, current signs, symptoms, expressions, and preferences and goals for treatment .identification of underlying causes (when possible). The indications for use of any psychotropic drug will be documented in the medical record .psychotropic medications shall be initiated only after medical, physical, functional, psychosocial, and environmental causes have been identified and addressed .nonpharmacological interventions that have been attempted, and the target symptoms for monitoring shall be included in the documentation. Residents who use psychotropic drugs shall receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue these drugs. Other medications not classified as antipsychotic, antidepressant, antianxiety, or hypnotic medications but can affect brain activity should not be used as a substitution for another psychotropic medication unless prescribed with a documented clinical indication consistent with accepted clinical standards of practice. The effects of the psychotropic medications on a resident's physical, mental, and psychosocial well-being will be evaluated on an ongoing basis, such as but not limited to during the pharmacist's monthly medication regimen review .in accordance with nurse assessments and medication monitoring parameters consistent with clinical standards of practice, manufacturer's specifications, and the resident's comprehensive care plan of care. During a review of the facility's P&P titled, Unnecessary Drugs-Without Adequate Indication for Use, revised 12/19/2022, the P&P indicated it is the facility's policy that each resident's drug regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being free form unnecessary drugs. Adverse consequence is a broad term referring to unwanted, uncomfortable, or dangerous effects that a drug may have, such as impairment or decline in an individual's mental or physical condition or functional or psychosocial status. Indication for use is the identified, documented clinical rationale for administering a medication that is based upon an assessment of the resident's condition and therapeutic goals and is consistent with manufacturer's recommendations and/or clinical practice guidelines, clinical standards of practice, medication references, clinical studies, or evidence-based review articles that are published in medical and/or pharmacy journals. Documentation will be provided in the resident's medical record to show adequate indications for the medication's use and the diagnosed condition for which it was prescribed. B. During a review of Resident 18's admission Record, the admission Record indicated, Resident 18 was admitted to the facility on [DATE], with diagnoses including dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities) without behavioral disturbances (a mental disorder that affects a cognition, emotions, or behavior), psychotic disturbances (severe mental disorder that causes abnormal thinking and perceptions), mood disturbances (mood disorders that affect a person's emotional state and quality of life) and anxiety (an intense excessive and persistent worry and fear about everyday situations During a review of Resident 18's Progress Notes, dated 5/8/2024, the Progress Note indicated Resident 18 was admitted to the facility with diagnoses of weakness, hypertension and rule out dementia. The Progress Note indicated Resident 18 was alert and oriented to name, place, and time and was able to make needs known. The Progress Notes indicated Resident 18 was pleasant upon approach, had a pleasant mood, and no unwanted behavior was witnessed. The Progress Notes indicated Resident 18's speech was clear, and the resident was able to understand and was understood when speaking. During a review of Resident 18's H&P dated 5/9/2024, the H&P indicated Resident 18 had the capacity to understand and make decisions. During a review of Resident 18's Progress Notes dated 5/9/2024 the Progress Notes indicated Resident 18 had no psychological problems. The Progress Notes indicated Resident 18 became angry and hostile after finding out she was in a nursing home. The Progress Note indicated Ativan (medication used to treat anxiety) one mg was offered to Resident 18, but the resident refused Ativan stating, You are trying to kill me and Leave me alone. The Progress Notes indicated the nursing staff was unable to give Ativan due to Resident 18's refusal to take the medication due to being afraid of being poisoned by staff. During a review of Resident 18's Progress Notes, dated 5/10/2024, the Progress Notes indicated Resident 18 had an Interdisciplinary Team ([IDT]- a group of healthcare providers from different fields who work together to provide the best care or best outcome for a resident) conference. The IDT documentation indicated Resident 18 was receiving psychotropic medications, Ativan 0.5 mg as needed, Risperdal 0.5 mg at night and Depakote 250 mg twice a day to treat anxiety, schizoaffective disorder (a mental disorder characterized by abnormal thought processes and unstable mood), and mood disturbances. During a review of Resident 18's Order Summary Report 5/9/2024, the Order Summary Report indicated on 5/12/2024, Resident 18 had a doctor's order for Risperdal 0.5 mg by mouth at bedtime for schizoaffective disorder manifested by paranoid delusions (fears anxieties, and suspicions that someone may feel even though they are not based on reality). During a review of Resident 18's MAR, dated 5/12/2024, the MAR indicated Resident 18 was started on Depakote 250 mg one tablet by mouth two times a day related to unspecified dementia, unspecified severity and without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. The MAR indicated Resident 18 was started on Ativan 0.5 mg one tablet by mouth every six hours for anxiety for 14 days manifested by restlessness with inability to relax. During a review of Resident 18's Progress Notes, dated 5/13/2024, the Progress Note indicated, Resident 18 denied a history of mental health illness. During a review of Resident 18's MDS dated [DATE], the MDS indicated Resident 18 had the ability to understand and comprehend others and was able to make self-understood and had the ability to express ideas and wants. The MDS indicated Resident 18 did not have evidence of an acute change in mental status and did not hallucinate or have delusions. The MDS indicated Resident 18 did not have a psychiatric or a mood disorder and did not exhibit physical or verbal behavioral symptoms directed towards others. The MDS indicated Resident 18 was taking antipsychotics and antianxiety medications on a routine basis and did not have a gradual dose reduction because it was contraindicated and documented by a physician. During a review of Resident 18's Progress Note, dated 5/14/2024, the Progress Note indicated Resident 18 had an IDT Care Conference, regarding behavior and psychotropic medication management. The IDT Care Conference was attended by the MDS nurse, Social Service Director, Rehabilitation Director, Dietary Supervisor, Activities Director, and the Director of Staff Development. The Progress Note indicated Resident 18 had a new order to start the medication Lexapro for depression manifested by hopelessness and flat affect and a change in psychotropic medications was contraindicated at this time because Resident 18 was a new admission and behavior observation was pending. During an observation on 6/5/2024 at 10:27 am, Resident 18 was observed in bed asleep. During an interview on 6/07/2024 at 2:19 pm the Licensed Vocational Nurse (LVN 3) stated Resident 18 was taking Risperdal and Depakote. LVN 3 stated Resident 18 had a diagnosis of dementia. LVN 3 stated the Depakote was care planned and the resident's behaviors were being monitored. LVN 3 stated she did not know what behaviors to monitor. During an interview on 6/7/2024 at 3:37 pm the Director of Nursing (DON) stated behaviors to monitor need to be more specific, so nursing staff know exactly what behaviors to monitor. During an interview on 6/10/2024 at 10:31 am the Registered Nurse Supervisor (RNS 1), stated Resident 18 had a diagnosis of dementia without behavior disturbances. RNS 1 stated Resident 18 was taking Depakote related to mood swings and Risperdal for schizophrenia with schizoaffective disorder. RNS 1 stated Resident 18 had an IDT meeting on 5/10/2024 to discuss anxiety and mood swings and the resident's doctor was not present at the meeting. RNS 1 stated Resident 18 does not have a diagnosis of schizophrenia. RNS 1 stated there was no documentation in Resident 18's chart to indicate Resident 18 was seen by a psychiatrist or a psychologist. During an interview on 6/10/2024 at 10:35 am, RNS 1 stated Resident 18 had a care plan for verbal aggression started on 5/11/2024. RNS 1 stated on 5/14/24 Resident 18 had an IDT meeting for behavior disturbance and psychotropic medication management. RNS 1 stated the MDS Nurse Coordinator, Director of Social Service, Director of Rehabilitation, Dietary Manager, Activities Director, and the Director of Staff Development were present at the IDT meeting. During an interview on 6/10/2024 at 10:40 am, RNS 1 stated usually the doctor is present for IDT meetings. RNS 1 stated the doctor should be present because it was their specialty to manage medication and behavior associated with mental illness. RNS 1 stated Resident 18 did not have a Gradual Dose Reduction ([GDR]- an attempt to decrease or discontinue psychotropic medication after no more than three months after starting on the psychotropic medication, unless clinically contraindicated) for the Depakote and Risperdal. During an interview on 6/10/2024 at 10:45 am, RNS 1 stated the GDR is done monthly to make sure residents are getting the correct medication doses for therapeutic effectiveness and not receiving medications they do not need. RNS 1 stated Resident 18 is being monitored for paranoid delusions because Resident 18 believes the nursing staff lie to her about medications and are untrustworthy. During a review of Resident 18's Progress Notes, dated 6/10/2024, the Progress Notes indicated Resident 18 was re-admitted on [DATE] to the facility with diagnoses of constipation, failure to thrive (a syndrome of weight loss, decreased appetite, poor nutrition and physical activity), arthritis (inflammation of the joints), pressure injury (localized damage to the skin and underlying damage to the skin and underlying soft tissue, usually occurring over a bony prominence or related medical device), falling, dementia, lymphedema (tissue swelling caused by an accumulation of protein-rich fluid) , hypertension, asthma, chronic kidney disease, and osteoarthritis (a condition that causes cartilage in the joints to wear down, leading to pain, stiffness, and swelling). The Progress Notes indicated nursing staff spoke with PPA 1 and were instructed to hold Depakote 250 mg, and Risperdal 0.5 mg until Resident 18 was seen and evaluated by him on the following day (6/11/2024). The Progress Notes indicated Resident 18 was pleasant and had no behaviors noted. During an interview on 6/11/2024 at 12:31 pm PPA 1 stated Resident 18 had not had any psychotic behaviors since her original admission to the facility on 5/8/2024. PPA 1 stated he spoke to Resident 18's family and the family stated Resident 18 did not have a history of mental illness. PPA 1 stated when a resident is admitted with antipsychotic medication the nursing staff need to obtain the antipsychotic medication consent from the hospital to see why the resident needs the antipsychotic medication. PPA 1 stated there had to be a justification as to why the resident needs antipsychotic medications. During an interview on 6/11/2024 at 12:36 pm PPA 1 stated the facility does not monitor behaviors appropriately. PPA 1 stated after speaking with Resident 18 he discontinued Depakote and Risperdal due to Resident 18 having no history of mental illness and the resident had not had any psychotic behaviors. PPA 1 stated a resident, taking antipsychotic medications without a history of mental illness and without any psychotic behaviors was at risk for extrapyramidal symptoms (EPS-side effects caused by certain antipsychotic drugs and other drugs such as involuntary or uncontrollable movements, tremors, muscle contractions, inability to sit still and muscle stiffness), drooling, confusion and the resident can become highly sedated. During an interview on 6/11/2024 at 3:56 pm the DON stated Resident 18 had dementia and did not have a diagnosis of anxiety or paranoia. The DON stated Resident 18 received antipsychotic medications upon admission. The DON stated there was no documentation obtained of a consent for administration of Depakote or Risperdal to Resident 18. The DON stated the admission nurse had to get consent for antipsychotic medications before the order was entered into the resident's medical record. During an interview on 6/11/2024 4:05 pm the DON stated upon admission to the facility, a consent for antipsychotic medication must be obtained from the resident or the resident's responsible party for the doctor to sign, and the risks and benefits of taking the medication and what it was for had to be explained. The DON stated this was another re-education for staff and Resident 18 should not have received antipsychotic medications without obtaining consent first. The DON stated Resident 18 did not have any previous hospital records to indicate Resident 18 received antipsychotic medications in the hospital. During an interview on 6/11/2024 at 4:09 pm the DON stated Resident 18 was started on antipsychotic medications at this facility. The DON stated Resident 18 was started on antipsychotic medications with no prior history of mental illness and no psychotic behaviors. The DON stated Resident 18 refused antipsychotic medications on 5/13/2024, 5/14/2024, 5/30/2024, and from 6/1/2024 to 6/6/2024. The DON stated when a resident refuses antipsychotic medication the risk and benefits are explained to the resident, the doctor and the family are notified, and the resident's behavior is monitored. The DON stated the staff will keep offering the antipsychotic medication to the resident because the antipsychotic medication cannot be discontinued abruptly. During an interview on 6/11/2024 at 4:15pm the DON stated this is unnecessary medication administration because the antipsychotic medication is being given with no indication for its use. The DON stated Resident 18 could have negative side effects from taking antipsychotic medication such as orthostatic hypertension (a type of high blood pressure that occurs when a person goes from prolonged sitting or lying down to standing), and changes in the level of consciousness. The DON stated the administration of antipsychotic medication to Resident 18 could be considered a form of a chemical restraint (a form of medical restraint in which a drug is used to restrict the freedom of movement of a patient or in some cases to sedate the patient). During a review of the facility's P&P titled, Informed Consent revised on 3/25/2024, the P&P indicated, It is the responsibility of the healthcare professional who proposes any medical intervention or treatment that requires informed consent to provide information to the resident/resident representative regarding the resident's condition and circumstances that are pertinent to a decision to accept or refuse the proposed intervention or treatment. In situations where the resident lacks capacity and has no legal surrogate, the facility may convene an interdisciplinary team to make medical decision that require informed consent. The interdisciplinary team must include a patient representative who is unaffiliated with the facility. IDTs are convened for the following reasons, medical intervention or treatment that requires informed consent is proposed for a resident. The resident lacks the capacity to understand the risk and benefits of the proposed intervention or treatment The resident does not have a legally authorized representative to act on his or her behalf in making the treatment decision. If the facility is unable, after reasonable effort, to locate a family member or other individual to serve as a patient representative on the IDT. During a review of the facility's P&P titled, Use of Psychotropic Medication, dated 12/19/2022, the P&P indicated, Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). During a review of the facility's policy and procedure (P&P) titled, Gradual Dose Reduction of Psychotropic Drugs, revised 12/19/2022, the P&P indicated, Policy: Residents who use psychotropic drugs receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Policy Explanation and Compliance Guidelines: 1. Reducing the need for and maximizing the effectiveness of medications shall be considered for all residents who use psychotropic drugs. Therefore, dose reductions and behavioral interventions are part of medication management. This policy pertains to gradual dose reductions . 6. For any individual who is receiving a psychotropic medication to treat expressions or indications of distress related to dementia, the GDR may be considered clinically contraindicated for reasons that include, but that are not limited to: a. The resident's target symptoms returned or worsened after the most recent attempt at a GDR within the facility, and b. The physician has documented the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident's function or increase distressed behavior . 9. Use of psychotropic medications, other than antipsychotics, should not increase when efforts to decrease antipsychotic medications are being implemented, unless the other types of psychotropic medications are clinically indicated. During a review of the facility's P&P titled, Behavioral Contracts, revised 12/19/2022, the P&P indicated, Policy Explanation and Compliance Guidelines .5. Documentation could[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to contact and notify the hospice agency (health care service that focuses on the care, comfort, and quality of life of a person with serious illness who is approaching the end of life) that one of five sampled residents (Resident 1) had missed dialysis treatments (mechanical process of removing waste products and toxins, and excess fluid from the body) on [DATE], [DATE], [DATE] and [DATE] due to issues with transportation from the facility to the dialysis center. This deficient practice resulted in Resident 1 being sent out via 911 (emergency medical transport) to a general acute care hospital (GACH) for emergency dialysis on [DATE]. Resident 1 ultimately expired (died) at 9:32 p.m. (3 hours 23 minutes after arriving to the GACH ' s Emergency Department) on [DATE] after receiving multiple rounds of life saving medications (names of medications not specified). Cross reference F698 Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted Resident 1 on [DATE] and readmitted on [DATE] with diagnoses of dependence on renal (kidney) dialysis and hypertensive heart disease (high blood pressure) without heart failure (heart is unable to pump blood around the body properly). During a review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool) dated [DATE], the MDS indicated Resident 1 was cognitively (thinking, reasoning, or remembering) intact. The MDS indicated Resident 1 was receiving dialysis. During a review of Resident 1 ' s last laboratory tests (diagnostic tests from a sample of blood), dated [DATE], Resident 1 ' s potassium level was 5.6 milliequivalent per liter (mEq/L, a unit of measure) (Normal range 3.5 mEq/L to 5.5 mEq/L). During a review of Resident 1 ' s Discharge Order from the GACH dated [DATE], the Discharge Order indicated Resident 1 was to discharge back to the facility under the hospice agency and to receive antibiotics (medicines that fight bacterial infections) for two weeks during his dialysis treatments. During a review of Resident 1 ' s (readmission) Order Summary Report dated 1/2024, the Order Summary Report indicated orders were entered on [DATE] for the following: 1. Continue orders for 45 days unless otherwise specified. 2. Dialysis: Tuesdays, Thursdays, Saturdays. Chair time 4:45 a.m., transportation pick up time 3:45 a.m. During a review of Resident 1 ' s care plans, an untitled care plan initiated on [DATE] indicated Resident 1 was receiving dialysis every Tuesday, Thursday, and Saturday with a dialysis chair time (appointment time) of 4:45 a.m. and was to be picked up by transportation at 3:45 a.m. The care plan goal indicated Resident 1 ' s clinical condition was to be managed. The care plan interventions included communicating with the dialysis center and the hospice agency as needed and to coordinate transportation as needed with the transportation company and the hospice agency. During a review of Resident 1 ' s Physicians ' Certification for Hospice Benefits dated [DATE], the Physician ' s Certificate indicated Resident 1 was admitted to the facility (on [DATE]) under a hospice agency ' s care and the diagnosis that qualified him for hospice was hypertensive heart disease without heart failure. Resident 1 was admitted to hospice under routine medical care. The Physician ' s Certificate indicated the facility staff were informed and aware to call the hospice agency for any concerns or changes of condition. During a review of Resident 1 ' s Nurses Progress Notes dated [DATE] (Saturday), the progress note indicated Resident 1 ' s scheduled transportation company did not pick him up for his scheduled dialysis treatment and a make-up dialysis treatment was scheduled for [DATE] (Monday). The Nurse Progress Note did not indicate the hospice agency was notified of Resident 1 not receiving his dialysis treatment on [DATE]. During a review of Resident 1 ' s Nurses Progress Notes dated [DATE], the progress note indicated Resident 1 again missed his make-up dialysis appointment due to transportation issues. The Nurse Progress Note did not indicate the hospice agency was notified of Resident 1 not receiving his dialysis treatment on [DATE]. During a review of Resident 1 ' s Nurses Progress Notes dated [DATE] (Tuesday), there was no mention in the progress notes that Resident 1 missed his scheduled dialysis appointment again or that the hospice agency was notified. During a review of the Physician ' s Progress Note dated [DATE], the Physician ' s Progress Note indicated Resident 1 wished to continue dialysis treatment while on hospice and staff were to communicate with the HSPC for dialysis treatment. During a review of Resident 1 ' s Hospice Agency Communication Log dated [DATE], the Hospice Agency Communication Log indicated the facility informed the hospice agency that Resident 1 had missed dialysis (this is the first communication to the hospice agency regarding missed dialysis) due to transportation issues and Resident 1 had not received dialysis since [DATE] but Resident 1 was currently stable and dialysis was scheduled for the next morning ([DATE], Thursday). During a review of Resident 1 ' s Hospice Agency Communication log dated [DATE] at 1:35 p.m., the Hospice Agency Communication log indicated the facility informed the hospice agency that Resident 1 missed dialysis again that morning due to transportation issues. During a review of Resident 1 ' s Hospice Agency Communication log dated [DATE] at 2:24 p.m., the Hospice Agency Communication log indicated the Hospice Agency reached out to Resident 1 ' s dialysis center to try to schedule an emergency dialysis treatment but the dialysis center informed the hospice agency that Resident 1 did not qualify for dialysis at their center, Resident 1 required emergency dialysis due to missing more than two ([DATE], [DATE] and [DATE]) consecutive dialysis appointments. The facility was instructed to call 911 to send Resident 1 to the GACH. During a review of Resident 1 ' s Hospice Agency Communication Log dated [DATE] at 2:53 p.m., the Hospice Agency Communication Log indicated the hospice agency spoke to the facility again and reiterated the urgency and instructed the facility to call 911. During a review of Resident 1 ' s Change of Condition Evaluation dated [DATE], the Change of Condition Evaluation indicated the hospice agency recommended sending Resident 1 to the GACH for dialysis after Resident 1 missed three consecutive, scheduled dialysis treatments ([DATE], [DATE], and [DATE]). During a review of Resident 1 ' s Order Summary Report dated 1/2024, the Order Summary Report indicated an order dated [DATE] indicating Resident 1 may transfer to the GACH due to missed dialysis ([DATE], [DATE], [DATE] and [DATE]) with a seven-day bed hold (reserve resident ' s bed while receiving care in the hospital). During a review of Resident 1 ' s GACH ED (Emergency Department) Note dated [DATE], the GACH ED Note indicated Resident 1 arrived at the ED at 6:09 p.m. with a chief complaint of missing dialysis for one week and was last dialyzed on [DATE]. The ED Note indicated Resident 1 presented with worsening SOB (shortness of breath) due to the missed dialysis. The GACH ED Note indicated that Resident 1 informed the ED physician that there was trouble with his transportation to the dialysis center and that was why he had missed dialysis for one week. During a review of Resident 1 ' s GACH ED Note dated [DATE], the GACH ED Note indicated Resident 1 ' s laboratory results came back with a potassium (a substance that is needed by all tissues in the body) level of 8.2 mEq/L and a hyperkalemia (high potassium level that can cause life-threatening abnormal heart beats) order set was initiated (Resident 1 received medications to try to lower the potassium level), Resident 1 ' s SOB was likely due to hypervolemia (fluid overload, too much fluid volume in the body), and the plan was to admit Resident 1 to the intensive care unit (ICU a higher level of care for critically ill patients) for emergency dialysis. During a review of Resident 1 ' s GACH ED Note dated [DATE], the GACH ED Note indicated Resident 1 ' s heart rate began to drop to the 30 ' s (very low heart rate, normal range 60 to 100 beats per minute) and he became unconscious. During a review of Resident 1 ' s GACH ED Note dated [DATE], the GACH ED Note indicated Resident 1 had refused intubation (insertion of a breathing tube) and cardiopulmonary resuscitation (CPR chest compressions done when the heart stops beating or beats ineffectively) but lifesaving medications (names of medications not specified) were to be given. Resident 1 received a total of 5 rounds of life saving medications in the ED before he finally went asystole (no pulse, resident expired). During a review of Resident 1 ' s GACH Discharge summary dated [DATE], the Discharge Summary indicated Resident 1 ' s admitting diagnoses were as follows: 1. Severe hyperkalemia secondary to missed dialysis 2. Fluid overload due to missed dialysis 3. Uremia (a condition involving abnormally high levels of waste products in the blood) secondary to missed dialysis 4. Acidosis (buildup of acid in the blood stream) secondary to missed dialysis After multiple rounds of life saving medications in the ED, Resident 1 had asystole and expired at 9:32 p.m. on [DATE]. Reason for death was cardiopulmonary arrest. Discharge diagnoses were as follows: 1. Cardiopulmonary arrest 2. Severe hyperkalemia 3. Missing dialysis During an interview on [DATE] at 11:53 a.m., Resident 1 ' s family member (FM1) stated Resident 1 had been released from the GACH on [DATE] on hospice. FM1 stated Resident 1 chose to be on hospice because Resident 1 was getting gangrene (death of body tissue due to a lack of blood flow or serious bacterial infection) infections on his limbs (hands, legs, feet) and did not want to get any more amputations (removal of limbs) but Resident 1 did not want to stop his dialysis treatments while on hospice. During an interview on [DATE] at 11:53 a.m. with FM1, FM1 stated he was not aware that Resident 1 missed multiple dialysis treatments ([DATE], [DATE], [DATE]) besides the one on [DATE]. FM1 stated he found out when Resident 1 went back to the GACH on [DATE]. FM1 stated the ED physician had called him and informed him that Resident 1 had missed a week of dialysis appointments due to transportation issues and that Resident 1 ' s laboratory results in the ED had come back catastrophic (involving or causing great damage or suffering) and Resident 1 ' s potassium level was twice what it should be. During an interview on [DATE] at 11:53 a.m. with FM1, FM1 stated the next call he received was from the ED physician telling him that Resident 1 had passed away. FM1 stated the hospice agency called FM1 after his death and said it was in the orders that Resident 1 was to continue dialysis at the facility and the hospice agency was not aware that the facility was having issues with transportation or why the resident missed all those dialysis days ([DATE], [DATE], [DATE], [DATE]). During an interview on [DATE] at 12:13 p.m., the HSPC administrator (ADM2) stated Resident 1 ' s wishes were to continue dialysis treatment while on hospice and that was to be respected. ADM2 stated the HSPC was first alerted on [DATE] that there were issues going on with Resident 1 ' s transportation to the dialysis center and Resident 1 had a dialysis appointment the next day for [DATE]. ADM2 stated the HSPC was informed [DATE] that Resident 1 missed his dialysis appointment again that day and the facility was directed to call 911 to send Resident 1 to the GACH for emergency dialysis. During an interview on [DATE] at 12:13 p.m., ADM2 stated the protocol for residents on hospice while residing in a facility was the facility was to inform the hospice agency with any issues, right away so the hospice agency could intervene and be aware. ADM2 stated the hospice agency should have been made aware when Resident 1 missed the first dialysis on [DATE] but they were not notified until 4 days later ([DATE]). During an interview on [DATE] at 1:16 p.m., a registered nurse supervisor (RN1) stated Resident 1 was supposed to attend dialysis appointments on Tuesdays, Thursdays, and Saturdays as ordered by the physician. RN1 stated Resident 1 missed dialysis on [DATE], [DATE] (make up dialysis for [DATE]), [DATE], and [DATE] due to the transportation company not picking up the resident. During an interview on [DATE] at 1:16 p.m. with RN1, RN1 stated when he informed Resident 1 ' s attending physician (MD1) on [DATE] regarding the missed dialysis she told RN1 to contact the hospice agency to manage Resident 1 ' s care. RN1 stated the hospice agency was informed on [DATE] regarding the missed dialysis sessions. RN1 stated when Resident 1 missed dialysis again on [DATE], he reached out to the hospice agency and was told to send Resident 1 to the GACH. During an interview on [DATE] at 11:17 a.m., with the SSD, the SSD stated when a resident was on hospice, facility staff have to inform the hospice agency of any issues the resident was encountering right away, and the hospice agency should have been made aware of the first missed dialysis on [DATE] on that same day. During an interview on [DATE], at 11:17 a.m., with the SSD, the SSD stated she was not informed of the number of missed dialysis appointments until [DATE] and if she had been aware prior to that day, she would have helped contact the hospice agency sooner for assistance. The SSD stated it was not okay for a resident to miss their dialysis appointments. The SSD stated dialysis was a very important treatment and the potential consequence of a resident missing dialysis was death. During an interview on [DATE] at 2:36 p.m., with licensed vocational nurse (LVN1), LVN 1 stated when Resident 1 was having problems with transportation on Saturday, [DATE], and missed dialysis, she did not contact the hospice agency. LVN1 stated on Monday, [DATE] when Resident 1 missed his make-up dialysis, she did not inform the hospice agency again. LVN1 stated facility staff must notify the hospice agency right away, if a resident on hospice was having any issues, so they could get orders from them on what needed to be done. During an interview on [DATE] at 4:12 p.m., with the Director Of Nursing (DON), the DON stated she was not informed of the issues regarding Resident 1 missing dialysis until [DATE] and she told RN1 (on [DATE]) to communicate with the hospice agency about what was going on. The DON stated when RN1 communicated with the hospice agency on [DATE], the hospice agency made the decision to transfer Resident 1 to the GACH for emergency dialysis. The DON stated she was notified at 2 a.m. (on [DATE]) that Resident 1 had expired in the GACH (on [DATE] at 9:32 p.m.). During an interview on [DATE] at 4:12 p.m., with the DON, the DON stated that all decisions for residents on hospice needed to go through the hospice agency, and the hospice agency should have been informed right away when Resident 1 was not making his dialysis appointments due to transportation issues. During an interview on [DATE] at 4:12 p.m., with the DON, the DON stated the risks of not receiving dialysis treatments were fluid overload, respiratory distress, toxin (a poisonous substance) build up in the body, altered level of consciousness (confusion) and death. The DON stated the facility management should have been notified of transportation issues right away so they could help the nurses make the arrangements to get the residents to their dialysis appointments. During an interview on [DATE] at 8:36 a.m., with LVN2, LVN2 stated she was assigned to Resident 1 on [DATE] (Resident 1 ' s scheduled dialysis day). LVN2 stated Resident 1 ' s transportation to dialysis was late on [DATE]. LVN2 stated Resident 1 was finally picked up late, at 5:40 a.m. (regular pick-up time was 3:35 a.m.) by the transportation company to go to dialysis. During an interview on [DATE] at 8:36 a.m., with LVN2, LVN2 stated she later learned that the dialysis center had sent Resident 1 back to the facility [DATE] because he was late and missed his dialysis chair time. LVN2 stated she did not inform the HSPC of the transportation issues on her shift [DATE]. During a review of the facility ' s policy and procedure (P/P) titled Notification of Changes revised [DATE], the P/P indicated the facility must promptly inform .the resident ' s physician when there is a change requiring notification. During a review of the facility ' s P/P titled Coordination of Hospice Services dated [DATE], the P/P indicated when a resident chose to receive hospice services, the facility staff was to coordinate and provide care in cooperation with hospice staff to promote the resident ' s highest practicable physical, mental, and psychosocial well-being. The P/P indicated the facility was to contact and communicate with hospice staff regarding any significant changes in the resident ' s status, clinical complications, or emergent situations. During a review of the HSPC Contract Agreement with the facility for Resident 1 dated [DATE], the Contract Agreement indicated the HSPC was to be notified if there were clinical complications that suggested a need to alter the resident ' s plan of care and/ or a need to transfer the patient from the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) received dialysis (process of mechanically removing waste products/ toxins and excess fluid from the body) according to the physician ' s orders and plan of care for dialysis management by failing to: 1. Ensure Resident 1 did not miss three scheduled dialysis treatments ([DATE], [DATE], and [DATE]) and one make-up dialysis treatment ([DATE]). 2. Notify the hospice (health care service that focuses on the care, comfort, and quality of life of a person with serious illness who is approaching the end of life) agency overseeing Resident 1 ' s care while in the facility when Resident 1 missed his first dialysis treatment in the facility ([DATE]). The hospice agency was not being notified of each missed dialysis treatment until [DATE] after Resident 1 had missed three dialysis treatments ([DATE], [DATE], and [DATE]). Resident 1 ' s last dialysis was on [DATE]. These deficient practices resulted in Resident 1 getting sent out via 911 (emergency medical transport) to a general acute care hospital (GACH) for emergency dialysis on [DATE]. Resident 1 was found to have severe hyperkalemia (high potassium [a substance that is needed by all tissues in the body] levels that can cause life-threatening abnormal heart beats) at a level of 8.2 milliequivalent per Liter (mEq/L, a unit of measure. A dialysis patient ' s optimal range of blood potassium levels is 3.5 mEq/L to 5.5 mEq/L), shortness of breath (SOB, trouble breathing), and hypervolemia (fluid overload, too much fluid volume in the body). Resident 1 expired (died) at 9:32 p.m. (3 hours 23 minutes after arriving to the GACH ' s Emergency Department) on [DATE] after receiving multiple rounds of life saving medications (names of medications not specified). Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted Resident 1 on [DATE] and readmitted on [DATE] with diagnoses of dependence on renal (kidney) dialysis and hypertensive heart disease (high blood pressure) without heart failure (heart is unable to pump blood around the body properly). During a review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool) dated [DATE], the MDS indicated Resident 1 was cognitively (thinking, reasoning, or remembering) intact. The MDS indicated Resident 1 was receiving dialysis. During a review of Resident 1 ' s last laboratory tests (diagnostic tests from a sample of blood), dated [DATE], Resident 1 ' s potassium level was 5.6 mEq/L, (Normal range 3.5 mEq/L to 5.5 mEq/L). During a review of Resident 1 ' s Discharge Order from the GACH dated [DATE], the Discharge Order indicated Resident 1 was to discharge back to the facility under the hospice agency and to receive antibiotics (medicines that fight bacterial infections) for two weeks during his dialysis treatments. During a review of Resident 1 ' s (readmission) Order Summary Report dated 1/2024, the Order Summary Report indicated orders were entered on [DATE] for the following: 1. Continue orders for 45 days unless otherwise specified. 2. Dialysis: Tuesdays, Thursdays, Saturdays. Chair time 4:45 a.m., transportation pick up time 3:45 a.m. During a review of Resident 1 ' s care plans, an untitled care plan initiated on [DATE] indicated Resident 1 was receiving dialysis every Tuesday, Thursday, and Saturday with a dialysis chair time (appointment time) of 4:45 a.m. and was to be picked up by transportation at 3:45 a.m. The care plan goal indicated Resident 1 ' s clinical condition was to be managed. The care plan interventions included communicating with the dialysis center and the hospice agency as needed and to coordinate transportation as needed with the transportation company and the hospice agency. During a review of Resident 1 ' s Physicians ' Certification for Hospice Benefits dated [DATE], the Physician ' s Certificate indicated Resident 1 was admitted to the facility (on [DATE]) under a hospice agency ' s care and the diagnosis that qualified him for hospice was hypertensive heart disease without heart failure. Resident 1 was admitted to hospice under routine medical care. The Physician ' s Certificate indicated the facility staff were informed and aware to call the hospice agency for any concerns or changes of condition. During a review of Resident 1 ' s Nurses Progress Notes dated [DATE] (Saturday), the progress note indicated Resident 1 ' s scheduled transportation company did not pick him up for his scheduled dialysis treatment and a make-up dialysis treatment was scheduled for [DATE] (Monday). The Nurse Progress Note did not indicate the hospice agency was notified of Resident 1 not receiving his dialysis treatment on [DATE]. During a review of Resident 1 ' s Nurses Progress Notes dated [DATE], the progress note indicated Resident 1 again missed his make-up dialysis appointment due to transportation issues. The Nurse Progress Note did not indicate the hospice agency was notified of Resident 1 not receiving his dialysis treatment on [DATE]. During a review of Resident 1 ' s Nurses Progress Notes dated [DATE] (Tuesday), there was no mention in the progress notes that Resident 1 missed his scheduled dialysis appointment again or that the hospice agency was notified. During a review of the Physician ' s Progress Note dated [DATE], the Physician ' s Progress Note indicated Resident 1 wished to continue dialysis treatment while on hospice and staff were to communicate with the hospice agency for dialysis treatment. During a review of Resident 1 ' s Hospice Agency Communication Log dated [DATE], the Hospice Agency Communication Log indicated the facility informed the hospice agency that Resident 1 had missed dialysis (this is the first communication to the hospice agency regarding missed dialysis) due to transportation issues and Resident 1 had not received dialysis since [DATE] but Resident 1 was currently stable and dialysis was scheduled for the next morning ([DATE], Thursday). During a review of Resident 1 ' s Hospice Agency Communication log dated [DATE] at 1:35 p.m., the Hospice Agency Communication log indicated the facility informed the HSPC that Resident 1 missed dialysis again that morning due to transportation issues. During a review of Resident 1 ' s Hospice Agency Communication log dated [DATE] at 2:24 p.m., the Hospice Agency Communication log indicated the hospice agency reached out to Resident 1 ' s dialysis center to try to schedule an emergency dialysis treatment but the dialysis center informed the hospice agency that Resident 1 did not qualify for dialysis at their center, Resident 1 required emergency dialysis due to missing more than two ([DATE], [DATE], [DATE] and [DATE]) consecutive dialysis appointments. The facility was instructed to call 911 (an emergency service) to send Resident 1 to the GACH. During a review of Resident 1 ' s Hospice Agency Communication Log dated [DATE] at 2:53 p.m., the Hospice Agency Communication Log indicated the hospice agency spoke to the facility again and reiterated the urgency and instructed the facility to call 911. During a review of Resident 1 ' s Change of Condition Evaluation dated [DATE], the Change of Condition Evaluation indicated the hospice agency recommended sending Resident 1 to the GACH for dialysis after Resident 1 missed three consecutive, scheduled dialysis treatments ([DATE], [DATE], and [DATE]). During a review of Resident 1 ' s Order Summary Report dated 1/2024, the Order Summary Report indicated an order dated [DATE] indicating Resident 1 may transfer to the GACH due to missed dialysis ([DATE], [DATE], [DATE] and [DATE]) with a seven-day bed hold (reserve resident ' s bed while receiving care in the hospital). During a review of Resident 1 ' s GACH ED (Emergency Department) Note dated [DATE], the GACH ED Note indicated Resident 1 arrived at the ED at 6:09 p.m. with a chief complaint of missing dialysis for one week and was last dialyzed on [DATE]. The ED Note indicated Resident 1 presented with worsening SOB due to the missed dialysis. The GACH ED Note indicated that Resident 1 informed the ED physician that there was trouble with his transportation to the dialysis center and that was why he had missed dialysis for one week. During a review of Resident 1 ' s GACH ED Note dated [DATE], the GACH ED Note indicated Resident 1 ' s laboratory results came back with a potassium level of 8.2 mEq/L and a hyperkalemia order set was initiated (Resident 1 received medications to try to lower the potassium level); Resident 1 ' s SOB was likely due to hypervolemia; and the plan was to admit Resident 1 to the intensive care unit (ICU a higher level of care for critically ill patients) for emergency dialysis. During a review of Resident 1 ' s GACH ED Noted dated [DATE], the GACH ED Note indicated before getting transferred to the ICU, Resident 1 ' s heart rate began to drop to the 30 ' s (very low heart rate, normal range 60 to 100 beats per minute) and he became unconscious. During a review of Resident 1 ' s GACH ED Note dated [DATE], the GACH ED Note indicated Resident 1 had refused intubation (insertion of a breathing tube) and cardiopulmonary resuscitation (CPR chest compressions done when the heart stops beating or beats ineffectively), but life saving medications were to be given. Resident 1 received a total of 5 rounds of life saving medications (names of medications not specified) in the ED before he finally went asystole (no pulse, resident expired). During a review of Resident 1 ' s GACH Discharge summary dated [DATE], the Discharge Summary indicated Resident 1 ' s admitting diagnoses were as follows: 1. Severe hyperkalemia secondary to missed dialysis 2. Fluid overload due to missed dialysis 3. Uremia (a condition involving abnormally high levels of waste products in the blood) secondary to missed dialysis 4. Acidosis (buildup of acid in the blood stream) secondary to missed dialysis After multiple rounds of life saving medications (names of medications not specified) in the ED, Resident 1 had asystole and expired at 9:32 p.m. on [DATE]. Reason for death was cardiopulmonary arrest. Discharge diagnoses were as follows: 1. Cardiopulmonary arrest 2. Severe hyperkalemia 3. Missing dialysis During an interview on [DATE] at 11:53 a.m. with Resident 1 ' s family member (FM1), FM1 stated Resident 1 had been released from the GACH on [DATE] on hospice. FM1 stated Resident 1 chose to be on hospice because Resident 1 was getting gangrene (death of body tissue due to a lack of blood flow or serious bacterial infection) infections on his limbs (hands, legs, feet) and did not want to get any more amputations (removal of limbs) but Resident 1 did not want to stop his dialysis treatments while on hospice. During an interview on [DATE] at 11:53 a.m. with FM1, FM1 stated he was not aware that Resident 1 missed multiple dialysis treatments ([DATE], [DATE], [DATE]) besides the one on [DATE]. FM1 stated he found out when Resident 1 went back to the GACH on [DATE]. FM1 stated the ED physician had called him and informed him that Resident 1 had missed a week of dialysis appointments due to transportation issues and that Resident 1 ' s laboratory results in the ED had come back catastrophic (involving or causing great damage or suffering) and Resident 1 ' s potassium level was twice what it should be. During an interview on [DATE] at 11:53 a.m. with FM1, FM1 stated the next call he received was from the ED physician telling him that Resident 1 had passed away. FM1 stated the hospice agency called FM1 after his death and said it was in the orders that Resident 1 was to continue dialysis at the facility and the hospice agency was not aware that the facility was having issues with transportation or why the resident missed all those dialysis days ([DATE], [DATE], [DATE], [DATE]). During an interview on [DATE] at 12:13 p.m., the hospice agency administrator (ADM2), ADM2 stated Resident 1 ' s wishes were to continue dialysis treatment while on hospice and that was to be respected. ADM2 stated the hospice agency was first alerted on [DATE] that there were issues going on with Resident 1 ' s transportation to the dialysis center and Resident 1 had a dialysis appointment the next day for [DATE]. ADM2 stated the hospice agency was informed on [DATE] that Resident 1 missed his dialysis appointment again that day and the facility was directed to call 911 to send Resident 1 to the GACH for emergency dialysis. During an interview on [DATE] at 12:13 p.m., ADM2 stated the protocol for residents on hospice while residing in a facility was the facility was to inform the hospice agency with any issues, right away so the hospice agency could intervene and be aware. ADM2 stated the hospice agency should have been made aware when Resident 1 missed the first dialysis on [DATE] but they were not notified until 4 days later ([DATE]). During an interview on [DATE] at 1:16 p.m., a registered nurse supervisor (RN1) stated Resident 1 was supposed to attend dialysis appointments on Tuesdays, Thursdays, and Saturdays as ordered by the physician. RN1 stated Resident 1 missed dialysis on [DATE], [DATE] (make up dialysis for [DATE]), [DATE], and [DATE] due to the transportation company not picking up the resident. During an interview on [DATE] at 1:16 p.m. with RN1, RN1 stated when he informed Resident 1 ' s attending physician (MD1) on [DATE] regarding the missed dialysis she told RN1 to contact the hospice agency to manage Resident 1 ' s care. RN1 stated the hospice agency was informed on [DATE] regarding the missed dialysis sessions. RN1 stated when Resident 1 missed dialysis again on [DATE], he reached out to the hospice agency and was told to send Resident 1 to the GACH. During an interview on [DATE] at 11:17 a.m., the social services director (SSD) stated if the facility was having issues with transportation for dialysis and the resident was on hospice, facility staff should inform the hospice company so they could coordinate another transportation company to ensure the resident made it to their dialysis appointments. During an interview on [DATE] at 11:17 a.m., with the SSD, the SSD stated when a resident was on hospice, facility staff have to inform the hospice agency of any issues the resident was encountering right away, and the hospice agency should have been made aware of the first missed dialysis on [DATE] on that same day. During an interview on [DATE], at 11:17 a.m., with the SSD, the SSD stated she was not informed of the number of missed dialysis appointments until [DATE] and if she had been aware prior to that day, she would have helped contact the hospice agency sooner for assistance. The SSD stated it was not okay for a resident to miss their dialysis appointments. The SSD stated dialysis was a very important treatment and the potential consequence of a resident missing dialysis was death. During an interview on [DATE] at 2:36 p.m., with licensed vocational nurse (LVN1), LVN 1 stated when Resident 1 was having problems with transportation on Saturday, [DATE], and missed dialysis, she did not contact the hospice agency. LVN1 stated on Monday, [DATE] when Resident 1 missed his make-up dialysis, she did not inform the hospice agency again. LVN1 stated facility staff must notify the hospice agency right away, if a resident on hospice was having any issues, so they could get orders from them. During an interview on [DATE] at 3:04 p.m., the Minimum Data Set nurse (MDSN), MDS N stated the facility nurses should have informed the hospice agency immediately that Resident 1 had missed a dialysis appointment (on [DATE]). The MDSN stated it was very important that the facility had good communication with the hospice agency, so they could be informed of what was going on with the resident because all orders for hospice patients needed to go through the hospice agency. The MDSN stated the importance of ensuring a resident received their dialysis treatments was a matter of life or death. During an interview on [DATE] at 4:12 p.m., with the Director Of Nursing (DON), the DON stated she was not informed of the issues regarding Resident 1 missing dialysis until [DATE] and she told RN1 (on [DATE]) to communicate with the hospice agency about what was going on. The DON stated when RN1 communicated with the hospice agency on [DATE], the hospice agency made the decision to transfer Resident 1 to the GACH for emergency dialysis. The DON stated she was notified at 2 a.m. (on [DATE]) that Resident 1 had expired in the GACH (on [DATE] at 9:32 p.m.). During an interview on [DATE] at 4:12 p.m., with the DON, the DON stated that all decisions for residents on hospice needed to go through the hospice agency, and the hospice agency should have been informed right away when Resident 1 was not making his dialysis appointments due to transportation issues. During an interview on [DATE] at 4:12 p.m., with the DON, the DON stated the risks of not receiving dialysis treatments were fluid overload, respiratory distress, toxin (a poisonous substance) build up in the body, altered level of consciousness (confusion) and death. The DON stated the facility management should have been notified of transportation issues right away so they could help the nurses make the arrangements to get the residents to their dialysis appointments. During an interview on [DATE] at 8:36 a.m., with LVN2, LVN2 stated she was assigned to Resident 1 on [DATE] (Resident 1 ' s scheduled dialysis day). LVN2 stated Resident 1 ' s transportation to dialysis was late on [DATE]. LVN2 stated Resident 1 was finally picked up late, at 5:40 a.m. (regular pick-up time was 3:35 a.m.) by the transportation company to go to dialysis. During an interview on [DATE] at 8:36 a.m., with LVN2, LVN2 stated she later learned that the dialysis center had sent Resident 1 back to the facility on [DATE] because he was late and missed his dialysis chair time. LVN2 stated she did not inform the hospice agency of the transportation issues during her shift on [DATE]. During a review of the facility ' s P/P titled, Coordination of Hospice Services dated [DATE], the P/P indicated when a resident chose to receive hospice services, the facility staff was to coordinate and provide care in cooperation with hospice staff to promote the resident ' s highest practicable physical, mental, and psychosocial well-being. The P/P indicated the facility was to contact and communicate with hospice staff regarding any significant changes in the resident ' s status, clinical complications, or emergent situations. During a review of the HSPC Contract Agreement with the facility for Resident 1 dated [DATE], the Contract Agreement indicated the HSPC was to be notified if there were clinical complications that suggested a need to alter the resident ' s plan of care and/ or a need to transfer the patient from the facility.