**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of R165's clinical record revealed: 11/17/16 - R165 was admitted to the facility with diagnoses including, but not limited to, dementia and heart failure. 1/5/23 - R165's medical record documented E52's (MD) order: Transfer Status: assist of 2, Bed Mobility: assist of 1, Ambulation 1 person assist with RW (rolling walker) with wheelchair following. 11/22/23 4:30 AM- R165 fell from an elevated bed while receiving incontinence care by E53 (former CNA). 11/22/23 7:07 AM - E54 (Emergency Department MD) documented in the ED (Emergency Department) Physician Record, . History of Present Illness . patient's bed was elevated and they [staff] were changing her when she was rolled and unfortunately fell out of the bed . Secondary Survey- Head: hematoma to the right parietal region . CT (computed tomography) scan chest/abdomen/pelvis shows evidence of acute displaced rib fractures on the right side including ribs 4,6,7 and 9. Also has progressive loss of height of L3 (lumbar vertebrae 3) when compared to prior imaging . Trauma evaluated the patient and will admit to their service . 11/25/23 12:53 PM - R165 was discharged back to the facility after a three day admission following her fall with resultant right rib fractures. 4/26/24 7:36 AM - During an interview, E25 (RN) stated, I was called and told R165 had fallen. I went to her room and found her sitting on her butt with her legs in a V shape kind of in the air . I thought she [R165] hurt her right hip because she complained of pain when I palpated her right hip area but she ended up having right rib fractures . 4/26/24 11:07 AM - During a telephone interview, E53 (former CNA) stated, I was changing her [R165] and she had poop all over. I was turning her away from me towards the door . there was no scoop mattress or side rail. There was another CNA on the floor but she was a one person assist for bed mobility. She rolled out of the bed and onto the floor. I went and got the nurse. They sent her to the hospital. 4/30/24 1:25 PM - During an interview, E1 (NHA) stated that the facility immediately started to educate the staff on the proper method of turning and repositioning residents that morning of the incident. She said that she would provide the documentation of the facility's efforts to correct this situation. 4/30/24 - Review of all documentation of the corrective action plan completed on 11/28/23 included: - Timely reporting to State Agency; - Education regarding bed mobility for all nursing staff providing direct care to residents; - Initiated competencies on turning and repositioning residents; - Initiated a perimeter mattress on R165's bed upon her return from the hospital; - Facility investigation of the incident; and - Observations of bed mobility care with audits that documented compliance. This was verified by the Surveyor with observations of resident repositioning as well as multiple staff interviews about the content of the turning and repositioning inservice/education. 4. Review of R12's clinical record revealed: Eliquis (Apixiban) is an anticoagulant medication used to prevent serious blood clots from forming due to a certain irregular heartbeat (Atrial fibrillation). Source: Drugs.com 2024 1/24/14 - R12 was admitted to the facility with diagnoses including, but not limited to, dementia and atrial fibrillation. 10/26/22 - E55 (NP) ordered, Eliquis tablet 2.5 mg (milligram) - give one tablet by mouth two times a day for A fib (Atrial fibrillation). 7/19/23 - R12's medical record documented E52 (MD) ordering: Updated Transfer Status: transfer and bed mobility- assist of 1, Ambulation with PT (Physical therapy) only. 11/17/23 - R12's quarterly Minimum Data Set (MDS) assessment documented her Brief Inventory of Mental Status (BIMS) score of three, which reflected severe cognitive impairment. 12/25/23 2:45 PM - A progress note documented that while receiving care by E56 (CNA), R12 was rolled to her side and her head struck the windowsill. 12/25/23 4:06 PM - E57 (DO) documented in the ED (Emergency Department) Physician Record, . patient was at her skilled nursing facility, nursing staff was rolling her in bed. Her bed is up against a wall/window, and they accidentally rolled her against the windowsill when she hit her head. She developed a large hematoma over her left forehead . 12/25/23 8:32 PM - R12 discharged from the ED back to the facility. 4/30/24 12:07 PM - During an interview, E14 (LPN) stated that R12 no longer was able to interact with the staff in a meaningful way. She just grunts and makes noises. 4/30/24 1:25 PM - During an interview, E1 (NHA) stated that the facility recognized immediately that this incident involved staff rolling a resident in an inappropriate manner and began to re-educate the staff. 4/30/23 - Review of all documentation of the corrective action plan completed on 1/1/24 included: - Timely reporting to State Agency; - Additional education regarding bed mobility for all nursing staff providing direct care to residents; - Facility investigation of the incident; and - Observations of bed mobility care with audits that documented compliance. This was verified by the Surveyor with observations of resident repositioning as well as multiple staff interviews about the content of the turning and repositioning inservice/education. The Surveyor also reviewed the competency sheets for the bedside staff, which involved observations by management. Based on interview and review of clinical records and other documentation as indicated, it was determined that for five (R12, R63, R165, R169 and R170) out of nine residents reviewed for accidents, the facility failed to ensure that the residents' environment were free from accident hazards and the residents received adequate supervision. - R170 eloped on 8/16/23 at approximately 6:40 AM and was found outside the facility. Due to the facility's corrective measures completed on 8/31/23, the facility was notified that R170's elopement was an Immediate Jeopardy (IJ) past non-compliance. - R169 was able to retrieve a pair of sharp utility scissors from a treatment cart on 11/21/23 at 10:45 AM. Due to the facility's corrective measures completed on 11/28/23, the facility was notified that R169's incident was an Immediate Jeopardy past non-compliance. - R165 fell from an elevated bed while receiving incontinence care on 11/22/23 and sustained multiple right rib fractures and a back fracture. Due to the facility's corrective measures completed on 11/28/23, the facility was notified that R165's incident was a harm past non-compliance. - R12 was rolled into the windowsill during care with resultant facial hematoma on 12/25/23. Due to the facility's corrective measures completed on 1/1/24, the facility was notified that R12's incident was a harm past non-compliance. - R63 was served a hot tea beverage on 11/30/23 with breakfast at an inappropriate temperature as she sustained a first degree burn to her stomach and second degree burn to her upper right thigh. Additionally, the facility failed to ensure that E35 (LPN), the assigned nurse, followed the facility's policy and procedure when R63 had a change of condition (burns). Due to the facility's corrective measures completed on 12/5/23, the facility was notified that R63's incident was a harm past non-compliance. Findings include: 1. Review of R170's record revealed: The facility's Wandering and Elopements Policy, revised April 2024, Policy Interpretation and Implementation . A wandering/elopement assessment is completed as well as an obtained wandering/elopement hx (history) if able. Review of R170's clinical record revealed the presence of the following progress notes and physician's orders from the previous facility that R170 was in prior to his 8/9/23 facility admission. The documents indicated that R170 had been a resident of the previous facility from 8/2/23 - 8/9/23. The notes and orders were scanned into the facility's Emr (electronic medical record) on 8/9/23 by E6 (AD): - A Physician Order Summary Report that included an 8/2/23 order for R170 to have a Wanderguard; to check placement and function every shift. - An 8/2/23 Elopement Risk assessment that scored R170 at 2, at risk for elopement, related to his history of elopement at home, wandering in the facility and his verbal desire to return to his home. - An 8/2/23 nursing progress note which revealed that R170's elopement risk was a 2, and that R170 had a Wanderguard placed on his right ankle. - An 8/3/23 physician progress note that documented that R170 was under elopement precautions. 8/9/23 2:00 PM - R170 was admitted to the facility with diagnoses including dementia, mood disturbance and anxiety. The facility's new resident admission process included an assessment for a facility elopement risk and R170 was assessed as zero risk of elopement. A 3:09 PM progress note was written by E33 (LPN) revealed that R170 was admitted to the facility after being at another nursing home in the same city. 8/16/23 9:20 AM - A progress note was written by E24 (RN) that R170 eloped to parking lot . on 8/16/23 at 6:50 AM secondary to wandering related to advanced dementia. 4/25/23 9:30 AM - During an interview, E2 (DON) stated that R170 was able to elope from the facility through a locked window in the dining room, and that the resident apparently pushed the window until he broke the window locks, raised the window, removed the screen and then climbed out the window. R170 landed on a grassy area and walked to a cement path area which was on the side of the parking lot, which was next to a vehicular traffic road. A staff member who was arriving to work saw the resident on the pathway. 4/25/23 10:45 AM - During an interview, E16 (CNA) stated that on 8/16/23 when she was arriving to work at approximately 6:45 AM that she saw R170 walking on the walking pathway at the side of the facility. E16 stated that she did not know the resident so she wasn't sure if he was a facility resident and that she came in the building and asked E25 (RN) for assistance to verify the identity of R170. E16 stated that R170 was frustrated at the time and he wanted to go home. 4/30/24 10:30 AM - During an interview, E2 (DON) confirmed the presence of the previous facility's documents related to R170 previous facility stay and which had been scanned into the facility Emr on 8/9/23 by E6 (AD). E2 confirmed that R170 had a physician order for a Wanderguard, elopement precautions and the progress notes that described R170's elopement precautions, and all of which had previously been scanned into the facility's Emr. E2 stated that she was unaware of the elopement precautions that previous facility had R170 under. 4/30/23 1:42 PM - E1 (NHA) submitted to the Surveyor documentation of the corrective action plan with correction completed 8/31/23 at 7:00 AM. Immediate actions taken: - R170 was immediately moved to the facility's secured dementia unit, with one-to-one supervision and with a Wanderguard in place. - Facility wide Elopement Assessments accuracy was verified by E29 (ADON) 8/16/23. - Elopement Drills were conducted on 8/16/23, 8/17/23 and 8/30/23. - QAPI ad hoc meeting to review the elopement was held on 8/18/23. - Maintenance conducted a sweep of all windows to ensure the window locks were in place. - All staff elopement education began on 8/16/23 and was completed 8/31/23. - All resident name bracelets were audited to ensure that the bracelets were on the residents. - The elopement book that contained the residents identified as an elopement risk was reviewed and updated. Ongoing Actions: - QAPI review of the elopement incident at the September and October 2023 meetings. - All new admissions will have notes reviewed and elopement assessments checked by the ADON/designee. - Elopement book was audited weekly and then monthly for three months after the 8/16/23 elopement. Ongoing, E2 will review and update the elopement book with changes. 4/30/24 1:42 PM - Received from E1 the corrective action plan that was fully corrected, signed, dated and timed for 8/31/23 at 7:00 AM. 5/1/24 8:00 AM - An Immediate Jeopardy past non-compliance was called and reviewed with the facility leadership, including E1 (NHA), E2 (DON) and E28 (CRM). No immediate action required related to facility correction and no further occurrences after the incident on 8/16/23. This was verified by interviews with staff about elopement education, spot inspection for window locks and inspection of the elopement book. 2. Review of R169's clinical record revealed: The facility's policy on Security of Medication/Treatment Cart (revised June 2023) documented, The medication/treatment cart shall be secured during medication/treatment passes . 1. The nurse must secure the . cart during the medication/treatment pass to prevent unauthorized entry . 3 . The cart must be locked before the nurse enters the resident's room. 4 . carts must be securely locked at all times when out of the nurse's view. 5. When the . cart is not being used, it must be locked. 11/2/23 - R169 was admitted to the facility with a wound on the right lower extremity. 11/3/23 - A care plan was initiated for R169's agitation with verbal abuse exhibiting behaviors of cursing and use of derogatory language towards staff. 11/6/23 - R169 was also care planned for alteration in thought process related to episodes of confusion and anxiety. 11/6/23 9:28 PM - A nurse's progress note documented, Resident [R169] making suicidal statements to son. Resident stated that he wants to find a gun and 'end it all' . Son does not want resident sent to hospital. On call provider notified - provider made aware of son's wish to not send him. Provider ordered q (every) 15 (sic) checks until tomorrow, stat (immediately) psych consultation Q (every) 15 minute checks initiated. 11/7/23 - R169's admission MDS assessment revealed an intact cognition, having fluctuating behaviors of difficulty focusing attention and easily distractible with verbal behavioral symptoms directed towards others. R169 required supervision or hand touch assistance with mobility. 11/8/23 - R169 was hospitalized on [DATE] and was readmitted to the facility with new diagnoses including, but not limited to, depression and anxiety disorder. 11/16/23 - R169's physician's order for lorazepam (for anxiety) 0.5 mg (milligram), 1 tablet by mouth every 12 hours as needed for 14 days was changed to every 8 hours as needed for 14 days. 11/21/23 10:45 AM - A facility incident submitted to the State Incident Reporting Center documented that, Resident while in his wheelchair approached wound cart took out a pair of scissors and told staff he was going to hurt himself. He then began to cut at the bandage on his lower leg. When staff approached him to take away scissors he began to swing them around stating to staff he would harm himself. Scissors were successfully removed from his person. Wound team had used the cart during wound rounds. Resident sent to (hospital) for evaluation and behavior. 11/21/23 11:05 AM - A nurse's progress note revealed, Resident became combative with staff physically and verbally . Resident then went into the wound care cart, grabbed scissors and attempted to harm himself. Resident then smacked a nurse on her leg twice and attempted to bite unit clerk. NP (Nurse Practitioner) made aware . pick up resident to take (hospital). 11/21/23 - A written statement by E8 (Wound Nurse/UM) documented, During wound rounds on 11/21/23, I went to treatment cart to obtain scissors, and found none. I obtained a pair of bandage shears from the lower cart nurse (sic) and proceeded to complete dressing changes for residents seen on wound rounds. After rounds completed I returned supplies to treatment cart and thought I locked cart, I did not . 11/21/23 - A written statement by E9 (LPN) documented, I was sitting at the nursing station starting to chart. I heard the treatment cart doors opening and closing. I got up and stated, '[R169] please stop opening those.' As I got closer to him I noticed [R169] had a pair of scissors from the treatment cart he had started cutting his leg bandage off. I immediately intervened and I tried to get the scissors from him. When I tried the first time he threw his hands back and almost hit me in the head with the sharp end of the scissors. I lightly held his wrists with my palms so he couldn't hurt me or himself. I yelled for E10 (Unit Clerk) to come help me and take the scissors away from him. As E10 came over (sic) [R169] stated 'he wanted to die'. Once [R169] was safe and away from the scissors and the treatment cart, I had him sit next to me at the nurses station. [R169] proceeded to be disruptive and violent. He started to hit me in the legs and tried to grab my computer. We removed him for my safety and place (sic) him where he couldn't hurt me or anyone else or himself. 11/21/23 - A written statement by E10 (Unit Clerk) documented, I was sitting at my desk when me and the nurse heard the resident [R169] slamming the drawers open & (and) close on the wound cart, the nurse got up and went over and he had scissors in his hand. She went to grab them because he was cutting his wound bandage and said he was going to hurt himself (sic) as she went to grab he would not let her and was swinging the scissors. I came over to help her and I was able to get the scissors. Afterwards he was very rude to the staff he wouldn't stay calm he tried to hit the nurse multiple times as she had him sit with her, he said, 'Ima (sic) get serious now' and then grabbed at her computer trying to knock it down (sic) he was calm for just a minute then rolled over by the wound cart again and the key attached to the oxygen tank near the wound cart he grabbed and had it around his hand pulling . I tried to get it from me (sic) and on multiple occasions he tried to bite me saying 'I'm going to bite you stop!' I called over the unit manager for help . 4/25/24 1:00 PM - In an interview, E10 confirmed that she removed the scissors away from R169, who was very agitated at that time. E10 further stated, He tried to bite me as I took the scissor away. I don't know what type of scissors it was but the ends were sharp . He was sent out to the hospital after that incident and he did not return anymore. 4/26/24 11:30 AM - A spot check of the five treatment carts, four oxygen carts and nine medication carts across the five units revealed all carts were locked. 4/26/24 3:20 PM through 3:34 PM - An interview with the following nursing staff E11, E12, E13, E8, E14 and E15 revealed that staff were educated to keep all of the medication and treatment carts locked at all times when not in use and in view. 4/26/24 3:36 PM - In a separate interview, E8 (RN/Wound Nurse) clarified that she used a regular utility scissor and not a bandage scissor. E8 stated, There was no bandage scissor on the treatment cart. I used a regular scissor and that was the same scissor that [R169) took out from the drawer. 4/29/23 10:54 AM - E1 (NHA) submitted to the Surveyor an acceptable documentation of a signed and dated corrective action plan that was fully corrected on 11/28/23. The facility's corrective actions at the time of the incident included: - Investigation found that the treatment cart was left unlocked and resident was able to open it and obtain a pair of non-safety scissors. - Scissors were removed and the resident was unharmed. The resident was sent out for psychosocial evaluation. - Staff education immediately initiated on 11/21/23 along with auditing of treatment carts being locked. Safety scissors were placed in all treatment carts. - Completed education as of 11/28/23. - Audits documented compliance as of 11/28/23. - Facility was in substantial compliance as of 11/28/23. - The facility continued to audit and maintained compliance. 4/29/24 2:54 PM - An IJ was called and reviewed with the facility leadership, including E1 (NHA), E2 (DON) and E28 (CRM). During this conference, both E1 and E2 confirmed that there had been no other incidents of residents opening unlocked medication and treatment carts after the 11/21/23 incident. No immediate action required related to no further occurrences after the incident on 11/21/23 and past non-compliance. This was verified by spot inspection of medication/treatment carts, review of facility documents and interview with facility staff and residents. 5. Review of R63's clinical record revealed: 3/23/23 - R63 was admitted to the facility with hemiplegia and hemiparesis following a stroke affecting the right dominant side. 9/20/23 - R63's quarterly MDS assessment documented that she was cognitively intact and required supervision and setup help only for eating. 12/1/23 - A physician's note documented that R63 was seen and evaluated for .spilled tea to right thigh and lower abdomen . Right thigh with intact blister, + (positive) erythema (redness), mild swelling, no tenderness or drainage. Right lower abdomen with mild erythema, no blisters, swelling or open wound . Burn of abdominal wall, first degree . Burn of thigh, second degree . Monitor for signs of pain or discomfort, or infection. Apply Silvadene cream . Tylenol . for pain . Peripheral neuropathy. Discussed with patient concerns with drinking hot beverages and she is unable to feel when she dropped hot liquids. Reiterated with patient the need to have a two handle cup for all hot beverages and this includes any beverages that family or friends may bring in from the outside . 12/1/23 - The facility's investigation documented the following timeline: - at 10 AM, E2 (DON) was notified by NP of R63's burn/blisters from a hot water spill. NP and Wound Nurse assessed resident and treatment ordered. - at 10:30 AM, R63 stated during an interview that on 11/30/23 she spilled the hot water from her breakfast tray onto herself. She stated that when she picked up the cup that her hand gave out and it spilled. Resident admitted that she did not tell any staff members of the incident. During care on 12/1/23 at approximately 6am resident said that the C.N.A. [E37] discovered the blisters to her right thigh while she was getting her up. Additional interviews on 12/1/23 revealed: - Nurse [E38] from 12/2/23 7-3 shift was interviewed and stated that the burn/blister area on the resident was passed along to her during shift to shift report to have the NP assess the resident. Stated that the 11-7 nurse had contacted the family regarding the findings. - Nurse [E35] from 11/30/23 11-7 shift was called and multiple messages left to return urgently. Supervisor for 11-7 shift was not made aware of the resident having a blister on her right upper thigh area. Update: nurse returned DON call later that day 12/1/23. Nurse stated after aide notified her of changes to residents skin she assessed and notified MD/NP and emergency contact. Emergency contact told the nurse that her mother spilled a hot beverage and the skin changes may be a result of her mother spilling the hot beverage on herself. She then reported to the oncoming nurse of skin changes and MD/NP will follow up. (It should be noted that E35 did not call the on-call provider at the time, but documented R63's burn/blisters in the MD/NP book to follow up.) - at 11 AM, interviews of multiple nursing staff assigned to provide care for R63 on 11/30/23 day and evening shifts revealed that R63 did not tell anyone that she spilled her tea nor did anyone see any skin issues during care. - On 12/1/23, Therapy was notified of the need for 2 handled lidded cups for hot beverages with meals. Cups ordered with meals and supplied to the kitchen for use. Therapy will evaluate for hand strengthening. - On 12/1/23 at approximately 12 pm, the kitchen manager was notified of incident with resident burn/blisters. Water coming from the coffee machine was tempted and showed to be 170 degrees. Maintenance director contacted manufacturer of coffee machine and was able to lower the temperature. Dietary staff was instructed that the temperature of coffee or hot water has to be served at 150 degrees or lower. Dietary manager immediately initiated new process of temping hot beverages at start of meal service and taking temp of hot beverage of each cart prior to service to ensure temps at 150 degrees or below. Education for dietary staff was initiated on 12/1/23 on new process for taking temperatures of hot beverages prior to service. - On 12/1/23, staff educator initiated education with nursing staff on the importance of notifying the Supervisor of burn/blister for proper resident assessment and investigation. - On 12/1/23 at 1:30 PM, facility reported R63's incident to the State Agency. - The facility identified and noted during the investigation that the Nurse [E35] who first assessed R63 was given a write up and education was conducted on proper process to follow when there is an observed change in a resident's condition. Plan to review the nurse's documentation to ensure proper documentation and following the facility's policy and procedure. 12/5/23 - E2 (DON) completed an Employee Performance Improvement/Action Notification for E35 (LPN) for Violation of Policy #501-1 Failure to report incident or change in resident condition to Supervisor. Failure to provide notification of a residents change in condition to the N.P. and or On Call Service. Failure to document note in chart and obtain treatment orders. Failure to initiate incident report. The corrective actions were: [Name of E35] will receive training on the proper procedure for reporting and documentation change in resident condition and notification of supervisor and or Nurse Practitioner . will be audited by supervisor to review documentation in order to insure following proper procedure for documenting. 12/5/24 at 4 PM - E8 (RN/UM) documented that she educated E35 (LPN) of the proper documentation/notification of a resident's change in condition, which was signed and dated by both nurses. Based on the immediate actions taken after R63's incident, reviewed by the Surveyor and confirmation of no further incidents, the facility returned to substantial compliance as of 12/5/23 at 4 PM. 5/1/24 1:30 PM - All findings were reviewed during the exit conference with E1 (NHA), E2 (DON) and E28 (CRM) and representative's of the Ombudsman's Office.