**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Cross Reference F842 Based on observation, interview, and record review, the facility failed to ensure a newly admitted resident (#6) out of five newly admitted residents reviewed was free from significant medication errors as evidenced by not receiving physician ordered medications for a period of seven days resulting in a readmission to a local hospital due to a hematoma and exacerbation of her medical diagnoses to include a flare-up of Multiple Sclerosis (MS) symptoms to include paralysis in her hands, confusion, and a low hemoglobin requiring a transfusion of packed red blood cells (PRBCs) . On 8/9/24, Resident #6 was admitted to the facility with medication orders from the acute facility. Resident #6's ordered medications were not entered into the electronic medical record. On 8/16/24, Resident #6 went to a scheduled outside medical appointment, which resulted in a transfer and admission back to the hospital on 8/16/24 with a hematoma. Facility staff did not discover Resident #6's missed medications until the re-admission back to the hospital. The failure to administer significant medications for a period of 7 days to include Prednisone, Amiodarone, Gabapentin, Ferrous Sulfate, and Wellbutrin resulted in serious harm and could have led to additional medical complications to include further serious medical complications, injury and possible death. This failure resulted in the determination of Immediate Jeopardy on 8/9/24. The findings of Immediate Jeopardy were determined to be removed on 8/29/24 and the severity and scope was reduced to a D. Findings included: Review of the census page in the electronical medical record revealed Resident #6 was initially admitted to the facility on Friday, 08/09/24 at 4:20 PM from an acute care facility. Review of the admission Record showed Resident #6 was re-admitted to the facility on [DATE] and had diagnoses to include subsequent encounter fracture with routine healing, multiple sclerosis (MS), paraplegia, urinary tract infection (UTI), major depressive disorder recurrent, ventricular fibrillation, paroxysmal atrial fibrillation and other pulmonary embolism without acute COR pulmonale (alteration in the structure and function of the right ventricle of the heart caused by a primary disorder of the respiratory system), acute kidney failure, anemia, acute respiratory failure with hypoxia, and personal history of other venous thrombosis and embolism. Review of the [Local Hospital] Discharge Patient Med Rec (Medication Reconciliation) - Single report, dated 08/08/24, showed: This is the list of medications for you to take upon discharge. Please take this list to your primary care doctor at the next visit. Your hospital doctor wants you to take the drugs on this list when you go home. The list of medications included the following: - Amiodarone 200 MG (milligrams), trade name Cordarone, Oral, twice daily. A note showed this order was sent to the resident's preferred pharmacy. - Atorvastatin 10 MG, trade name Lipitor, Oral, daily. - Bupropion HCL 100 MG, trade name Wellbutrin, Oral, daily. - Collagenase Clostridium 1 application, trade name Santyl, Topical, twice daily. A note showed this order was sent to the resident's preferred pharmacy. - Ferrous Sulfate 325 MG, trade name Feosol, Oral, every other day. - Gabapentin 300 MG, trade name Neurontin, per feeding tube, three times daily. A note showed this prescription was printed. - Guaifenesin/Dextromethorphan 5 ML (milliliters), per feeding tube, Q6H (every six hours). A note showed this order was sent to the resident's preferred pharmacy. - Metoprolol Tartrate 25 MG, trade name Lopressor, Oral, twice daily. - Multivitamin 1 tablet, trade name Multivitamin-Mineral Daily, Oral, daily. - Pantoprazole 40 MG, trade name Protonix, Oral, before breakfast and dinner. - Polyethylene Glycol 3350 17 MG, trade name Miralax, Oral, daily as needed. A note showed this prescription was printed. - Prednisone 5 MG, trade name Prednisone, Oral, take 1 tablet by mouth 1 time every 72 hours. - Rivaroxaban 20 40 MG, trade name Xarelto, Oral, with breakfast. - Sennosides 1 tablet, trade name Senokot, Oral, daily as needed. A note showed this order was sent to the resident's preferred pharmacy. - Sodium Chloride 3% Inhalation Solution 4 ML, trade name Sodium Chloride 3% Inhalation Solution, inhalation every 6 hours while awake. A note showed this order was sent to the resident's preferred pharmacy. Review of the complete Order Summary Report and the August Medication Administration (MAR) showed only two of the 15 medications were ordered by the facility on 08/09/24 during Resident #6's initial admission: - Metoprolol Tartrate oral tablet 25 milligrams (MG)- Give 1 tablet by mouth twice daily. - Multivitamin 1 tablet, trade name Multivitamin-Mineral Daily, Oral, daily. Review of the Medication Reconciliation dated 08/09/24 showed A. Completed medication reconciliation utilizing the following data sources (check all that apply); 2. Discharge Summary Section B. Medication Issues Identified was blank. Section C. Physician Contact was blank. Review of Resident #6's admission Minimum Data Set (MDS), dated [DATE], showed in Section C- Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 13 (cognitively intact). Section I-Active Diagnosis showed Resident #6 had the following diagnoses: anemia, deep venous thrombosis (DVT) or pulmonary embolism (EP), hypertension, renal insufficiency, multidrug-resistant organism (MDRO), urinary tract infection (UTI), wound infection, hyperlipemia, paraplegia, multiple sclerosis, depression and respiratory failure. Section N-Medications showed Resident #6 was taking none of the above medication classifications that included: antipsychotic, antianxiety, antidepressant, hypnotic, anticoagulant, antibiotic diuretic, opioid and antiplatelet. Review of a Nursing Progress Note, dated 08/13/24, showed Resident complained of being hot. Temp in room was decreased to 60 degrees. NP [Nurse Practitioner] notified. Nurse gave resident some PRN [as needed] Tylenol. NP states it could be MS [Multiple Sclerosis] flush. Nurse also put wet washcloth on neck and forehead. Will continue to observe. Review of a Nursing Progress Note, dated 08/14/24, showed, Resident [family member] has concern that his [Resident #6] has an UTI, he stated her current orientation is not her baseline the pt [patient] is showing signs of increased confusion and would like for her to be tested for an UTI. The writer notified the house NP about [family member] concerns, NP gave new orders to give for UA C&S [Urine Analysis Culture and Sensitivity] and to monitor for other s/s[signs and symptoms]. Review of a Physician Progress Note dated 08/15/24, with a service date of 08/12/24, showed Patient seen today is new to provider. She was in the hospital for hypoxia due to respiratory failure. She was also found to be tachycardia, hypotensive, and had a fever, she was a sepsis alert. She has multiple sclerosis is a paraplegic. She has a foley catheter for urinary retention. She is seen at bedside and states she is doing well .She is currently on 2L [liters] oxygen, she is at baseline. She has tube feeds and states that she eats regular food too. Medications Reconciled .Medications: Metoprolol Tartrate Oral Tablet 25 MG, Multivitamin-Minerals Oral Tablet, Tubersol Solution 5 unit/0.1 ml, Fleet Enema 7-19 GM [gram]/118 ML, Milk of Magnesia Suspension 400 MG/5ML, Biscolax Suppository 10 MG, Acetaminophen Tablet 325 MG, Santyl External Ointment 250 Unit/GM. Review of a Nursing Progress Note, dated 08/16/24, showed, Resident went to [Local Hospital] wound care appointment this am [morning]. Received a call from them approximately 11:30 am stating that the resident is being sent to the ER to evaluate a hematoma to her left arm. NP made aware. Review of the Emergency Provider Report, dated 8/16/24, revealed the chief complaint was left arm swelling and reports extremity pain, extremity swelling. The section for Home Medications - Active Scripts included: - Amiodarone 200 MG, PO (by mouth). - Collagenase Clostridium 1 application, trade name Santyl, Topical, BID (two times daily). - Ferrous Sulfate 325 MG, PO Q48HR (every other day). - Gabapentin 300 MG, per feeding tube, TID (three times daily). - Guaifenesin/Dextromethorphan 5 ML (milliliters), per feeding tube, Q6H (every six hours), 7 days. - Multivitamin 1 tablet, PO daily. - Pantoprazole 40 MG, PO AC BK DIN (before breakfast and dinner). - Polyethylene Glycol 3350 17 GM, PO daily, PRN (as needed). - Rivaroxaban 20 MG, PO (by mouth). - Sennosides 1 tablet, PRN daily as needed. - Sodium Chloride 3% Inhalation Solution 4 ML, INH RTQ6H (inhalation every 6 hours while awake). Reported Medications included: - Prednisone 5 MG, PO Q72HR (every 72 hours). - Bupropion HCL 100 MG, PO daily. - Atorvastatin 10 MG, PO daily. - Metoprolol Tartrate 25 MG, PO BID. The Impression for the vascular Lab, dated 8/16/24, of her upper left arm showed: No sonographic evidence of deep venous thrombosis. Left upper arm soft tissue mass most consistent with fluid which may reflect hematoma, seroma, abscess of lymphocele. Ultrasound-guided aspiration appears technically possible if clinically indicated. The Impression for the radiology report, dated 8/16/24, of the left forearm showed: Diffuse infiltrative changes soft tissues distal left upper arm and proximal-mid forearm consistent with edema or cellulitis. The Re-Evaluation/Progress #1 note showed: Left upper extremity shows a moderate-sized hematoma. There is no DVT. I consulted with plastics, and they recommended admission for hematoma evacuation. The patient will require cardiology clearance given her recent cardiac arrest. Review of the History and Physical Report from the local hospital and dated 8/17/24 revealed Patient is a . year old female with a past medical history paroxysmal atrial fibrillation, VFib [ventricular fibrillation] cardia arrest, MS, anxiety, OSA [obstructive sleep apnea], hyperlipidemia, PE [pulmonary embolism]/DVT previously on Xarelto, sacral decubitus ulcer, and ESBL [extended spectrum beta-lactamase] E [Escherichia] coli bacteremia that presented to [local hospital] for evaluation of upper extremity swelling and pain. Patient was found to have a hematoma. Plastics evaluated and recommended no intervention at this time .Labs were remarkable for hemoglobin 6.6 and given a unit of PRBCs. Review of https://medlineplus.gov/ency/article/003645.htm showed Hemoglobin is a protein in red blood cells that carries oxygen . Normal results for adults vary, but in general are: . Female: 12.1 to 15.1 . The ranges above are common measurements for results of these tests. Normal value ranges may vary slightly among different laboratories During an interview on 08/27/24 at 9:50 a.m. Resident #6 stated she was out of it and did not remember much about her stay at the facility between 08/09/24 and 08/16/24. Resident #6 stated she knew the medications she took and why. Resident #6 stated that had she not been confused during the initial admission on [DATE]. She reported that if she had not become confused, she would have asked about the facility not administering her regular medications. Resident #6 stated her family member was very upset about the facility not administering all the medications as ordered during the initial admission. Resident #6 stated both she and her family member still did not understand why the facility was not treating the multiple sclerosis (MS) flareup causing her hands to be paralyzed and did not understand why the facility would not provide her with Prednisone, which assists her in regaining her functions when MS attacks. Resident #6 stated because of the latest MS flareup she was not able to feed herself because the MS flareup attacked her hands. During an interview on 08/27/24 at 10:32 a.m. Resident #6's family member stated the Director of Nursing (DON) from the facility called him to let him know Resident #6 did not receive her medications from the initial admission date on 08/09/24 through her hospitalization on 08/16/24. The family member stated the DON told him the facility did not input Resident #6's medications into the medical record. The family member stated when he came to visit Resident #6, he spoke with staff who came into Resident #6's room and voiced his concerns that Resident #6 seemed to be out of it. The family member stated Resident #6 was fuzzy about things and was not able to pay attention, which was not her normal. The family member stated prior to her initial admission on [DATE] Resident #6 was her normal self, and he noticed the change in her status during the week after her initial admission to the facility until the time of discharge to the hospital on [DATE]. The family member stated Resident #6 went out to the wound center and when the wound care physician was looking at the wound, they noticed the hematoma on her arm. The family member stated the wound care center immediately sent her over to the ER (emergency room) where she was admitted into the hospital. The family member stated he noticed a positive change in her mental status back to normal once she was at the hospital and stated she began acting more like her coherent self again. During an interview on 08/27/24 at 2:50 p.m. the DON stated Resident #6 went to a scheduled outside appointment on 08/16/24. The DON stated it was then that the outside provider sent Resident #6 to the ER. The DON stated she reviewed Resident #6's medical record when Resident #6 was hospitalized . This was when she recognized Resident #6 was not administered all her physician ordered medications. The DON stated Resident #6 did not have a DVT (deep vein thrombosis) and the hospital said it was just cellulitis. The DON stated upon reviewing Resident #6's medications it was discovered they were not reconciled and were not entered into the medical record. The DON stated that Staff E, Licensed Practical Nurse (LPN), was the admitting nurse for Resident #6 on Friday, 08/09/24. The DON stated that Staff E, LPN should have ensured all medications were entered into the electronical medical record as medications are a priority. The DON stated her understanding was Staff E, LPN started the admission process and was called away and failed to communicate with the oncoming nurse that all the medications were not added into the electronical medical record. The DON stated nurses are supposed to document the medication reconciliation. The DON stated after speaking with Staff E, LPN she was informed that Staff E, LPN left at 7:00 p.m., the end of her scheduled shift, and assumed the oncoming nurse scheduled for the 7:00 p.m. to 7:00 a.m. shift would complete Resident #6's physician ordered medications. The DON stated she then spoke with Staff F, LPN (the oncoming nurse) for the 7:00 p.m. to 7:00 a.m. shift. The DON discovered Staff F, LPN thought the admission was completed by the 7:00 a.m. to 7:00 p.m. nurse since some entries were completed in the physician orders of Resident #6's medical record. The DON stated chart scrubs (reviews) should be completed on Mondays (more than 48 hours after Resident #6's admission), however the Unit Manager ended up having to work on the medication cart passing medications and the Assistant Director of Nursing (ADON) was not in the facility. During an interview on 08/27/24 at 5:50 p.m. Staff E, LPN stated the admission process was to get a list of admissions, and the nurses were responsible for getting the chart ready. Staff E, LPN stated the nurse was also responsible for checking the new admissions' medication lists. Staff E, LPN stated that her work schedule was usually 7:00 a.m. to 7:00 p.m. shift and medications were the responsibility of the night shift nurse working 7:00 p.m. to 7:00 a.m. since the medications were usually delivered after 7:00 p.m. During an interview on 08/28/24 at 1:45 p.m. Staff F, LPN stated he has worked in the facility for two years. Staff F, LPN stated when the new admission comes to the facility it is the nurse's responsibility to complete the admission, however if the nurse is new, a seasoned nurse will help to train them. Staff F, LPN stated the nurse's responsibility for a resident who is newly admitted would consist of assessments to include skin and wounds, consents for treatment, and then the physician orders for medications are entered into the electronical medical record. Staff F, LPN stated, ensuring everything is entered into the electronical medical record, a seasoned nurse would check to make sure a medication reconciliation was completed. Staff F, LPN stated if medications were not available the nurse could also look in the [Emergency Drug Kit] for the medications. An interview was conducted with the Consultant Pharmacist on 8/28/24 at 8:37 a.m. The consultant reported that although he does not review new admissions, new admission medications should arrive to the facility within 24 hours. During an interview on 08/28/24 at 12:00 p.m. the NP confirmed Resident #6 had medications that were not entered into the medical record when she was initially admitted into the facility on [DATE]. The NP stated the missing medications were not found until after Resident #6 went out to the hospital. During an interview on 08/28/24 at 3:11p.m., the Pharmacist in Charge (PC) stated in review of Resident #6's medications upon admission all the medications put into the electronical medical record system were house stocked medications except for Metoprolol. The PC stated that should the drug Amiodarone be stopped abruptly this drug was a serious drug for the heart and should be tapered off if possible. The PC stated for the drug Gabapentin this drug should be tapered off gradually over a week's time and had withdrawal side effects such as Tachycardia and Seizures. The PC stated for the drug Wellbutrin this drug should also be tapered off and if stopped abruptly withdrawal symptoms would be depression, irritation and confusion however all these medications could cause confusion. Review of the website medlineplus.gov showed: Gabapentin should be gradually reduced. Do not stop taking gabapentin without talking to your doctor, even if you experience side effects such as unusual changes in behavior or mood. If you suddenly stop taking gabapentin tablets, capsules, oral solution, you may experience withdrawal symptoms such as anxiety, difficulty falling asleep or staying asleep, nausea, pain, and sweating. If you are taking gabapentin to treat seizures and you suddenly stop taking the medication, you may experience seizures more often. Your doctor may decrease your dose gradually over at least a week. Review of the website addictionresources.com showed: Wellbutrin if discontinued may cause the following withdrawal symptoms within two to four days after discontinuation of the drug: Mood Changes: Mood swings, irritability, heightened emotional sensitivity Physical Symptoms: Headaches, fatigue, dizziness and flu-like symptoms Cognitive Effects: Difficulty concentrating, memory lapse and cognitive fog. Review of the website medlineplus.gov showed: Amiodarone You may need to be closely monitored or even hospitalized when you stop taking amiodarone . Review of the website https://my.clevelandclinic.org/health/drugs/14568-iron-oral-supplements-for-anemia showed: Ferrous sulfate is a type of iron supplement. Iron is one of the minerals your body needs to function properly. Your body needs iron to produce hemoglobin and myoglobin. Hemoglobin is a protein in your red blood cells. Hemoglobin helps your blood carry oxygen from your lungs to all your body's tissues and organs. Myoglobin is a protein in your muscles and helps supply oxygen to the cells in your muscles. If you don't have enough iron, your body can't make these proteins, and you may develop iron-deficiency anemia. Iron-deficiency anemia is the most common type of anemia. Anemia is a blood disorder in which your body doesn't have enough red blood cells. During an interview on 08/28/24 at 4:12 p.m., the Medical Director (MD)(who was the resident's primary care physician at the facility) stated the process for new admissions would be medications are uploaded into the electronic medical record system by the nurse and then facility staff would message him so he could look at the new resident's profile within 24 hours. The MD stated he was not aware that Resident #6 was not getting all her medications. The MD stated that he was at the facility and met with Resident #6 on 08/12/24. The MD stated that according to his physician notes, he only discussed Metoprolol with Resident #6 so that must have been the only medication that was documented in her medical record. The MD stated he was not aware all the medications were not entered into the electronic medical record system, but stated he did remember questioning that she only had one medication and had found it odd. The MD stated that if you review my physician note when I came to the facility and examined Resident #6 for her re-admission you will see I listed a lot more medications because the facility had entered all the medications into the electronic medical record system during the re-admission process. During an interview on 08/29/24 at 4:00 p.m. Registered Nurse (RN)/Regional Director of Clinical Services (RDCS) confirmed the medication errors for Resident #6 at the time of her initial admission on [DATE]. The RN/RDCS stated a resident missing a cardiac medication is significant. Review of the policy titled, Physician Orders, revised 3/3/21, revealed: The center will ensure that physician orders are appropriately and timely documented in the medical record. The policy described the procedure for admission orders as Information received from the referring facility or agency to be reviewed, verified with the physician, and transcribed to the electronic medical record. The attending physician will review and confirm orders. Confirmation of admission orders requires that the physician sign and date the order during, or as soon as practical after it is provided, to maintain an accurate medical record. Review of the facility's policy Administering Medications revised date 04/2019 showed Policy Statement: Medications are administered in a safe and timely manner, and as prescribed .3. Staffing schedules are arranged to ensure that medications are administered without necessary interruption. 4. Medications are administered in accordance with prescriber orders, including any required time frame .6. Medication errors are documented, reported and reviewed by the QAPI committee to inform process changes and or the need for additional staffing. 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before or after meal orders). Review of the facility's policy titled, Nursing Documentation Guidelines, not dated, revealed Policy: Pertinent Information should be documented in the individual's record in an accurate, timely and legible manner. Procedure: General Guidelines When to Chart 1. Record resident's condition, nursing actions and individual responses as soon as possible after they occur What to Chart 1. Symptoms/Subjective Data 2. Your observations and/or Assessments, 3. All injuries, illness and unusual health changes until they are resolved. There should be entries in the nursing notes on a regular basis until the problem is no longer present. When the problem is resolved, it should be documented. 4. All contacts with the primary care prescriber. A. document what information was relayed to the primary care prescriber. b. If the primary care prescriber sees or reviews an individual's specific health problem, document what occurred: the chart was reviewed, the individual was seen or if the individual was examined. c. contact is made by phone document what was discussed and results of the contact (e.g. [for example] no orders given, observe) d. document the plan for follow-up (e.g. to see the physician on morning rounds) e. Documentation on all meds. 5. response to a medication or treatment this includes therapeutic effects as well as side effects 6. new symptoms or conditions document in then nurses notes at time of occurrence or as soon as possible. Document nursing action taken and person's response. Facility immediate actions to remove the Immediate Jeopardy included: Immediate and Five (5) day reports were completed for Resident #6 on 8/17/24 and 8/23/24 related to neglect respectively. Resident was discharged on 8/16/2024 from a physician office visit to the hospital. re-admitted to facility on 8/19/24. Medication reconciliation completed on 8/19/2024 by licensed nurse. Education completed with one identified nurse directly related to Resident #6's identified deficiency on 8/17/24. Education provided reviewed the process of new admissions, medication reconciliation of physician orders, and follow up with pharmacy regarding delivery of medications. As of 8/28/24, corrective action was written for the one identified nurse. A thirty (30) day look back of all admissions and readmissions from 7/16/2024 to 8/16/2024 to ensure systems are in place to confirm residents are admitted into the facility's electronic medical record and medications ordered at the time of admission are received and administered per physician orders. As of 8/27/2024, a MAR to cart audit reconciliation was completed by the Director of Nursing/designee to ensure medications are available according to physician order. A pharmacy representative also conducted a full cart audit on 8/28/2024. Facility personnel received education beginning on 8/28/2024 related to abuse policy to include preventing abuse, identification, protection, investigating and reporting and reporting inappropriate resident behaviors to the nurse. Neglect is the failure of the center, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. As of 8/17/2024 all license nurses were educated by Director of Nursing/Designee on the admission process to ensure discharge medications are reconciled before clarifying with physician and ensure residents are receiving their physician ordered medications to meet their needs. Licensed Nurses received additional education beginning on 8/27/2024 on errors in medication administration to include: -omissions of medications not given -transcribing and reconciliation of discharge orders -following physician orders -steps taken when medication is not available (check med bank backup machine, check central supply, call pharmacy and notify physician of medication unavailability and document in progress note) If unable to reach physician in timely manner, contact Director of Nursing/Designee Any staff member that did not receive education related to the above-mentioned items will be sent a letter as of 8/29/2024 indicating they may not return to work until the education is received. Newly hired staff will receive education in orientation. Verification of the facility's removal plan was conducted by the survey team on 8/29/24. All steps contained in the removal plan were reviewed and verified. Interviews were conducted with 15 of the 20 licensed nurses employed by the facility. The LPN's and RN's interviewed worked across all shifts. All nurses were able to provide details on the medication order process for new admissions. The nurses responded appropriately when asked what they would do in various situations if a concern was to arise. No concerns were identified with the answers provided. Based on verification of the facility's Immediate Jeopardy removal plan, the immediate jeopardy was determined to be removed on 08/29/24 and the non-compliance was reduced to a scope and severity of D.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Cross Reference F760 Based on observation, review of medical records, policy and procedure review, interviews with residents, resident representative, nursing staff, key management staff, the residents' physician and pharmacist, it was determined the facility failed to ensure the medical records were complete and accurate in accordance to accepted professional standards and practices for two residents (#3, and #6) out of 9 residents reviewed. This failure contributed to the lack of communication amongst staff in delivering care and services for Resident #3 and Resident #6 resulting in the residents not receiving physician ordered medications. The facility staff did not ensure documentation was completed upon admission for Resident #6 related to medication reconciliation. The facility failed to enter physician ordered medications resulting in the resident not receiving prescribed medications from 8/9/24 to 8/16/24. In addition, an antibiotic, deemed to be ineffective for Resident #6's urinary tract infection (UTI) by a lab result, was administered eight times upon the readmission of Resident #6. The nursing staff administered two different antibiotic medications on the same day at the same time for the same infection without consulting the physician. The facility staff did not ensure Resident #3's physician order for Methadone was obtained or administered for approximately 77 hours resulting in the resident suffering pain and withdrawal symptoms. The facility staff failed to complete the medication reconciliation by not clarifying the physicians order for Methadone timely with the physician. The report did not document if the physician or the date and time the physician had been contacted to reconcile the discharged medications. The failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death and resulted in the determination of Immediate Jeopardy on 8/9/24. The findings of Immediate Jeopardy were determined to be removed on 8/29/24 and the severity and scope was reduced to a D. Findings included: 1. Review of the facility's policy titled, Nursing Documentation Guidelines, not dated, revealed Policy: Pertinent Information should be documented in the individual's record in an accurate, timely and legible manner. Procedure: General Guidelines When to Chart 1. Record resident's condition, nursing actions and individual responses as soon as possible after they occur What to Chart 1. Symptoms/Subjective Data 2. Your observations and/or Assessments, 3. All injuries, illness and unusual health changes until they are resolved. There should be entries in the nursing notes on a regular basis until the problem is no longer present. When the problem is resolved, it should be documented. 4. All contacts with the primary care prescriber. A. document what information was relayed to the primary care prescriber. b. If the primary care prescriber sees or reviews an individual's specific health problem, document what occurred: the chart was reviewed, the individual was seen or if the individual was examined. c. contact is made by phone document what was discussed and results of the contact (e.g. [for example] no orders given, observe) d. document the plan for follow-up (e.g. to see the physician on morning rounds) e. Documentation on all meds. 5. response to a medication or treatment this includes therapeutic effects as well as side effects 6. new symptoms or conditions document in then nurses notes at time of occurrence or as soon as possible. Document nursing action taken and person's response. Further review of the policy titled, Nursing Documentation Guideline, undated, showed the policy defined an individual's record as A permanent legal document that provides a comprehensive account of information about the individual's health care status. Review of the policy titled, Physician Orders, revised 3/3/21, revealed: The center will ensure that physician orders are appropriately and timely documented in the medical record. The policy described the procedure for admission orders as Information received from the referring facility or agency to be reviewed, verified with the physician, and transcribed to the electronic medical record. The attending physician will review and confirm orders. Confirmation of admission orders requires that the physician sign and date the order during, or as soon as practical after it is provided, to maintain an accurate medical record. Review of the census page in the electronical medical record revealed Resident #6 was initially admitted to the facility on Friday, 08/09/24 at 4:20 PM. Review of the admission Record confirmed the initial admission on [DATE] and a re-admission to the facility on [DATE] with diagnoses that included subsequent encounter fracture with routine healing, multiple sclerosis (MS), paraplegia, urinary tract infection (UTI), major depressive disorder recurrent, ventricular fibrillation, paroxysmal atrial fibrillation and other pulmonary embolism without acute COR pulmonale (alteration in the structure and function of the right ventricle of the heart caused by a primary disorder of the respiratory system), acute kidney failure, anemia, acute respiratory failure with hypoxia, personal history of other venous thrombosis and embolism. Review of the Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (3008), dated 8/8/24, revealed Resident #6 had no medication due near the time of transfer on 08/09/24, and a script was checked as not attached for a controlled substance. Resident #6 had ESBL (extended spectrum beta-lactamase) of the urine, a pressure ulcer on coccyx, and the reason for transfer was for care/rehabilitation with a poor prognosis for rehabilitation potential. Review of the [Local Hospital] Discharge Patient Med Rec (Medication Reconciliation) - Single report, dated 08/08/24, showed: This is the list of medications for you to take upon discharge. Please take this list to your primary care doctor at the next visit. Your hospital doctor wants you to take the drugs on this list when you go home. The list of medications included the following: - Amiodarone 200 MG (milligrams), trade name Cordarone, Oral, twice daily. A note showed this order was sent to the resident's preferred pharmacy. - Atorvastatin 10 MG, trade name Lipitor, Oral, daily. - Bupropion HCL 100 MG, trade name Wellbutrin, Oral, daily. - Collagenase Clostridium 1 application, trade name Santyl, Topical, twice daily. A note showed this order was sent to the resident's preferred pharmacy. - Ferrous Sulfate 325 MG, trade name Feosol, Oral, every other day. - Gabapentin 300 MG, trade name Neurontin, per feeding tube, three times daily. A note showed this prescription was printed. - Guaifenesin/Dextromethorphan 5 ML (milliliters), per feeding tube, Q6H (every six hours). A note showed this order was sent to the resident's preferred pharmacy. - Metoprolol Tartrate 25 MG, trade name Lopressor, Oral, twice daily. - Multivitamin 1 tablet, trade name Multivitamin-Mineral Daily, Oral, daily. - Pantoprazole 40 MG, trade name Protonix, Oral, before breakfast and dinner. - Polyethylene Glycol 3350 17 MG, trade name Miralax, Oral, daily as needed. A note showed this prescription was printed. - Prednisone 5 MG, trade name Prednisone, Oral, take 1 tablet by mouth 1 time every 72 hours. - Rivaroxaban 20 40 MG, trade name Xarelto, Oral, with breakfast. - Sennosides 1 tablet, trade name Senokot, Oral, daily as needed. A note showed this order was sent to the resident's preferred pharmacy. - Sodium Chloride 3% Inhalation Solution 4 ML, trade name Sodium Chloride 3% Inhalation Solution, inhalation every 6 hours while awake. A note showed this order was sent to the resident's preferred pharmacy. Review of the Order Summary Report for Active Orders as of 8/9/24 and the August 2024 Medication Administration Report (MAR) revealed the following medications were ordered on 08/09/24 during Resident #6's initial admission: - Metoprolol Tartrate oral tablet 25 MG- Give 1 tablet by mouth twice daily. - Multivitamin-Minerals Oral Tablet Give 1 tablet by mouth one time a day. Review of the Medication Reconciliation form, dated 08/09/24, showed: Section A. Completed medication reconciliation utilizing the following data sources (check all that apply) - 2. Discharge Summary: Section B. Medication Issues Identified was blank and showed no medications listed or needing clarification; Section C. Physician Contact was blank. Review of the baseline care plan for the 8/9/24 admission showed for the Problem of Pain that Goal was for Resident #6 will maintain comfort to highest degree possible and the Interventions included to administer pain medication as ordered. The Problems of Psychotropic Use, Infection, Altered Cardiac/Respiratory Functioning and Altered Mood State and/or Behavior were blank. Review of Resident #6's admission Minimum Data Set (MDS), dated [DATE], showed in Section C- Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 13 (cognitively intact). Section I-Active Diagnosis showed Resident #6 had the following diagnoses: anemia, deep venous thrombosis (DVT) or pulmonary embolism (EP), hypertension, renal insufficiency, multidrug-resistant organism (MDRO), urinary tract infection (UTI), wound infection, hyperlipidemia, paraplegia, multiple sclerosis, depression and respiratory failure. Section N-Medications showed Resident #6 was taking none of the above medication classifications that included: antipsychotic, antianxiety, antidepressant, hypnotic, anticoagulant, antibiotic, diuretic, opioid and antiplatelet. Review of a Nursing Progress Note, dated 08/14/24, showed, Resident [family member] has concern that [Resident #6] has an UTI, he stated her current orientation is not her baseline the pt [patient] is showing signs of increased confusion and would like for her to be tested for an UTI. The writer notified the house NP about [family member's] concerns, NP gave new orders to give for UA C&S [Urine Culture and Sensitivity] and to monitor for other s/s [signs and symptoms]. Review of a SBAR (Situation, Background, Action, Response) Communication Form, dated 8/14/24, showed since the situation started the staff member was unable to determine if it had gotten worse and the condition, symptom or sign occurring prior was unknown. The Resident/Patient Evaluation showed increased confusion or disorientation. Review of a Physician Progress Note, dated 08/15/24, with a service date of 08/12/24, showed, Patient seen today is new to provider. She was in the hospital for hypoxia due to respiratory failure. She was also found to be tachycardia, hypotensive, and had a fever, she was a sepsis alert. She has multiple sclerosis is a paraplegic. She has a foley catheter for urinary retention. She is seen at bedside and states she is doing well .She is currently on 2L [liters] oxygen, she is at baseline. She has tube feeds and states that she eats regular food too. Medications Reconciled .Medications: Metoprolol Tartrate Oral Tablet 25 MG, Multivitamin-Minerals Oral Tablet, Tubersol Solution 5 unit/0.1 ml, Fleet Enema 7-19 GM [gram]/118 ML, Milk of Magnesia Suspension 400 MG/5ML, Biscolax Suppository 10 MG, Acetaminophen Tablet 325 MG, Santyl External Ointment 250 Unit/GM. Review of a Nursing Progress Note, dated 08/16/24, showed, Resident went to [Local Hospital] wound care appointment this am [morning]. Received a call from them approximately 11:30 am stating that the resident is being sent to the ER [Emergency Room] to evaluate a hematoma to her left arm. NP made aware. Review of a Nursing Progress Note, dated 08/16/24, showed, [Local] hospital was called to check the resident's status; the nurse informed this writer that resident was admitted to the hospital with dx [diagnosis] of hematoma to the left arm and resident is scheduled for surgery on Monday. [Medical Director] made aware. Review of the Emergency Provider Report, dated 8/16/24, revealed the chief complaint was left arm swelling and reports extremity pain, extremity swelling. The section for Home Medications - Active Scripts included: - Amiodarone 200 MG, PO (by mouth). - Collagenase Clostridium 1 application, trade name Santyl, Topical, BID (two times daily). - Ferrous Sulfate 325 MG, PO Q48HR (every other day). - Gabapentin 300 MG, per feeding tube, TID (three times daily). - Guaifenesin/Dextromethorphan 5 ML (milliliters), per feeding tube, Q6H (every six hours), 7 days. - Multivitamin 1 tablet, PO daily. - Pantoprazole 40 MG, PO AC BK DIN (before breakfast and dinner). - Polyethylene Glycol 3350 17 GM, PO daily, PRN (as needed). - Rivaroxaban 20 MG, PO (by mouth). - Sennosides 1 tablet, PRN daily as needed. - Sodium Chloride 3% Inhalation Solution 4 ML, INH RTQ6H (inhalation every 6 hours while awake). Reported Medications included: - Prednisone 5 MG, PO Q72HR (every 72 hours). - Bupropion HCL 100 MG, PO daily. - Atorvastatin 10 MG, PO daily. - Metoprolol Tartrate 25 MG, PO BID. Review of the History and Physical Report from the local hospital dated 8/17/24 revealed Patient is a . year old female with a past medical history paroxysmal atrial fibrillation, VFib [ventricular fibrillation] cardiac arrest, MS, anxiety, OSA [obstructive sleep apnea], hyperlipidemia, PE[pulmonary embolism]/DVT previously on Xarelto, sacral decubitus ulcer, and ESBL E coli bacteremia that presented to [local hospital] for evaluation of upper extremity swelling and pain. Patient was found to have a hematoma. Plastics evaluated and recommended no intervention at this time .Labs were remarkable for hemoglobin 6.6 and given a unit of PRBCs [packed red blood cells - transfusion]. Review of the August physician orders, and the August MAR showed the following medications were ordered on or after 08/19/24 during Resident #6's re-admission: - Amiodarone HCI Oral Tablet 200 MG- Give 1 tablet by mouth one time a day related to htn (hypertension) with start date of 08/20/24 and d/c (discontinue) date of 8/20/24. - Amiodarone HCI Oral Tablet 200 MG- Give 1 tablet by mouth one time a day related to Paroxysmal Atrial Fibrillation with start date of 08/21/24. Atorvastatin Calcium Oral Tablet 10 MG- Give one tablet by mouth at bedtime for hyperlipidemia with start date of 08/20/24. Cipro Oral Tablet 500 MG- Give 1 tablet by mouth two times a day for UTI for 7 days with start date 08/17/24 and d/c 8/23/24. Bactrim DS Oral Tablet 800-160 MG- Give 1 tablet by mouth two times a day for infection for 14 days with start date of 08/23/24. Bupropion HCI Oral Tablet 100 MG- Give 1 tablet by mouth one time a day related to Mood Disorder, Recurrent with start date of 08/20/24 and d/c date of 8/20/24. Bupropion HCI Oral Tablet 100 MG- Give 1 tablet by mouth one time a day related to Major Depressive Disorder, Recurrent with start date of 08/21/24. Ferrous Sulfate Oral Tablet 325 MG- Give 1 tablet by mouth in the morning every 2 day(s) for anemia with start date of 08/20/24 and d/c date of 8/20/24. Ferrous Sulfate Oral Tablet 325 MG- Give 1 tablet by mouth in the morning every other day for anemia with start date of 08/21/24. Metoprolol Tartrate Oral Table 25 MG Give 1 tablet by mouth two times a day for HTN with a start date of 8/9/24. Gabapentin Oral Capsule 300 MG- Give 1 capsule by mouth three times a day for neuropathy with start date 08/20/24. Pantoprazole Sodium Oral Tablet Delayed Release 40 MG- Give 1 tablet by mouth two times a day for GERD with start date 08/20/24. Review of the Lab Results Report, with a report date of 08/17/24 at 10:03 a.m., showed the NP reviewed the Urinalysis (UA) results, Urine Culture and Sensitivity (C&S) results on 08/19/24 at 8:09 a.m. The results of the Urine C&S revealed Ciprofloxacin (Trade Name Cipro) was R meaning resistant greater than four. Review of a Physician Progress Note, dated 08/19/24 at 3:09 p.m., showed, Patient seen today for a follow up visit . She is seen at bedside and states she was positive for a UTI while in the hospital but did not receive any antibiotics . A UA was obtained and is positive for UTI. Cipro 500 was started until C&S is completed. Further review of the August MAR showed Resident #6 was administered Cipro Oral Tablet 500 MG eight doses between the first administration on 08/19/24 at 5:00 p.m. to the last administration on 08/23/24 at 9:00 a.m. In addition, Resident #6 was also administered Bactrim DS Oral Tablet 800-160 MG on 08/23/24 at 9:00 a.m. The August MAR showed both the medications of Cipro and Bactrim were administered at their scheduled times of 9:00 a.m. on 08/23/24 prior to the discontinuation of Cipro. During an interview on 08/27/24 at 9:50 a.m. Resident #6 stated she was out of it and did not remember much about her stay at the facility between 08/09/24 and 08/16/24. Resident #6 stated she knew the medications she took and why. Resident #6 stated that had she not been confused during the initial admission on [DATE], she would have asked about the facility not administering her regular medications. Resident #6 stated her family member was very upset about the facility not administering all the medications as ordered during the initial admission. Resident #6 stated both she and her family member still did not understand why the facility was not treating the multiple sclerosis (MS) flareup causing her hands to be paralyzed and did not understand why the facility would not provide her with Prednisone, which assists her in regaining her functions when MS attacks. Resident #6 stated because of the latest MS flareup she was not able to feed herself because the MS flareup attacked her hands. During an interview on 08/27/24 at 10:32 a.m. Resident #6's family member stated the Director of Nursing (DON) from the facility called him to let him know Resident #6 did not receive her medications from the initial admission date on 08/09/24 through her hospitalization on 08/16/24. The family member stated the DON told him the facility did not input Resident #6's medications into the medical record. The family member stated when he came to visit Resident #6, he spoke with staff who came into Resident #6's room and voiced his concerns that Resident #6 seemed to be out of it. The family member stated Resident #6 was fuzzy about things and was not able to pay attention, which was not her normal. The family member stated prior to her initial admission on [DATE] Resident #6 was her normal self, and he noticed the change in her status during the week after her initial admission to the facility until the time of discharge to the hospital on [DATE]. During an interview on 08/27/24 at 2:50 p.m. the DON stated Resident #6 went to a scheduled outside appointment on 08/16/24. The DON stated it was then that the outside provider sent Resident #6 to the ER. The DON stated she reviewed Resident #6's medical record when Resident #6 was hospitalized . This was when she recognized Resident #6 was not administered all her physician ordered medications. The DON stated Resident #6 did not have a DVT (deep vein thrombosis) and the hospital said it was just cellulitis. The DON stated upon reviewing Resident #6's medications it was discovered they were not reconciled and were not entered into the medical record. The DON stated that Staff E, Licensed Practical Nurse (LPN), was the admitting nurse for Resident #6 on Friday, 08/09/24. The DON stated that Staff E, LPN should have ensured all medications were entered into the electronical medical record as medications are a priority. The DON stated her understanding was Staff E, LPN started the admission process and was called away and failed to communicate with the oncoming nurse that all the medications were not added into the electronical medical record. The DON stated after speaking with Staff E, LPN she was informed that Staff E, LPN left at 7:00 p.m., the end of her scheduled shift, and assumed the oncoming nurse scheduled for the 7:00 p.m. to 7:00 a.m. shift would complete Resident #6's physician ordered medications. The DON stated she then spoke with Staff F, LPN (the oncoming nurse) for the 7:00 p.m. to 7:00 a.m. shift. The DON discovered Staff F, LPN thought the admission was completed by the 7:00 a.m. to 7:00 p.m. nurse since some entries were completed in the physician orders of Resident #6's medical record. The DON stated chart scrubs (reviews) should be completed on Mondays (more than 48 hours after Resident #6's admission). The DON stated Resident #6's medical record and medication reconciliation was just overlooked. The DON stated the nurses were continually being educated on the importance of completing medication reconciliation, documentation of admissions assessments, and who they spoke to in clarifying any medications. The DON stated that both Staff E, LPN and Staff F, LPN were educated about the admission process after Resident #6's 08/09/24 incident. During an interview on 08/28/24 at 10:42 a.m. the DON stated all UA C&S results were reviewed by the facility's nurse practitioner. The DON reviewed Resident #6's Lab Results Report with a reported date of 08/17/24 and stated that the R (resistance greater than four for Ciprofloxacin) meant that this specific medication would not help Resident #6's UTI if administered. The DON stated after reviewing the Lab Results Report she was not sure why the NP did not change the medication when reviewed. The DON stated the only thing that could have happened was when Resident #6 was hospitalized , I didn't clear the medication list, and when Resident #6 was re-admitted on [DATE] the medications that were ordered were just resumed. During an interview on 08/28/24 at 12:00 p.m. the NP reviewed Resident #6's Lab Results with a report date of 08/17/24. The NP stated she ordered Ciprofloxacin but once Resident #6's Lab Report was reviewed and showed Ciprofloxacin was resistant it was not administered. The NP stated Resident #6 did not get a dose of Ciprofloxacin when re-admitted to the facility on [DATE]. The NP was presented with Resident #6's August MAR and the NP responded, What is this? The NP reviewed Resident #6's August MAR, and the NP responded, I don't ever look at that. The NP stated she did not have access to residents' electronic medical records but had asked about obtaining access to the electronic medical record system in the past. The NP confirmed that Ciprofloxacin being R resistant to the UTI bacteria would not have helped clear Resident #6's UTI. The NP reviewed Resident #6's August MAR and stated Bactrim was prescribed on 08/23/24 and this was S sensitive to the bacteria for Resident #6's UTI. The NP stated when Resident #6 returned to the facility on [DATE] there should have been another order for labs. The NP looked in Resident #6's electronical medical record and confirmed no further lab testing was completed upon re-admission on [DATE]. Further interview with the NP was conducted regarding medication reconciliation during admission. The NP stated Resident #6 had medications that were not entered into the medical record when she was initially admitted into the facility on [DATE]. The NP stated the missing medications were not found until after Resident #6 went out to the hospital. The NP stated that Xarelto was held upon Resident #6's admission because she believed Resident #6 had some bleeding. The NP stated that any medications that are considered on hold are not entered into a resident's medical record because the facility was afraid the nursing staff would disregard the hold and give those medications anyway. The NP stated that any medications on hold would not show up on a resident's MAR because it was simply not entered in the medical record as a physician ordered medication. The NP stated that either the NP or the Medical Director (MD) would revisit all medications on hold for a later time. The NP stated that no medications were revisited for Resident #6 because she went out to the hospital and when she re-admitted the medications were reconciled again off the hospital discharge summary. The NP stated that if the hospital wanted Resident #6 to be on any additional medication the hospital would have made those changes there and sent the updated medication list back on the discharge summary. The NP stated some medications placed on hold may never be resumed or are not lifelong medications but stated the MD may have different views about this. During an interview on 08/28/24 at 3:11p.m. the Pharmacist in Charge (PC) stated in review of Resident #6's medications upon admission on [DATE] all the medications put into the electronical medical record system were house stocked medications except for Metoprolol. During an interview on 08/28/24 at 4:12 p.m. the Medical Director (MD) (who was the resident's primary care physician at the facility) stated the process for new admissions would be medications are uploaded into [Electronical Medical Record System] by the nurse and then facility staff would message me so that I can look at the new resident's profile within 24 hours. The MD stated he was not aware that Resident #6 was not getting all of her medications. The MD stated he was at the facility and met with Resident #6 on Monday, 08/12/24. The MD stated that according to his physician notes, he only discussed Metoprolol with Resident #6 so that must have been the only medication that was documented in her medical record. The MD stated he was not aware all the medications were not entered into the electronic medical record system, but stated he did remember questioning that she only had one physician ordered medication and had found it odd. The MD stated if you review my physician note when I came to the facility and examined Resident #6 for her re-admission, you will see I listed a lot more medications because the facility had entered all the medications into the electronic medical record system during that re-admission process. The MD stated as far as Resident #6 being administered Ciprofloxacin for the UTI, it would not have made a significant change in the UTI because it was resistant. The MD stated he remembered addressing the concern as to why Resident #6 was ordered two antibiotics (Bactrim and Ciprofloxacin) when he visited with Resident #6 and ordered the Ciprofloxacin at that time to be discontinued. The MD stated he was not presented with the results of Resident #6's Urinalysis with Sensitivities for review. The MD reported this was only reviewed by the NP. Review of a Physician Progress Note, dated 08/22/24, showed: - -Cont. [continue] Metoprolol for BP [blood pressure] Cont. Atorvastatin for HLD [Hyperlipidemia] - Cont. Pantoprazole for GERD [Gastroesophageal Reflux Disease] - Cont. Amiodarone for cardiac dysrhythmia (history of VF[Ventricular Fibrillation] arrest) - Cont. bowel regimen - Cont. Burprion [trade name Wellbutrin] for mood - Currently on Cipro [Ciprofloxacin] and Bactrim for undefined source. Clarify need for both antibiotics. During an interview on 08/29/24 at 10:16 a.m. the DON stated the nurse does assessments, checks the papers, reconciles orders, and verifies MD orders, especially if they have a discrepancy. They should call the acute care facility for clarification if needed. They are supposed to reconcile medications with the primary care physician (PCP) with every admission. They reconcile the hospital records with the PCP. The DON stated they review admissions over the weekend. She looks through what is uploaded. She checks to see if the records are accurate with proper diagnoses based on what is uploaded in the computer. The DON stated that she does not always get notification when the admit comes, but she would like to be notified when they arrive. The DON stated that she does not look at the MAR; she looks on the dashboard to see what was and was not done. The DON stated they (nurses) should be looking for new orders. When they get a new admit, the next nurse would audit the admission. During an interview on 08/29/24 at 4:00 p.m. RN/Regional Director of Clinical Services (RDCS) confirmed the medication errors for Resident #6. She stated a resident missing a cardiac medication is significant. 2. On 8/27/24 at 11:15 a.m. Resident #3 was sitting in his wheelchair at bedside. The resident was frail-looking, with bony prominences noted, pleasant, and able to answer questions appropriately. Resident #3 reported having pain all the time, has taken the opioid, Methadone, for the last 5 years, and has been on pain management for the past 28 years. The resident described his current pain as achy sharp pains, and rated the current pain between 7 and 8 out of a scale of 1 to 10, with 10 being the worst. The resident stated while at the facility the pain has not been below a 6. Resident #3 reported being at the facility for 5 days and has started to go through withdraw symptoms. Resident #3 described those symptoms as watery eyes, watery nose, nausea, and loose stools. Resident #3 stated he was normally constipated. The resident stated nurses say they are doing what they can, and the Methadone was on order. Resident #3 reported the facility made an admission exception for him due to his use of Methadone. Review of the admission Data Collection form revealed an initial admission date on Friday, 8/23/24. The admission nurse's note showed Patient arrived to facility at 1905 [7:05PM] . Review of the admission Record showed Resident #3 admission diagnoses to include malignant neoplasm of unspecified part of left bronchus or lung, malignant neoplasm of parietal lobe, lumbar region osteomyelitis of vertebra, unspecified site other specified arthritis, lumbar region fusion of spine, unspecified site unspecified discitis, right shoulder abscess of bursa, and other low back pain. Review of the admission MDS dated [DATE] showed in Section C - a BIMS score of 15 out of 15, indicating intact cognition. Review of the care plan, dated 8/26/24 for Resident #3 revealed the following: - Resident is on pain medication therapy r/t (related to) cancer. The goal was for the resident to be free of any discomfort or adverse side effects from pain medication through the review date. Interventions related to the resident's pain instructed staff to Administer medications as ordered by physician. Monitor/document side effects and effectiveness every shift. - Resident has actual/potential for pain r/t cancer (and) chronic back pain. The goals were for the resident to have minimal interruption in normal activities due to pain through the review date, and resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. The interventions included: Administer analgesia as per orders; Anticipate the resident's need for pain relief and respond immediately to any complaint of pain; and evaluate the effectiveness of pain interventions and review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Review of the acute facility's Finalized Discharge Medications, dated 8/22/24 at 12:55 p.m., showed Resident #3 was ordered Methadone Dispersible 40 mg orally daily for non-acute pain. The medication summary rev

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to protect the resident's right to be free from abuse/neglect by 1) failing to respond to a serious change in condition in a timely manner for one resident (#404) out of seven residents sampled for abuse/neglect and, 2) use of a Geri-chair as a restraint to limit a residents movement for one resident (#248) out of seven sampled for abuse/neglect. Resident #404 experienced a change of condition secondary to bleeding from four skin wounds on his arms and legs, which began on [DATE] at 1:00 p.m. The bleeding required four dressing changes to the upper extremities and two dressing changes to the lower extremities due to bleeding through the dressings over the course of 17 hours. On [DATE] at 7:25 a.m. Resident #404 was transferred to the hospital and subsequently died from widespread sepsis and bleeding caused by DIC (disseminated intravascular anticoagulation [a rare but serious condition that causes abnormal blood clotting throughout the body's blood vessels]). The resident was not provided the care and services to benefit from earlier assessment and treatment from a higher level of care. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Resident #404 and resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to a D after verification of removal of immediacy of harm. Findings included: 1. On [DATE] at 4:15 p.m. an interview was conducted with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) to review a reportable incident for Resident #404. The DON stated she was familiar with Resident #404, and she could speak to the investigation conducted at the time of the incident. The DON stated a family member complaint was received on social media. The DON stated they investigated and did not find any problem with the care. The DON stated Resident #404 was not compliant with care and had displaced a wound vac. She stated Resident #404 was in and out of the hospital and the last time he was sent to the hospital he passed away. The DON stated Resident #404 was sent to the hospital due to bleeding, and he had saturated the dressings on his arms. The DON stated the resident was on Eliquis as a blood thinner, and the family member complained that the resident was not sent to the hospital soon enough. A review of the medical record revealed Resident #404 was admitted on [DATE] with diagnoses, including but not limited to, cerebral infarction due to thrombosis of right middle cerebral artery, chronic pancreatitis, unspecified open wounds to left ankle, neck, right lower leg, right thigh, left hip, left lower leg, lower back, and pelvis without penetration to retroperitoneum (the tissue that lines the abdominal wall and covers most of the organs in the abdomen), unspecified atrial fibrillation, gastrostomy status, unspecified gastrointestinal hemorrhage, unspecified anemia, and unspecified coagulation defect. A review of the Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #404 had a Brief Interview of Mental Status (BIMS) score of 14, indicating intact cognition. A review of the Order Summary Report for Resident #404 revealed the following: [DATE] Full Code. [DATE] Labs: CBC (complete blood count), CMP (comprehensive metabolic profile) one time only for admission labs for one day. [DATE] Aspirin 81 tablet chewable 81 MG (milligrams) give one tablet by mouth one time a day for DVT (deep vein thrombosis) prevention. [DATE] Eliquis oral tablet 5 MG (Apixaban) give one tablet by mouth two times a day for coagulopathy. [DATE] Furosemide oral tablet 80 MG give one tablet by mouth two times a day for pleural effusion. [DATE] Left hip cleanse with normal saline, silver nitrate dampened gauze, and place border dressing every day shift every Tuesday and Friday for wound. [DATE] Left lateral ankle change wound vac every Tuesday and Friday, apply black granulofoam, set section to 125 MMHG (millimeters/mercury) every day shift every Tuesday and Friday for wound. [DATE] Mid thoracic back cleanse with normal saline, xeroform, and place border dressing every day shift for wound. [DATE] Right heel cleanse with normal saline, apply skin prep, leave open to air every day shift every other day for DTI (deep tissue injury). [DATE] Left lateral ankle change wound vac, apply black granulofoam, set suction to 125 MMHG one time only for wound care for one day. [DATE] Right heel cleanse with normal saline, apply skin prep, leave open to air every night shift every other day to DTI. [DATE] Mid thoracic back cleanse with normal saline, xeroform, and place border dressing every night shift for wound. [DATE] Left ischium cleanse with normal saline, apply medihoney, then cover with mepilex every day shift every other day for wound care. [DATE] Left lateral ankle and mid back change wound vac every Monday and Thursday, apply black granulofoam, set suction to 125 MMHG, connect with Y-tubing every day shift every Monday and Thursday for wound. [DATE] Cleanse skin tear to left elbow apply TAO (triple antibiotic ointment) and DSD (dry sterile dressing) until healed then discontinue every night shift for skin tear care. [DATE] Cleanse skin tear to upper leg apply TAO and DSD until healed then discontinue every night shift for skin tear care. [DATE] Zofran oral tablet 4 MG (Ondansetron) give one table by mouth every six hours as needed for nausea/vomiting. [DATE] CBC, CMP one time only for bleeding for one day. [DATE] Send to ER (emergency room) for evaluation one time only for bleeding for one day. A review of the Comprehensive Care Plan, initiated on [DATE], for Resident #404 revealed the following: Focus: The resident is on anticoagulant/anti-platelet therapy related to atrial fibrillation and CVA (cardiovascular accident). Revision [DATE]. Goal: The resident will be free from discomfort or adverse reactions related to anticoagulant use through the review date. Interventions: Administer anticoagulant medications as ordered by physician. Monitor for side effects and effectiveness every shift. Daily skin inspection. Report abnormalities to the nurse. Monitor/document/report as needed adverse reactions of anticoagulant therapy: blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs. Focus: The resident has a skin tear to left elbow and left leg. Initiated on [DATE]. Goal: The resident's skin tear will show signs of healing by review date. Interventions: Monitor/document location, size, and treatment of skin tear. Report abnormalities. A review of the Progress Notes for Resident #404 revealed the following: -[DATE] 10:17 a.m. Physician progress note: Patient is seen today for follow-up visit. It was reported by staff that he had a fall last night and hit his head. He was sitting on the side of the bed and was trying to position himself back to lying down when he fell over. He did not ask for help or use call light. Patient states he was having hallucinations and confused after he hit his head. The incident was not reported until this morning. Patient is on Eliquis and Aspirin, so he was sent out to the ER for a CT (computed tomography scan) of the head. He did receive multiple skin tears on his arm and leg. He also has a bruise/redness on his face. -[DATE] 10:50 a.m. Nursing progress note: Resident heard calling out, resident observed on side of bed holding onto bed on right side and bedside table to the left side. Resident was in between. Resident assisted back to bed and care provided. ROM [range of motion] WNL [within normal limits]. No s/s [signs/symptoms] of acute distress. Routine pain med given, and wound care provided to skin tears. -[DATE] 7:51 a.m. Nursing progress note: Patient observed to have dislodged/saturated dressing to LUE [left upper extremity] at start of shift, changed patients dressing per physicians order. after receiving PM [evening] medications dressings observed to be saturated again, cleaned wounds to LUE and R [right] forearm and applied ABD [abdominal] pads with krelix [sig] and ace wrap on top to apply pressure. Patient c/o [complains of] nausea and prior emesis,, administer PRN [as needed] Zofran to good effect. Notified physician at 2130 of patients saturation of dressings and treatment applied. Physician ordered for dressing to stay in place until am then to be removed for assessment and CBC to be drawn on [DATE]. At approximately 0630 dressing was removed with some saturation through the ace wrap with the gauze noted to be heavily saturated. Notified physician and received order to send to ER to evaluation and to control bleeding .Called 911 at 0714 upon entering room at approximately 0725 with EMS [emergency medical services] patient had emesis in container dark brown with some red noted approximately 100 ML [milliliter] in container, Resident left facility with EMS at approximately 0730 via stretcher, notified patients emergency contact A review of the Treatment Administration Record (TAR), dated [DATE]-[DATE], for Resident #404 revealed the following: Cleanse Skin tear to left elbow apply TAO and DSD until healed every night shift for skin tear documented as completed once on [DATE]. Cleanse skin tear to left upper leg apply TAO and DSD until healed every night shift for skin tear care documented as completed once on [DATE]. A review of the Medication Administration Record (MAR), dated [DATE]-[DATE], for Resident #404 revealed the following: Aspirin 81 MG give one tablet by mouth one time a day for DVT prevention documented as administered on [DATE] at 9:00 a.m. Eliquis oral tablet 5 MG give one tablet by mouth two times a day for coagulopathy documented as administered on [DATE] at 9:00 a.m. and 5:00 p.m. Furosemide oral tablet 80 MG give one tablet by mouth two times a day for pleural effusion documented as administered on [DATE] at 9:00 a.m. and 5:00 p.m. Zofran oral tablet 4 MG give one tablet by mouth every six hours as needed for N/V not documented as given on [DATE]. On [DATE] at 5:49 p.m., a telephone interview was conducted with a Family Member (FM) of Resident #404. The FM stated Resident #404 transferred from the hospital to the facility in March and seemed to be getting better. The FM stated the resident went to the hospital for an abscessed tooth. The FM stated she went to see Resident #404 every day and stayed with him all day long at the facility. The FM stated she would have a good friend drive her there and pick her up. The FM stated on [DATE] she escorted the resident to the courtyard to smoke and when she put her hand on the handle of the wheelchair she picked up her hand to find it full of blood. She stated that was a few days before Resident #404 died. The FM stated the resident was bleeding from his leg, arm, and shoulder area. The FM stated the shoulder was sopping with blood, and she took the dressing off and went in to the facility to get someone to put something over the area. The FM stated the nurse started yelling at Resident #404 for taking off the dressing. She stated then someone came in and put a dressing on the area. The FM stated she had seen the Resident #404 throwing up blood during the day in his urinal. The FM stated she went to the nursing station and asked the nurse to please call EMS and get an ambulance to come. The FM stated when she told the nurse Resident #404 was bleeding out the staff all started laughing and said they wouldn't let him bleed out. She stated the nurse never went down to check on the resident at all. She stated her friend was with Resident #404 in the room and saw him take two sips of water and throw up blood in the urinal. The FM stated it was close to 7pm [DATE], the day before he went to the hospital. The FM stated the next morning she got a call from a man who said he sent Resident #404 to the hospital because he was bleeding out. The FM stated when she got to the hospital, Resident #404 was on life support, and they had to keep giving him blood. The FM stated the nurse never left the nurse's station the night she was there to go in and check on Resident #404 from the time she asked for the resident to go to the hospital until the time she left the facility. On [DATE] at 07:06 p.m., an interview was conducted with Staff A, Licensed Practical Nurse (LPN). She stated she remembers the resident, and mentioned the mother visited daily. She confirmed she was the assigned nurse to Resident #404 on [DATE] day shift a.m. to 7 p.m. She stated she remembered he was bleeding while in the courtyard with his FM. She stated the resident told her he took his bandages off so he could let them breathe. She stated after he returned inside the facility, she applied dressings to both upper extremities. Staff A stated she informed the oncoming nurse for the night shift. She stated during her shift she changed the dressings twice because of visible blood and saturation through the dressings. She stated she used a kerlix roll dressing. She stated she thought she changed it around 1-2 p.m., then prior to shift change at 7 p.m. it needed to be changed again. She stated the FM was on the patio with the resident while he was smoking. Staff A stated she let the night nurse know Resident #404 was bleeding from his arms. She stated she reported she had re-wrapped the arms. She stated it was unusual to have to change the dressings twice. She stated she did not call the doctor. She stated Resident #404 had quite a few wounds and she had changed one on his leg and his wound vac. She stated the wound vac had quite a bit of drainage and had an odor to it. She stated she did not recall any nausea or vomiting. She stated she really was not thinking about the resident being on blood thinners. She stated she did not make any notes, do a change of status, or notify the doctor of the need to change dressings due to bleeding. On [DATE] at 7:29 p.m., an interview was conducted with Staff O, RN (Registered Nurse, Unit Manager). She stated Resident #404 was admitted from the hospital but unable to recall the specifics of his admission. She stated Resident #404 had a lot of different wounds. She said his FM visited almost every day. She stated she knew the resident was sent out for a bleed. She stated she was told there were allegations of neglect because of an on-line review. She stated she did not participate in the investigation and stated abuse investigations are generally completed by the DON/NHA. She stated the nurses are expected to document changes in condition and notify the physician in the medical record. She stated if a resident's family asked for them to be sent to the hospital the nurses are supposed to do so and let the doctor know what is happening. On [DATE] at 9:22 a.m., an interview was conducted with Staff P, LPN (Licensed Practical Nurse). He stated he knew Resident #404 had falls, skin tears and could be grumpy, but did not recall Resident #404's plan of care. He stated Resident #404 had dressings all over, had a lot of skin tears, and a wound vac to his sacrum. The nurse stated in report he was told while the FM visited with the resident in the courtyard, the resident was picking at his dressings, and (Staff A) told him she had just changed his dressings. He stated he did not recall (Staff A) saying that was the second time she had to change the dressings. He stated, After report around 7:45 p.m., I saw the dressing on his left arm was not really on but the mepilex dressing had some bleeding on it. I'm not sure who transferred the resident back to bed but there was some blood smeared on the wall by his bed. I changed the dressings to his arms and legs all at once and cleaned the blood off the wall. When giving him his night meds [9:00 p.m.], I saw the dressings on his upper arms were saturated and the current dressing was not appropriate for the amount of bleeding. The dressing was red in color. The dressing to his legs were not saturated. I changed the dressings on his legs. I applied ABD, Kerlix and pressure dressings to his arms. I changed all the dressings [legs and arms] to have a timeline of how much he was bleeding. I used gauze pads on his legs, because they were absorbent and easy to see changes. I notified the MD about 9:30 p.m. and he said to leave the dressings in place and draw a CBC [[DATE]] and leave those dressings in place until the morning and then to remove them for assessment. I rounded on him to make sure there was no visible bleeding throughout the shift. The nurse stated he did not remove the ace wrap during the night to keep pressure on the arms. He stated about 6:00 a.m. he removed the ace wrap and saw the wound had bled through to the ace and Resident #404 told him he had vomited on the prior shift. Staff P, LPN stated the previous nurse had not reported the resident had vomited. On [DATE] at 11:02 a.m. an interview was conducted with the Primary Care Physician (PCP) for Resident #404. The PCP stated he did not recall specifically being notified about Resident #404 on [DATE]. He stated if he was notified for the first time that a resident was having a bleeding episode he would have told them to monitor and apply a pressure dressing. He stated he did not recall being contacted during the day shift about any bleeding the resident was having. He stated if he was told of previous episodes of bleeding and multiple changes of dressings he would have told them to send the resident out to be evaluated. He stated it was not ideal that the nurses did not notify him of multiple dressing changes, and he would have expected them to report any vomiting of blood as well. The PCP stated if he had been aware of the bleeding wounds and vomiting blood, he would have sent him out. He stated what he was told was not the same as what occurred. He stated his partner admitted Resident #404 to the hospital and the resident died of sepsis with complications. He stated the resident had fungus in the blood cultures. He stated he reviewed the chart in the hospital and Resident #404 had DIC, his platelets dropped, and the resident passed away. He stated he usually investigates the reason if a resident passes away because he wants to know what happened. Disseminated intravascular coagulation, or DIC, is a complicated condition that can occur when someone has severe sepsis or septic shock. Both blood clotting and difficulty with clotting may occur, causing a vicious cycle. Small blood clots can develop throughout your bloodstream, especially in the microscopic blood vessels called capillaries. This blocks the blood flow to many parts of your body, including your limbs and your organs. Blood is then not able to bring oxygen and nutrients to the tissues. On the reverse side of the cycle, DIC can increase bleeding. The body uses up so many of the blood clotting proteins for the multiple blood clots in the blood vessels that there are not enough left to clot the blood elsewhere. Several medical conditions can cause DIC, including sepsis. DIC affects about 35% of patients who have sepsis. Sepsis, which was often called blood poisoning, is the body's life-threatening response to infection. Like strokes or heart attacks, sepsis is a medical emergency that requires rapid diagnosis and treatment. (Sepsis Alliance, Sepsis and Disseminated Intravascular Coagulation. 2023. https://www.sepsis.org/sepsisand?disseminated-intravascular-coagulation-dic/) On [DATE] at 11:23 a.m. an interview was conducted with Staff Q, CNA (Certified Nursing Assistant). The CNA stated she remembered Resident #404 and she provided care for him often. She stated a FM came to see the resident almost every day. She stated she remembered the resident vomiting a lot and bleeding from the dressings. She stated the resident always asked for pain medications. She stated she would clean up the resident and empty his urinal because he would vomit in it. She stated she always reported vomiting to the nurse, but she did not document that in the medical record because there is no place for them to do that, she stated she left that for the nurse to do. She stated she did recall him having bleeding and vomiting before he went to the hospital, and she told the nurse, but she does not recall if the nurse went in to check on the resident. She described the bleeding and vomiting as dark brown. She stated the only reasons Resident #404 would call was to be changed, have his dressings changed, vomiting, or taking pain pills. On [DATE] at 8:07 p.m. an interview was conducted with a Family Friend (FF), who would transport the FM to and from the facility and visit with Resident #404. The FF stated he would take the FM to visit Resident #404 nearly every day and he was present at the facility on [DATE] the weekend before Resident #404 passed away. He stated when he saw Resident #404 on the evening of [DATE] the resident was coherent and he had bruises all over, blood on his sheets, and blood on the walls in his room. He stated he and the FM where in the room with Resident #404 for about an hour and a half. The FF stated he got the resident a glass of water, but the resident was not able to keep it down and he was throwing up blood. He stated they informed the nurses. The FF stated if the resident took a drink of water he would throw up blood in less than a minute and it was dark red. The FF stated Resident #404 asked him to take him to the hospital to avoid getting charged any money and he told him he couldn't take him because of his medical needs. The FF stated he went to the hallway and told a lady nurse that Resident #404 was throwing up blood and she was just like oh ok. He stated the nurse did not go to the room to see what was going on. He stated he has really tried to block the whole incident out of his memory. A review of the facility policy titled Anticoagulant Therapy, revised on [DATE], revealed the following: Procedure: -Obtain physician's order for anticoagulant therapy and labs. -Alert lab -Initiate anticoagulant flow sheets or electronic equivalent -Post lab results on flow sheet or electronic equivalent, indicating date -Identify resident and explain therapy -Perform hand hygiene -Document the time, dose administration on MAR and anticoagulant flow sheet/ electronic equivalent -Monitor the resident for signs of bleeding. *Observe for hematoma development or excessive bleeding or bruising. *Test stool, urine, emesis for Guaiac/Hemoccult as ordered by physician. *Monitor labs per physician's order. *Use pressure-dressing PRN until bleeding stops. *Perform hand hygiene. *Document in the medical record. Note-Residents requiring Coumadin (Warfarin) administration should have lab work drawn as ordered by the physician to determine effectiveness of therapy and subsequent dosages. A review of the facility policy titled Notification of Change in Condition, revised on [DATE], revealed the following: Policy: The Center to promptly notify the Patient/Resident, the attending physician, and the Resident Representative when there is a change in the status or condition. Procedure: -The nurse to notify the attending physician and Resident Representative when there is a(n): *Accidents *Significant change in the patient/resident's physical, mental, or psychosocial status *Need to alter treatment significantly -New treatment -Discontinuation of a current treatment due to but not limited to: *Adverse consequences *Acute condition *Exacerbation of a chronic condition *A transfer or discharge of the Patient/Resident from the Center *Patient/Resident consecutively refuses medication and/or treatment (i.e. two or more times) *Patient/Resident is discharged without proper medical authority -In the event of an emergency situation, 911 to be called and the attending physician and the Resident Representative to be notified as soon as possible. -The nurse to complete an evaluation of the Patient/Resident. Document evaluation in the medical record. -The nurse will contact the physician. In the event that the attending physician does not respond in a reasonable amount of time, the Medical Director may be contacted. -If the Medical Director does not respond, call 911 and document in the medical record. -Notify the patient/resident and the resident representative of the change in condition. Document notification in the medical record. -Document resident/patient change in condition on 24 hour report -Complete SBAR as indicated 2. On [DATE] at 10:33 a.m. Resident #248 was observed lying in a geriatric chair by the entrance to the courtyard and facing the nurses' station. On [DATE] at 12:33 p.m. Resident #248 was observed upright in a geriatric chair with a family member assisting him with his meal. On [DATE] at 03:05 p.m. an interview was conducted with Resident #248's. The family member said Resident #248 likes to sleep in a quiet area and he is always placed by the nurses' station which is noisy. On [DATE] at 8:32 a.m. an interview and observation was conducted with Resident #248. Resident #248 was sitting in a geriatric chair facing the nurses' station. He said he does not necessarily like sitting at the nurses' station I would rather go to my bed A review of Resident #248's admission records showed he was admitted to the facility on [DATE], with diagnoses to include traumatic brain injury, Parkinson's Disease, dementia, and seizures. Review of Resident #248's five-day Minimum Data Set (MDS), dated [DATE], Section C- Cognitive Patterns revealed a Brief Interview for Mental Status (BIMS) score of four indicating severe cognitive impairment. A review of Resident #248's order summary report, dated [DATE] showed orders to include: full activity and may have restorative/ maintenance program as indicated. A review of Resident #248's active care plan, initiated [DATE], showed the resident had an actual fall with minor injury related to unsteady gait. The interventions include place resident in common areas, initiated [DATE]. On [DATE] at 12:16 p.m. an interview was conducted with the Director of Rehabilitation (DOR) he said the use of geriatric chairs can decrease resident function .and it is not an ideal intervention to prevent falls. On [DATE] at 1:39 p.m. an interview was conducted with Staff G, Licensed Practical Nurse (LPN) Resident #248's nurse. Staff G, LPN said the use of the geriatric chair is because Resident #248 is a fall risk and can get up from the chair when the footrest is lowered. Staff G confirmed Resident # 248 cannot independently get out the geriatric chair. On [DATE] at 2:40 p.m. an interview was conducted with the Director of Nursing (DON), she said resident #248 was placed in the geriatric chair for comfort. The DON said the geriatric chair's restriction on Resident #248, it did not cross my mind and is not ideal. On [DATE] at 8:00 p.m. Resident #248 was observed with eyes closed and laying in a geriatric chair facing the nurses' station. On [DATE] at 08:15 a.m. Resident #248 was observed with eyes closed and laying in a geriatric chair facing the nurses' station. A review of the facility policy titled Abuse, Neglect, Exploitation & Misappropriation, revised on [DATE], revealed the following: Policy: It is inherent in the nature and dignity of each resident that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation and/or misappropriation of property. The management of the facility recognizes these rights and hereby establishes the following statements, policies, and procedures to protect these rights and to establish a disciplinary policy, which results in the fair and timely treatment of occurrences of resident abuse. Employees of the center are charged with a continuing obligation to treat residents, so they are free from abuse, neglect, mistreatment and/or misappropriation of property. No employee may at any time commit an act of physical, psychological, or emotional abuse, neglect, mistreatment, and/or misappropriation of property against any resident. Violation of this standard will subject employees to disciplinary action, including dismissal, provided herein. [ .] Neglect is the failure of the center, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Examples include but are not limited to: -Failure to provide adequate nutrition and fluids. -Failure to take precautionary measures to protect the health and safety of the resident. -Intentional lack of attention to physical needs including, but not limited to, toileting and bathing. Failure to provide services that result in harm to the resident, such as not turning a bedfast resident or leaving a resident in a soiled bed. -Failure or refusal to provide a service for the purpose of punishing or disciplining a resident, unless withholding of a service is being used as part of a documented integrated behavioral management program. -Failure to notify a resident's legal representative in the event of a significant change in the resident's physical, mental or emotional condition that a prudent person would recognize. -Failure to notify a resident's legal representative in the event of an incident involving the resident, such as failure to report a fall or conflict between residents that result in injury or possible injury. -Failure to report observed or suspected abuse, neglect or misappropriation of resident property to the proper authorities. -Failure to adequately supervise a resident known to wander from the facility without the staff knowledge. Note: Such things as failure to comb a resident's hair on occasion would not necessarily constitute a reportable incidence of neglect. However, continued omission in providing daily care and/or failure to address and resolve the omission could constitute neglect. [ .] Involuntary seclusion is defined as separation of the resident from his/her room or confinement to his/her room (with or without roommates) against the resident's will, or the will of the resident representative. [ .] Procedure: [ .] Non-action, which results in emotional, psychological, or physical injury, is viewed in the same manner as that caused by improper or excessive action. All actions in which employees[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice related to 1) a failure to communicate a significant change of condition to other licensed nurses and the physician, resulting in a delay of treatment for one resident (#404) out of seven residents sampled; 2) a failure to implement physician orders related to vital signs monitoring for one resident (#94) out of seven residents sampled and, 3) a failure to recognize and respond to a change in condition related to hypotension for one resident (#401) out of seven residents sampled. Resident #404 experienced a change of condition secondary to bleeding from four skin wounds on his arms and legs, which began on [DATE] at 1:00 p.m. The bleeding required four dressing changes to the upper extremities and two dressing changes to the lower extremities due to bleeding through the dressings over the course of 17 hours. On [DATE] at 7:25 a.m. Resident #404 was transferred to the hospital and subsequently died from widespread sepsis and bleeding caused by DIC (disseminated intravascular anticoagulation [a rare but serious condition that causes abnormal blood clotting throughout the body's blood vessels]). The resident was not provided professional standards of care and services to benefit from earlier assessment and treatment from a higher level of care. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Resident #404 and resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to a D after verification of removal of immediacy of harm. Findings included: 1. On [DATE] at 4:15 p.m. an interview was conducted with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) to review a reportable incident for Resident #404. The DON stated she was familiar with Resident #404, and she could speak to the investigation conducted at the time of the incident. The DON stated a family member complaint was received on social media. The DON stated they investigated and did not find any problem with the care. The DON stated Resident #404 was not compliant with care and had displaced a wound vac. She stated Resident #404 was in and out of the hospital and the last time he was sent to the hospital he passed away. The DON stated Resident #404 was sent to the hospital due to bleeding, and he had saturated the dressings on his arms. The DON stated the resident was on Eliquis as a blood thinner, and the family member complained that the resident was not sent to the hospital soon enough. A review of the medical record revealed Resident #404 was admitted on [DATE] with diagnoses, including but not limited to, cerebral infarction due to thrombosis of right middle cerebral artery, chronic pancreatitis, unspecified open wounds to left ankle, neck, right lower leg, right thigh, left hip, left lower leg, lower back, and pelvis without penetration to retroperitoneum, unspecified atrial fibrillation, gastrostomy status, unspecified gastrointestinal hemorrhage, unspecified anemia, and unspecified coagulation defect. A review of the Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #404 had a Brief Interview of Mental Status (BIMS) score of 14, indicating intact cognition. A review of the Order Summary Report for Resident #404 revealed the following: [DATE] Full Code. [DATE] Labs: CBC (complete blood count), CMP (comprehensive metabolic profile) one time only for admission labs for one day. [DATE] Aspirin 81 tablet chewable 81 MG (milligrams) give one tablet by mouth one time a day for DVT (deep vein thrombosis) prevention. [DATE] Eliquis oral tablet 5 MG (Apixaban) give one tablet by mouth two times a day for coagulopathy. [DATE] Furosemide oral tablet 80 MG give one tablet by mouth two times a day for pleural effusion. [DATE] Left hip cleanse with normal saline, silver nitrate dampened gauze, and place border dressing every day shift every Tuesday and Friday for wound. [DATE] Left lateral ankle change wound vac every Tuesday and Friday, apply black granulofoam, set section to 125 MMHG (millimeters/mercury) every day shift every Tuesday and Friday for wound. [DATE] Mid thoracic back cleanse with normal saline, xeroform, and place border dressing every day shift for wound. [DATE] Right heel cleanse with normal saline, apply skin prep, leave open to air every day shift every other day for DTI (deep tissue injury). [DATE] Left lateral ankle change wound vac, apply black granulofoam, set suction to 125 MMHG one time only for wound care for one day. [DATE] Right heel cleanse with normal saline, apply skin prep, leave open to air every night shift every other day to DTI. [DATE] Mid thoracic back cleanse with normal saline, xeroform, and place border dressing every night shift for wound. [DATE] Left ischium cleanse with normal saline, apply medihoney, then cover with mepilex every day shift every other day for wound care. [DATE] Left lateral ankle and mid back change wound vac every Monday and Thursday, apply black granulofoam, set suction to 125 MMHG, connect with Y-tubing every day shift every Monday and Thursday for wound. [DATE] Cleanse skin tear to left elbow apply TAO (triple antibiotic ointment) and DSD (dry sterile dressing) until healed then discontinue every night shift for skin tear care. [DATE] Cleanse skin tear to upper leg apply TAO and DSD until healed then discontinue every night shift for skin tear care. [DATE] Zofran oral tablet 4 MG (Ondansetron) give one table by mouth every six hours as needed for nausea/vomiting. [DATE] CBC, CMP one time only for bleeding for one day. [DATE] Send to ER (emergency room) for evaluation one time only for bleeding for one day. A review of the Comprehensive Care Plan, initiated on [DATE], for Resident #404 revealed the following: Focus: The resident is on anticoagulant/anti-platelet therapy related to atrial fibrillation and CVA (cardiovascular accident). Revision [DATE]. Goal: The resident will be free from discomfort or adverse reactions related to anticoagulant use through the review date. Interventions: Administer anticoagulant medications as ordered by physician. Monitor for side effects and effectiveness every shift. Daily skin inspection. Report abnormalities to the nurse. Monitor/document/report as needed adverse reactions of anticoagulant therapy: blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs. Focus: The resident has a skin tear to left elbow and left leg. Initiated on [DATE]. Goal: The resident's skin tear will show signs of healing by review date. Interventions: Monitor/document location, size, and treatment of skin tear. Report abnormalities. A review of the Progress Notes for Resident #404 revealed the following: -[DATE] 10:17 a.m. Physician progress note: Patient is seen today for follow-up visit. It was reported by staff that he had a fall last night and hit his head. He was sitting on the side of the bed and was trying to position himself back to lying down when he fell over. He did not ask for help or use call light. Patient states he was having hallucinations and confused after he hit his head. The incident was not reported until this morning. Patient is on Eliquis and Aspirin, so he was sent out to the ER for a CT (computed tomography scan) of the head. He did receive multiple skin tears on his arm and leg. He also has a bruise/redness on his face. -[DATE] 10:50 a.m. Nursing progress note: Resident heard calling out, resident observed on side of bed holding onto bed on right side and bedside table to the left side. Resident was in between. Resident assisted back to bed and care provided. ROM [range of motion] WNL [within normal limits]. No s/s [signs/symptoms] of acute distress. Routine pain med given, and wound care provided to skin tears. -[DATE] 7:51 a.m. Nursing progress note: Patient observed to have dislodged/saturated dressing to LUE [left upper extremity] at start of shift, changed patients dressing per physicians order. after receiving PM [evening] medications dressings observed to be saturated again, cleaned wounds to LUE and R [right] forearm and applied ABD [abdominal] pads with krelix [sig] and ace wrap on top to apply pressure. Patient c/o [complains of] nausea and prior emesis,, administer PRN [as needed] Zofran to good effect. Notified physician at 2130 of patients saturation of dressings and treatment applied. Physician ordered for dressing to stay in place until am then to be removed for assessment and CBC to be drawn on [DATE]. At approximately 0630 dressing was removed with some saturation through the ace wrap with the gauze noted to be heavily saturated. Notified physician and received order to send to ER to evaluation and to control bleeding .Called 911 at 0714 upon entering room at approximately 0725 with EMS [emergency medical services] patient had emesis in container dark brown with some red noted approximately 100 ML [milliliter] in container, Resident left facility with EMS at approximately 0730 via stretcher, notified patients emergency contact A review of the Treatment Administration Record (TAR), dated [DATE]-[DATE], for Resident #404 revealed the following: Cleanse Skin tear to left elbow apply TAO and DSD until healed every night shift for skin tear documented as completed once on [DATE]. Cleanse skin tear to left upper leg apply TAO and DSD until healed every night shift for skin tear care documented as completed once on [DATE]. A review of the Medication Administration Record (MAR), dated [DATE]-[DATE], for Resident #404 revealed the following: Aspirin 81 MG give one tablet by mouth one time a day for DVT prevention documented as administered on [DATE] at 9:00 a.m. Eliquis oral tablet 5 MG give one tablet by mouth two times a day for coagulopathy documented as administered on [DATE] at 9:00 a.m. and 5:00 p.m. Furosemide oral tablet 80 MG give one tablet by mouth two times a day for pleural effusion documented as administered on [DATE] at 9:00 a.m. and 5:00 p.m. Zofran oral tablet 4 MG give one tablet by mouth every six hours as needed for N/V not documented as given on [DATE]. On [DATE] at 5:49 p.m., a telephone interview was conducted with a Family Member (FM) of Resident #404. The FM stated Resident #404 transferred from the hospital to the facility in March and seemed to be getting better. The FM stated the resident went to the hospital for an abscessed tooth. The FM stated she went to see Resident #404 every day and stayed with him all day long at the facility. The FM stated she would have a good friend drive her there and pick her up. The FM stated on [DATE] she escorted the resident to the courtyard to smoke and when she put her hand on the handle of the wheelchair she picked up her hand to find it full of blood. She stated that was a few days before Resident #404 died. The FM stated the resident was bleeding from his leg, arm, and shoulder area. The FM stated the shoulder was sopping with blood, and she took the dressing off and went in to the facility to get someone to put something over the area. The FM stated the nurse started yelling at Resident #404 for taking off the dressing. She stated then someone came in and put a dressing on the area. The FM stated she had seen the Resident #404 throwing up blood during the day in his urinal. The FM stated she went to the nursing station and asked the nurse to please call EMS and get an ambulance to come. The FM stated when she told the nurse Resident #404 was bleeding out the staff all started laughing and said they wouldn't let him bleed out. She stated the nurse never went down to check on the resident at all. She stated her friend was with Resident #404 in the room and saw him take two sips of water and throw up blood in the urinal. The FM stated it was close to 7pm [DATE], the day before he went to the hospital. The FM stated the next morning she got a call from a man who said he sent Resident #404 to the hospital because he was bleeding out. The FM stated when she got to the hospital, Resident #404 was on life support, and they had to keep giving him blood. The FM stated the nurse never left the nurse's station the night she was there to go in and check on Resident #404 from the time she asked for the resident to go to the hospital until the time she left the facility. On [DATE] at 07:06 p.m., an interview was conducted with Staff A, Licensed Practical Nurse (LPN). She stated she remembers the resident, and mentioned the mother visited daily. She confirmed she was the assigned nurse to Resident #404 on [DATE] day shift a.m. to 7 p.m. She stated she remembered he was bleeding while in the courtyard with his FM. She stated the resident told her he took his bandages off so he could let them breathe. She stated after he returned inside the facility, she applied dressings to both upper extremities. Staff A stated she informed the oncoming nurse for the night shift. She stated during her shift she changed the dressings twice because of visible blood and saturation through the dressings. She stated she used a kerlix roll dressing. She stated she thought she changed it around 1-2 p.m., then prior to shift change at 7 p.m. it needed to be changed again. She stated the FM was on the patio with the resident while he was smoking. Staff A stated she let the night nurse know Resident #404 was bleeding from his arms. She stated she reported she had re-wrapped the arms. She stated it was unusual to have to change the dressings twice. She stated she did not call the doctor. She stated Resident #404 had quite a few wounds and she had changed one on his leg and his wound vac. She stated the wound vac had quite a bit of drainage and had an odor to it. She stated she did not recall any nausea or vomiting. She stated she really was not thinking about the resident being on blood thinners. She stated she did not make any notes, do a change of status, or notify the doctor of the need to change dressings due to bleeding. On [DATE] at 7:29 p.m., an interview was conducted with Staff O, RN (Registered Nurse, Unit Manager). She stated Resident #404 was admitted from the hospital but unable to recall the specifics of his admission. She stated Resident #404 had a lot of different wounds. She said his FM visited almost every day. She stated she knew the resident was sent out for a bleed. She stated she was told there were allegations of neglect because of an on-line review. She stated she did not participate in the investigation and stated abuse investigations are generally completed by the DON/NHA. She stated the nurses are expected to document changes in condition and notify the physician in the medical record. She stated if a resident's family asked for them to be sent to the hospital the nurses are supposed to do so and let the doctor know what is happening. On [DATE] at 9:22 a.m., an interview was conducted with Staff P, LPN (Licensed Practical Nurse). He stated he knew Resident #404 had falls, skin tears and could be grumpy, but did not recall Resident #404's plan of care. He stated Resident #404 had dressings all over, had a lot of skin tears, and a wound vac to his sacrum. The nurse stated in report he was told while the FM visited with the resident in the courtyard, the resident was picking at his dressings, and (Staff A) told him she had just changed his dressings. He stated he did not recall (Staff A) saying that was the second time she had to change the dressings. He stated, After report around 7:45 p.m., I saw the dressing on his left arm was not really on but the mepilex dressing had some bleeding on it. I'm not sure who transferred the resident back to bed but there was some blood smeared on the wall by his bed. I changed the dressings to his arms and legs all at once and cleaned the blood off the wall. When giving him his night meds [9:00 p.m.], I saw the dressings on his upper arms were saturated and the current dressing was not appropriate for the amount of bleeding. The dressing was red in color. The dressing to his legs were not saturated. I changed the dressings on his legs. I applied ABD, Kerlix and pressure dressings to his arms. I changed all the dressings [legs and arms] to have a timeline of how much he was bleeding. I used gauze pads on his legs, because they were absorbent and easy to see changes. I notified the MD about 9:30 p.m. and he said to leave the dressings in place and draw a CBC [[DATE]] and leave those dressings in place until the morning and then to remove them for assessment. I rounded on him to make sure there was no visible bleeding throughout the shift. The nurse stated he did not remove the ace wrap during the night to keep pressure on the arms. He stated about 6:00 a.m. he removed the ace wrap and saw the wound had bled through to the ace and Resident #404 told him he had vomited on the prior shift. Staff P, LPN stated the previous nurse had not reported the resident had vomited. On [DATE] at 11:02 a.m. an interview was conducted with the Primary Care Physician (PCP) for Resident #404. The PCP stated he did not recall specifically being notified about Resident #404 on [DATE]. He stated if he was notified for the first time that a resident was having a bleeding episode he would have told them to monitor and apply a pressure dressing. He stated he did not recall being contacted during the day shift about any bleeding the resident was having. He stated if he was told of previous episodes of bleeding and multiple changes of dressings he would have told them to send the resident out to be evaluated. He stated it was not ideal that the nurses did not notify him of multiple dressing changes, and he would have expected them to report any vomiting of blood as well. The PCP stated if he had been aware of the bleeding wounds and vomiting blood, he would have sent him out. He stated what he was told was not the same as what occurred. He stated his partner admitted Resident #404 to the hospital and the resident died of sepsis with complications. He stated the resident had fungus in the blood cultures. He stated he reviewed the chart in the hospital and Resident #404 had DIC, his platelets dropped, and the resident passed away. He stated he usually investigates the reason if a resident passes away because he wants to know what happened. Disseminated intravascular coagulation, or DIC, is a complicated condition that can occur when someone has severe sepsis or septic shock. Both blood clotting and difficulty with clotting may occur, causing a vicious cycle. Small blood clots can develop throughout your bloodstream, especially in the microscopic blood vessels called capillaries. This blocks the blood flow to many parts of your body, including your limbs and your organs. Blood is then not able to bring oxygen and nutrients to the tissues. On the reverse side of the cycle, DIC can increase bleeding. The body uses up so many of the blood clotting proteins for the multiple blood clots in the blood vessels that there are not enough left to clot the blood elsewhere. Several medical conditions can cause DIC, including sepsis. DIC affects about 35% of patients who have sepsis. Sepsis, which was often called blood poisoning, is the body's life-threatening response to infection. Like strokes or heart attacks, sepsis is a medical emergency that requires rapid diagnosis and treatment. (Sepsis Alliance, Sepsis and Disseminated Intravascular Coagulation. 2023. https://www.sepsis.org/sepsisand?disseminated-intravascular-coagulation-dic/) On [DATE] at 11:23 a.m. an interview was conducted with Staff Q, CNA (Certified Nursing Assistant). The CNA stated she remembered Resident #404 and she provided care for him often. She stated a FM came to see the resident almost every day. She stated she remembered the resident vomiting a lot and bleeding from the dressings. She stated the resident always asked for pain medications. She stated she would clean up the resident and empty his urinal because he would vomit in it. She stated she always reported vomiting to the nurse, but she did not document that in the medical record because there is no place for them to do that, she stated she left that for the nurse to do. She stated she did recall him having bleeding and vomiting before he went to the hospital, and she told the nurse, but she does not recall if the nurse went in to check on the resident. She described the bleeding and vomiting as dark brown. She stated the only reasons Resident #404 would call was to be changed, have his dressings changed, vomiting, or taking pain pills. On [DATE] at 8:07 p.m. an interview was conducted with a Family Friend (FF), who would transport the FM to and from the facility and visit with Resident #404. The FF stated he would take the FM to visit Resident #404 nearly every day and he was present at the facility on [DATE] the weekend before Resident #404 passed away. He stated when he saw Resident #404 on the evening of [DATE] the resident was coherent and he had bruises all over, blood on his sheets, and blood on the walls in his room. He stated he and the FM where in the room with Resident #404 for about an hour and a half. The FF stated he got the resident a glass of water, but the resident was not able to keep it down and he was throwing up blood. He stated they informed the nurses. The FF stated if the resident took a drink of water he would throw up blood in less than a minute and it was dark red. The FF stated Resident #404 asked him to take him to the hospital to avoid getting charged any money and he told him he couldn't take him because of his medical needs. The FF stated he went to the hallway and told a lady nurse that Resident #404 was throwing up blood and she was just like oh ok. He stated the nurse did not go to the room to see what was going on. He stated he has really tried to block the whole incident out of his memory. A review of the facility policy titled Anticoagulant Therapy, revised on [DATE], revealed the following: Procedure: -Obtain physician's order for anticoagulant therapy and labs. -Alert lab -Initiate anticoagulant flow sheets or electronic equivalent -Post lab results on flow sheet or electronic equivalent, indicating date -Identify resident and explain therapy -Perform hand hygiene -Document the time, dose administration on MAR and anticoagulant flow sheet/ electronic equivalent -Monitor the resident for signs of bleeding. *Observe for hematoma development or excessive bleeding or bruising. *Test stool, urine, emesis for Guaiac/Hemoccult as ordered by physician. *Monitor labs per physician's order. *Use pressure-dressing PRN until bleeding stops. *Perform hand hygiene. *Document in the medical record. Note-Residents requiring Coumadin (Warfarin) administration should have lab work drawn as ordered by the physician to determine effectiveness of therapy and subsequent dosages. 2. A review of the medical record revealed Resident #94 was admitted to the facility with diagnoses including pulmonary fibrosis, unspecified, acute respiratory failure with hypoxia, acute respiratory failure hypercapnia, Chronic Obstructive Pulmonary Disease (COPD), unspecified, emphysema, unspecified, pneumoconiosis due to other dust containing silica, shortness of breath (SOB), obstructive sleep apnea, pneumothorax, unspecified. A review of Resident #94's admission Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 14, indicating intact cognition. A review of the Comprehensive Care Plan, dated [DATE], for Resident #94 revealed the following: Focus: The resident has emphysema/COPD r/t (related to) exposure to industrial pollutants. Goals: Resident will be free of signs/symptoms of respiratory infections through review date. Interventions: Give aerosol or bronchodilators as ordered; Monitor/ document and side effect and effectiveness; Head of the bed elevated or out of bed upright in a chair during episodes of difficulty breathing; Monitor for difficulty breathing (dyspnea) on exertion; Remind resident not to push beyond endurance; Monitor for signs and symptoms of acute respiratory insufficiency: anxiety, confusion, restlessness, shortness of breath at rest, cyanosis, somnolence; Monitor/document/report as needed any signs/symptoms of respiratory infection. Focus: The resident has altered respiratory breathing status/difficulty breathing related to sleep apnea. Goals: The resident will have minimal risk of complications related to SOB. Interventions: Administer medication/puffers as ordered; Monitor for effectiveness and side effects; Monitor/document changes in orientation, increased restlessness, anxiety and air hunger; Monitor for signs/symptoms of respiratory distress and report to doctor as needed. A review of progress notes, dated [DATE] at 08:09:00, revealed a nursing progress note as follows: Certified nursing assistant (CNA) assigned to client called this writer to assess client. This writer observed client lying in semi-Fowlers position and oxygen continues at 3 liters per minute via nasal cannula unresponsive. This writer checked for pulse; no pulse noted. CPR [cardiopulmonary resuscitation] was initiated, and this writer called out to another nurse to call 911. CPR continued till EMS's [emergency medical services] arrived. CPR was terminated @0355. MD [medical doctor] and clients POA [power of attorney] was notified @0400 and new orders received to release body. A review of physician orders for Resident #94 revealed an order for vital signs every day shift. The order was to begin on [DATE], there was no end date listed. An order for full code with a start date of [DATE], and end date of [DATE] A review of the medical record revealed under the weights/ vital sign tab only pulse oximetry and respirations were recorded between [DATE] and [DATE]. An interview was conducted on [DATE] at 01:00 PM with the Director of Nursing (DON). She stated vital signs should be documented in the weight/vital signs tab, or in progress notes, and in nursing assessments. She stated the vital signs (V/S) may show up in the POC (point of care) if the CNA (Certified Nursing Assistant) puts them in. The DON stated the orders for the V/S are part of a batch order and should be followed by nursing. The DON confirmed there were no VS taken as ordered from 4-20-24 through 4-26-24. A review of the code sheet, dated [DATE], revealed no vital signs were listed on the document. A review of the facility policy titled Physician Orders, revised on [DATE], revealed the following: Policy: The center will ensure that Physician orders are appropriately and timely documented in the medical record. Procedure: admission ORDERS: Information received from the referring facility or agency to be reviewed, verified with the physician and transcribed to the electronic medical record. The attending physician will review and confirm orders. Confirmation of admission orders requires that the physician sign and date the order during, or as soon as practicable after it is provided, to maintain an accurate medical record. ROUTINE ORDERS: A Nurse may accept a telephone order from the Physician, Physician Assistant or Nurse Practitioner (as permitted by state law). The order will be repeated by the physician, PA or ARNP for his/her verbal confirmation. The other is transcribed to all appropriate areas of the electronic health record (eMAR/eTAR). For pharmacy orders, the nurse will notify the pharmacy per pharmacy policy by telephoning, faxing or completing the order electronically. The ordering physician or physician extender will review and confirm orders. Confirmation of routine orders requires that the physician sign and date the order as soon as practicable after it is provided to maintain an accurate medical record. 3. Resident #401 was admitted to the facility on [DATE] with diagnoses including unspecified peritonitis, essential hypertension, Type 2 Diabetes Mellitus without complications, unspecified chronic kidney disease stage 3, acute appendicitis with localized peritonitis without perforation or gangrene, cognitive communication deficit, unsteadiness on feet, and need for personal assistance with personal care. Resident #401 was discharged to a higher level of care [hospital] on [DATE]. A review of the physician orders for Resident #401 revealed the following: -Lisinopril -Hydrochlorothiazide oral tablet 20-25 milligrams(mg) to give one tablet by mouth one time a day for hypertension. -Carvedilol oral tablet 12.5 mg to give one tablet by mouth two times a day for hypertension. -Monitor vital signs every shift. On [DATE] during the day shift, Resident #401's blood pressure was documented as 100/60 mmHg (millimeters of Mercury). A review of the Medication Administration Record (MAR), [DATE], showed Lisinopril-Hydrochlorothiazide and the Carvedilol were administered as scheduled at 09:00 a.m., and Carvedilol was administered as scheduled at 5:00 p.m. A review of Resident #401's progress note, dated [DATE] at 2:39 p.m., showed the following: Resident up for PT (Physical Therapy), resident BP 110 / 67 before PT interaction. [Staff R, Speech Therapist], to give resident fluids previous to PT to ensure swallowing capabilities intact, [Staff S, Physical Therapist] returned patient, resident BP 117 / 72 per [Staff S]. PT reported resident did well in PT, report given to oncoming nurse to ensure residents stay hydrated and eats dinner, also advised oncoming nurse to check BP to ensure patient is not hypotensive. A review of occupational therapy notes, dated [DATE] at 2:59 p.m., showed Client required maximal assist for all bed mobility. She required Hoyer lift into the chair. Attempted to get patient to hold head up and follow verbal directive to sit, lean forward, however she required total assist. A review of physical therapy notes, dated [DATE] at 4:43 p.m., showed Resident #401 participating in therapy. Patient limited with minimal active muscle engagement with bilateral lower extremity therapeutic exercises with maximal performance cuing, assist to complete each. Blood pressure reading have been in a lower range per nursing, and they are aware of functional decline since evaluation. A review of speech therapy notes, dated [DATE] at 5:38 p.m., showed Patient required moderate to maximal cues to follow simple commands and answer simple questions. Patient noted to be lethargic, which nursing noted. Patient was able to indicate personal information independently however response time was increased. A review of the Change of Condition document, dated [DATE] at 6:45 p.m., showed the following: -altered level of consciousness -blood pressure of 71/38 mmHg -summary: This nurse entered pt. (patient) room and observed pt. not behaving in her usual self and difficult to arouse. Vital signs taken B/P 71/38, P-88, temperature 97.7, unable to take O2 (oxygen) sat (saturation) at this moment. The physician was notified at 6:45 p.m. with instructions to call 911. Family member notified on [DATE] at 6:51 p.m. A review of the facility policy titled Notification of Change in Condition, revised on [DATE], revealed the following: Policy: The Center to promptly notify the Patient/Resident, the attending physicia[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure there were competent staff to provide nursing services in order to assure resident safety and well-being for three residents (#404, #94, and #401) out of seven residents sampled. Findings included: 1. A review of the medical record revealed Resident #404 was admitted on [DATE] with diagnoses, including but not limited to, cerebral infarction due to thrombosis of right middle cerebral artery, chronic pancreatitis, unspecified open wounds to left ankle, neck, right lower leg, right thigh, left hip, left lower leg, lower back, and pelvis without penetration to retroperitoneum, unspecified atrial fibrillation, gastrostomy status, unspecified gastrointestinal hemorrhage, unspecified anemia, and unspecified coagulation defect. A review of the Order Summary Report for Resident #404 revealed the following: [DATE] Full Code. [DATE] Labs: CBC (complete blood count), CMP (comprehensive metabolic profile) one time only for admission labs for one day. [DATE] Aspirin 81 tablet chewable 81 MG (milligrams) give one tablet by mouth one time a day for DVT (deep vein thrombosis) prevention. [DATE] Eliquis oral tablet 5 MG (Apixaban) give one tablet by mouth two times a day for coagulopathy. [DATE] Cleanse skin tear to left elbow apply TAO (triple antibiotic ointment) and DSD (dry sterile dressing) until healed then discontinue every night shift for skin tear care. [DATE] Cleanse skin tear to upper leg apply TAO and DSD until healed then discontinue every night shift for skin tear care. [DATE] Zofran oral tablet 4 MG (Ondansetron) give one table by mouth every six hours as needed for nausea/vomiting. [DATE] CBC, CMP one time only for bleeding for one day. [DATE] Send to ER (emergency room) for evaluation one time only for bleeding for one day. A review of the Comprehensive Care Plan, initiated on [DATE], for Resident #404 revealed the following: Focus: The resident is on anticoagulant/anti-platelet therapy related to atrial fibrillation and CVA (cardiovascular accident). Revision [DATE]. Goal: The resident will be free from discomfort or adverse reactions related to anticoagulant use through the review date. Interventions: Administer anticoagulant medications as ordered by physician. Monitor for side effects and effectiveness every shift. Daily skin inspection. Report abnormalities to the nurse. Monitor/document/report as needed adverse reactions of anticoagulant therapy: blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs. Focus: The resident has a skin tear to left elbow and left leg. Initiated on [DATE]. Goal: The resident's skin tear will show signs of healing by review date. Interventions: Monitor/document location, size, and treatment of skin tear. Report abnormalities. A review of the Progress Notes for Resident #404 revealed the following: [DATE] 7:51 a.m. Nursing progress note: Patient observed to have dislodged/saturated dressing to LUE [left upper extremity] at start of shift, changed patients dressing per physicians order. after receiving PM [evening] medications dressings observed to be saturated again, cleaned wounds to LUE and R [right] forearm and applied ABD [abdominal] pads with krelix [sig] and ace wrap on top to apply pressure. Patient c/o [complains of] nausea and prior emesis,, administer PRN [as needed] Zofran to good effect. Notified physician at 2130 of patients saturation of dressings and treatment applied. Physician ordered for dressing to stay in place until am then to be removed for assessment and CBC to be drawn on [DATE]. At approximately 0630 dressing was removed with some saturation through the ace wrap with the gauze noted to be heavily saturated. Notified physician and received order to send to ER to evaluation and to control bleeding .Called 911 at 0714 upon entering room at approximately 0725 with EMS [emergency medical services] patient had emesis in container dark brown with some red noted approximately 100 ML [milliliter] in container, Resident left facility with EMS at approximately 0730 via stretcher, notified patients emergency contact A review of the Treatment Administration Record (TAR), dated [DATE]-[DATE], for Resident #404 revealed the following: Cleanse Skin tear to left elbow apply TAO and DSD until healed every night shift for skin tear documented as completed once on [DATE]. Cleanse skin tear to left upper leg apply TAO and DSD until healed every night shift for skin tear care documented as completed once on [DATE]. A review of the Medication Administration Record (MAR), dated [DATE]-[DATE], for Resident #404 revealed the following: Aspirin 81 MG give one tablet by mouth one time a day for DVT prevention documented as administered on [DATE] at 9:00 a.m. Eliquis oral tablet 5 MG give one tablet by mouth two times a day for coagulopathy documented as administered on [DATE] at 9:00 a.m. and 5:00 p.m. Zofran oral tablet 4 MG give one tablet by mouth every six hours as needed for N/V not documented as given on [DATE]. On [DATE] at 07:06 p.m., an interview was conducted with Staff A, Licensed Practical Nurse (LPN). She stated she remembers the resident, and mentioned the mother visited daily. She confirmed she was the assigned nurse to Resident #404 on [DATE] day shift a.m. to 7 p.m. She stated she remembered he was bleeding while in the courtyard with his FM. She stated the resident told her he took his bandages off so he could let them breathe. She stated after he returned inside the facility, she applied dressings to both upper extremities. Staff A stated she informed the oncoming nurse for the night shift. She stated during her shift she changed the dressings twice because of visible blood and saturation through the dressings. She stated she used a kerlix roll dressing. She stated she thought she changed it around 1-2 p.m., then prior to shift change at 7 p.m. it needed to be changed again. She stated the FM was on the patio with the resident while he was smoking. Staff A stated she let the night nurse know Resident #404 was bleeding from his arms. She stated she reported she had re-wrapped the arms. She stated it was unusual to have to change the dressings twice. She stated she did not call the doctor. She stated Resident #404 had quite a few wounds and she had changed one on his leg and his wound vac. She stated the wound vac had quite a bit of drainage and had an odor to it. She stated she did not recall any nausea or vomiting. She stated she really was not thinking about the resident being on blood thinners. She stated she did not make any notes, do a change of status, or notify the doctor of the need to change dressings due to bleeding. On [DATE] at 7:29 p.m., an interview was conducted with Staff O, RN (Registered Nurse, Unit Manager). She stated Resident #404 was admitted from the hospital but unable to recall the specifics of his admission. She stated Resident #404 had a lot of different wounds. She said his FM visited almost every day. She stated she knew the resident was sent out for a bleed. She stated she was told there were allegations of neglect because of an on-line review. She stated she did not participate in the investigation and stated abuse investigations are generally completed by the DON/NHA. She stated the nurses are expected to document changes in condition and notify the physician in the medical record. She stated if a resident's family asked for them to be sent to the hospital the nurses are supposed to do so and let the doctor know what is happening. On [DATE] at 9:22 a.m., an interview was conducted with Staff P, LPN (Licensed Practical Nurse). He stated he knew Resident #404 had falls, skin tears and could be grumpy, but did not recall Resident #404's plan of care. He stated Resident #404 had dressings all over, had a lot of skin tears, and a wound vac to his sacrum. The nurse stated in report he was told while the FM visited with the resident in the courtyard, the resident was picking at his dressings, and (Staff A) told him she had just changed his dressings. He stated he did not recall (Staff A) saying that was the second time she had to change the dressings. He stated, After report around 7:45 p.m., I saw the dressing on his left arm was not really on but the mepilex dressing had some bleeding on it. I'm not sure who transferred the resident back to bed but there was some blood smeared on the wall by his bed. I changed the dressings to his arms and legs all at once and cleaned the blood off the wall. When giving him his night meds [9:00 p.m.], I saw the dressings on his upper arms were saturated and the current dressing was not appropriate for the amount of bleeding. The dressing was red in color. The dressing to his legs were not saturated. I changed the dressings on his legs. I applied ABD, Kerlix and pressure dressings to his arms. I changed all the dressings [legs and arms] to have a timeline of how much he was bleeding. I used gauze pads on his legs, because they were absorbent and easy to see changes. I notified the MD about 9:30 p.m. and he said to leave the dressings in place and draw a CBC [[DATE]] and leave those dressings in place until the morning and then to remove them for assessment. I rounded on him to make sure there was no visible bleeding throughout the shift. The nurse stated he did not remove the ace wrap during the night to keep pressure on the arms. He stated about 6:00 a.m. he removed the ace wrap and saw the wound had bled through to the ace and Resident #404 told him he had vomited on the prior shift. Staff P, LPN stated the previous nurse had not reported the resident had vomited. On [DATE] at 11:23 a.m. an interview was conducted with Staff Q, CNA (Certified Nursing Assistant). The CNA stated she remembered Resident #404 and she provided care for him often. She stated a FM came to see the resident almost every day. She stated she remembered the resident vomiting a lot and bleeding from the dressings. She stated the resident always asked for pain medications. She stated she would clean up the resident and empty his urinal because he would vomit in it. She stated she always reported vomiting to the nurse, but she did not document that in the medical record because there is no place for them to do that, she stated she left that for the nurse to do. She stated she did recall him having bleeding and vomiting before he went to the hospital, and she told the nurse, but she does not recall if the nurse went in to check on the resident. She described the bleeding and vomiting as dark brown. She stated the only reasons Resident #404 would call was to be changed, have his dressings changed, vomiting, or taking pain pills. On [DATE] at 11:02 a.m. an interview was conducted with the Primary Care Physician (PCP) for Resident #404. The PCP stated he did not recall specifically being notified about Resident #404 on [DATE]. He stated if he was notified for the first time that a resident was having a bleeding episode he would have told them to monitor and apply a pressure dressing. He stated he did not recall being contacted during the day shift about any bleeding the resident was having. He stated if he was told of previous episodes of bleeding and multiple changes of dressings he would have told them to send the resident out to be evaluated. He stated it was not ideal that the nurses did not notify him of multiple dressing changes, and he would have expected them to report any vomiting of blood as well. The PCP stated if he had been aware of the bleeding wounds and vomiting blood, he would have sent him out. He stated what he was told was not the same as what occurred. He stated his partner admitted Resident #404 to the hospital and the resident died of sepsis with complications. He stated the resident had fungus in the blood cultures. He stated he reviewed the chart in the hospital and Resident #404 had DIC, his platelets dropped, and the resident passed away. He stated he usually investigates the reason if a resident passes away because he wants to know what happened. A review of the facility policy titled Anticoagulant Therapy, revised on [DATE], revealed the following: Procedure: -Obtain physician's order for anticoagulant therapy and labs. -Alert lab -Initiate anticoagulant flow sheets or electronic equivalent -Post lab results on flow sheet or electronic equivalent, indicating date -Identify resident and explain therapy -Perform hand hygiene -Document the time, dose administration on MAR and anticoagulant flow sheet/ electronic equivalent -Monitor the resident for signs of bleeding. *Observe for hematoma development or excessive bleeding or bruising. *Test stool, urine, emesis for Guaiac/Hemoccult as ordered by physician. *Monitor labs per physician's order. *Use pressure-dressing PRN until bleeding stops. *Perform hand hygiene. *Document in the medical record. Note-Residents requiring Coumadin (Warfarin) administration should have lab work drawn as ordered by the physician to determine effectiveness of therapy and subsequent dosages. 2. A review of the medical record revealed Resident #94 was admitted to the facility with diagnoses including pulmonary fibrosis, unspecified, acute respiratory failure with hypoxia, acute respiratory failure hypercapnia, Chronic Obstructive Pulmonary Disease (COPD), unspecified, emphysema, unspecified, pneumoconiosis due to other dust containing silica, shortness of breath (SOB), obstructive sleep apnea, pneumothorax, unspecified. A review of the Comprehensive Care Plan, dated [DATE], for Resident #404 revealed the following: Focus: The resident has emphysema/COPD r/t exposure to industrial pollutants. Goals: Resident will be free of signs/symptoms of respiratory infections through review date. Interventions: Give aerosol or bronchodilators as ordered; Monitor/ document and side effect and effectiveness; Head of the bed elevated or out of bed upright in a chair during episodes of difficulty breathing; Monitor for difficulty breathing (dyspnea) on exertion; Remind resident not to push beyond endurance; Monitor for signs and symptoms of acute respiratory insufficiency: anxiety, confusion, restlessness, shortness of breath at rest, cyanosis, somnolence; Monitor/document/report as needed any signs/symptoms of respiratory infection. Focus: The resident has altered respiratory breathing status/difficulty breathing related to sleep apnea. Goals: The resident will have minimal risk of complications related to SOB. Interventions: Administer medication/puffers as ordered; Monitor for effectiveness and side effects;; Monitor/document changes in orientation, increased restlessness, anxiety and air hunger; Monitor for signs/symptoms of respiratory distress and report to doctor as needed. A review of progress notes, dated [DATE] at 08:09:00, revealed a nursing progress note as follows: Certified nursing assistant (CNA) assigned to client called this writer to assess client. This writer observed client lying in semi-Fowlers position and oxygen continues at 3 liters per minute via nasal cannula unresponsive. This writer checked for pulse; no pulse noted. CPR [cardiopulmonary resuscitation] was initiated, and this writer called out to another nurse to call 911. CPR continued till EMS's [emergency medical services] arrived. CPR was terminated @0355. MD [medical doctor] and clients POA [power of attorney] was notified @0400 and new orders received to release body. A review of physician orders for Resident #94 revealed an order for vital signs every day shift. The order was to begin on [DATE], there was no end date listed. An order for full code with a start date of [DATE], and end date of [DATE] A review of the medical record revealed under the weights/ vital sign tab only pulse oximetry and respirations were recorded between [DATE] and [DATE]. An interview was conducted on [DATE] at 01:00 PM with the Director of Nursing (DON). She stated vital signs should be documented in the weight/vital signs tab, or in progress notes, and in nursing assessments. She stated the vital signs (V/S) may show up in the POC (point of care) if the CNA (Certified Nursing Assistant) puts them in. The DON stated the orders for the V/S are part of a batch order and should be followed by nursing. The DON confirmed there were no VS taken as ordered from 4-20-24 through 4-26-24. A review of the facility policy titled Physician Orders, revised on [DATE], revealed the following: Policy: The center will ensure that Physician orders are appropriately and timely documented in the medical record. Procedure: admission ORDERS: Information received from the referring facility or agency to be reviewed, verified with the physician and transcribed to the electronic medical record. The attending physician will review and confirm orders. Confirmation of admission orders requires that the physician sign and date the order during, or as soon as practicable after it is provided, to maintain an accurate medical record. ROUTINE ORDERS: A Nurse may accept a telephone order from the Physician, Physician Assistant or Nurse Practitioner (as permitted by state law). The order will be repeated by the physician, PA or ARNP for his/her verbal confirmation. The other is transcribed to all appropriate areas of the electronic health record (eMAR/eTAR). For pharmacy orders, the nurse will notify the pharmacy per pharmacy policy by telephoning, faxing or completing the order electronically. The ordering physician or physician extender will review and confirm orders. Confirmation of routine orders requires that the physician sign and date the order as soon as practicable after it is provided to maintain an accurate medical record. 3. Resident #401 was admitted to the facility on [DATE] with diagnoses including unspecified peritonitis, essential hypertension, Type 2 Diabetes Mellitus without complications, unspecified chronic kidney disease stage 3, acute appendicitis with localized peritonitis without perforation or gangrene, cognitive communication deficit, unsteadiness on feet, and need for personal assistance with personal care. Resident #401 was discharged to a higher level of care [hospital] on [DATE]. A review of the physician orders for Resident #401 revealed the following: -Lisinopril -Hydrochlorothiazide oral tablet 20-25 milligrams(mg) to give one tablet by mouth one time a day for hypertension. -Carvedilol oral tablet 12.5 mg to give one tablet by mouth two times a day for hypertension. -Monitor vital signs every shift. On [DATE] during the day shift, Resident #401's blood pressure was documented as 100/60 mmHg (millimeters of Mercury), with a second blood pressure documented on the afternoon shift as 71/38 mmHg. A review of the Medication Administration Record (MAR), [DATE], showed Lisinopril-Hydrochlorothiazide and the Carvedilol were administered as scheduled at 09:00 a.m., and Carvedilol was administered as scheduled at 5:00 p.m. A review of the Change of Condition document, dated [DATE] at 6:45 p.m., showed the following: -altered level of consciousness -blood pressure of 71/38 mmHg -summary: This nurse entered pt. room and observed pt. not behaving in her usual self and difficult to arouse. Vital signs taken B/P 71/38, P-88, temperature 97.7, unable to take O2 sat at this moment. The physician was notified at 6:45 p.m. with instructions to call 911. Family member notified on [DATE] at 6:51 p.m. A review of physical therapy notes, dated [DATE] at 4:43 p.m., showed Resident #401 participating in therapy. patient limited with minimal active muscle engagement with bilateral lower extremity therapeutic exercises with maximal performance cuing, assist to complete each. Blood pressure reading have been in a lower range per nursing, and they are aware of functional decline since evaluation. A review of occupational therapy notes, dated [DATE] at 2:59 p.m., showed client required maximal assist for all bed mobility. She required Hoyer lift into the chair. Attempted to get patient to hold head up and follow verbal directive to sit, lean forward, however she required total assist. A review of speech therapy notes, dated [DATE] at 5:38 p.m., showed patient required moderate to maximal cues to follow simple commands and answer simple questions. Patient noted to be lethargic, which nursing noted. Patient was able to indicate personal information independently however response time was increased. A review of Resident #401's progress note, dated [DATE] at 2:39 p.m., showed the following: resident up for PT, resident BP 110 / 67 before PT interaction. [Staff R, Speech Therapist], to give resident fluids previous to PT to ensure swallowing capabilities intact, [Staff S, Physical Therapist]returned patient, resident BP 117 / 72 per [Staff S], PT reported resident did well in PT, report given to oncoming nurse to ensure residents stay hydrated and eats dinner, also advised oncoming nurse to check BP to ensure patient is not hypotensive. A review of the facility policy titled Notification of Change in Condition, revised on [DATE], revealed the following: Policy: The Center to promptly notify the Patient/Resident, the attending physician, and the Resident Representative when there is a change in the status or condition. Procedure: -The nurse to notify the attending physician and Resident Representative when there is a(n): *Accidents *Significant change in the patient/resident's physical, mental, or psychosocial status *Need to alter treatment significantly -New treatment -Discontinuation of a current treatment due to but not limited to: *Adverse consequences *Acute condition *Exacerbation of a chronic condition *A transfer or discharge of the Patient/Resident from the Center *Patient/Resident consecutively refuses medication and/or treatment (i.e. two or more times) *Patient/Resident is discharged without proper medical authority -In the event of an emergency situation, 911 to be called and the attending physician and the Resident Representative to be notified as soon as possible. -The nurse to complete an evaluation of the Patient/Resident. Document evaluation in the medical record. -The nurse will contact the physician. In the event that the attending physician does not respond in a reasonable amount of time, the Medical Director may be contacted. -If the Medical Director does not respond, call 911 and document in the medical record. -Notify the patient/resident and the resident representative of the change in condition. Document notification in the medical record. -Document resident/patient change in condition on 24 hour report -Complete SBAR as indicated A review of the facility policy titled Nursing Documentation Guidelines, undated, revealed the following: POLICY: Pertinent information should be documented in the individual's record in an accurate, timely, and legible manner. Definitions: Individual's Record: A permanent legal document that provides a comprehensive account of information about the individual's health care status. PROCEDURE: GENERAL GUIDELINES When to Chart 1. Record resident's condition, nursing actions and individual responses as soon as possible after they occur. 2. Document medications and treatments at the time they are administered. What to Chart 1. Symptoms/Subjective Data 2. Your observations and/or Assessments 3. All injuries, illnesses and unusual health changes until they are resolved. There should be entries in the nursing notes on a regular basis until the problem is no longer present. When the problem is resolved, it should documented [sic]. 4. All contacts with the primary care prescriber. a. Document what information was relayed to the primary care prescriber. b. If the primary care prescriber sees or reviews an individual's specific health problem, document what occurred: -the chart was reviewed, -the individual was seen, or -if the individual was examined. c. If the contact was made by phone, document what was discussed and results of the contact (e.g., no orders given, observe). d. Document the plan for follow-up (e.g., to see the physician on morning rounds). e. Documentation on all meds. 5. Response to a medication or treatment: This includes therapeutic effects as well as side effects. 6. New symptoms or conditions: Document in the nurse's notes at time of occurrence or as soon as possible. Document nursing action taken and the person's response. 7. As a general rule, do not chart actions completed by others. How to Chart 1. All entries in the individual's record should be typed in the electronic health record (EHR) or paper if EHR is not used. 2. Use only abbreviations and symbols approved in agency policies. 3. All entries in the individual's record should be written objectively and without bias, personal opinion, or value judgment. 4. The use of slang, cliches, or labels should be avoided unless used in the context of a direct quote. 5. Interpretations of data should be supported by descriptions of specific observations. 6. Documentation should be clear, concise and specific -Don't use vague terms. -Generalizations such as good, fair, moderate, and normal should be avoided -Findings should be as descriptive as possible including specific information about the appearance or findings related to size, shape, and amount. 7. Correcting errors: -Do a correction note in medical record if necessary 8. Late entries: If you forget to chart something, it may be entered into the record at a later time, but you must clearly state the date and time the entry is being made and the date and time the care or observations actually occurred. The entry should begin with the words, Late entry. 9. All entries in nursing notes are attributed to the author of the note.