**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure resident rights for advanced directives were honored by failing to follow physician's order to Do Not Resuscitate (DNR) when the resident was found unresponsive and absent of vital signs for 1 of 3 residents, Resident #1. The facility failed to ensure resident rights were honored when the resident was found unresponsive and absent of vital signs by initiating CPR (Cardiopulmonary Resuscitation) for a resident with a Do Not Resuscitate Order. The facility failure to honor Resident #1's advanced directives resulted in likely serious harm to Resident #1. This resulted in Immediate Jeopardy. The Immediate Jeopardy began on [DATE] and was removed on February 1, 2023 after the facility submitted an acceptable removal plan. Findings include: Review of the admission record for Resident #1 revealed the resident was admitted to the facility on [DATE] with the diagnoses including acute respiratory failure with hypoxia (low oxygen level in the blood), other speech and language deficits following cerebrovascular accident (a stroke), idiopathic peripheral autonomic neuropathy, cerebral infarction (a stroke) due to occlusion (blockage) or stenosis narrowing) of small artery, other sequalae of cerebral infarction, presence of cerebrospinal fluid drainage device (a shunt that drains fluid from the brain), pneumonia due to Coronavirus 2019, sepsis (an overwhelming infection), unspecified protein calorie malnutrition, essential (primary) hypertension, hyperlipidemia (high cholesterol), unspecified dementia, dysphagia, idiopathic normal pressure hydrocephalus (a brain disorder where excess spinal fluid accumulates in the brain), anemia in chronic disease, and history of malignant neoplasm (cancer) of the skin. Review of the Medical Certificate for Medicaid Long Term Services and Patient Transfer form provided to the facility by the sending hospital dated [DATE], under Section H, read, Advance Care Planning: DO NOT Resuscitate (DNR). Review of the admission Assessment completed by Staff A, LPN (Licensed Practical Nurse), dated [DATE], read, Section 1: admission details. Code Status: Full Code. Review of the Narrative Note dated [DATE] at 12:44 PM read, Type: Social Service Note. Narrative Note: [Resident #1's name] does have a wife in the community who is active with his care in the facility. We did discuss advanced directives. Review of the physician's order dated [DATE] at 11:36 AM read, DNR. Review of the Order Summary Report read, DNR. Communication Method: Verbal. Order Status: Active. Order Date: [DATE]. FULL CODE. Communication Method: Phone. Order Status: Active. Order Date: [DATE]. Review of the form titled State of Florida Department of Health Do Not Resuscitate Order (Florida Department of Health, Form 1869) dated [DATE] revealed the form was signed by Resident #1's representative on [DATE] and the physician on [DATE]. Review of the Electronic Medical Record (EMR) showed Resident #1's vital signs on [DATE] at 8:01 AM as a temperature of 97.6 degrees Fahrenheit and an SPO2 [oxygen saturation] of 92% on room air. Review of the Code Blue [Code for staff response to cardiac arrest] Documentation form for Resident #1 dated [DATE] at 8:50 to 9:16 AM read, Could not obtain VS [vital signs] started CPR Time CPR Started: 8:50. Periodic notes: Time: 8:50 am, absence of VS. EMT [Emergency Medical Technician] arrival time 9:16 Fire Rescue arrived first. Time resident expired 09:25 AM. Review of the nursing progress note for Resident #1 dated [DATE] at 11:00 AM authored by the Director of Nursing (DON) read, Nurse while making rounds start of shift noticed that he was with congestion. He was alert vital signs 168/90 [Blood pressure, mmHg], 97 pulse [beats per minute], respirations 19 [breaths per minute], on two-liter nasal cannula [flexible tube that is placed under the nose] with an O2 [oxygen] sat [saturation] at 92%. He was alert at his normal baseline. Was able to give meds had a residual of 20 CC [cubic centimeters]. Due to his congestion nurse did put his tube feed on hold. She left message with nurse practitioner [name of practitioner] about his condition and waiting on call back for further direction. CNA [Certified Nursing Assistant] alerted me the nurse that he appeared not to be breathing at approximately 8:50 this AM, looked in PCC [Point Click Care- electronic medical record software] resident was entered a full code, immediately started CPR due to the absence of vital signs, 911 called, continued CPR until EMS [Emergency Medical Services] arrived at approximately 9:16 AM and called the code. Review of the handwritten statement authored by Staff B, LPN dated [DATE] read, On Monday [DATE] I came onto the floor and got report at 0700 [7:00 AM] from night nurse [name]. In report [Nurses name] reported to me that [Resident #1's name] was off sounding, very congested and had been coughing. He told me that he contacted the on call night doctor but left a voicemail and hadn't heard back. At 0720 [7:20 AM] I went in to check on [Resident #1's name]. At the time [Resident #1's name] was alert, talking and when asked had no c/o [complaint of] shortness of breath or chest pain. He did sound very congested and was coughing on and off at times. I took his vital signs b/p [blood pressure] 168/90 [mmHg] HR [heart rate] 87, 19 [breaths per minute] resp and temp [respirations and temperature] of 97.9 [degrees Fahrenheit]. I notified MD [Medical Doctor] by texting the PA [Physician Assistant] for [Doctor's name]. She responded back at a later time. [CNA's name] reported to me that [Resident #1's name] was not breathing. I ran down to his room found he had no pulse or respirations. I went back to the nurse's station logged into PCC to his profile to check code status. He was listed as full code. I ran back down to his room yelling code blue [CNA's name] grabbed the crash cart and [CNA's name] paged overhead code blue. I stopped his tube feeding laid him flat and began chest compressions with relief came into room. [LPN's name] did breaths with Ambu bag [self-inflating bag resuscitator] while [LPN's name], and myself rotated doing compressions EMS arrived on scene approx. 0915 [9:15 AM] and took over breaths and chest compressions. [DON's name] came into room with the DNR showed it to EMS who called time of death and stopped compressions. Review of Resident #1's care plan read, Focus: [Resident #1's name] has expressed the following wishes regarding code status and has the following advanced directives in place: DNR, DPOA [Durable Power of Attorney] for health care and finances, Health Care Surrogate. Date Initiated: [DATE]. Goal: Resident's wishes regarding code status and advanced directives will be followed by staff. During an interview via telephone on [DATE] at 10:15 AM, Resident #1's spouse stated, He was a do not resuscitate in the hospital and I thought that he was always a do not resuscitate while he was there. I know they wanted me to sign a paper and I did. I did not want to prolong his suffering and he had a living will that stated he did not want any life prolonging measures at all. I can't understand why they would have done CPR, that is not what he wanted and it is not what I wanted. I thought that my husband was a DNR from the time he got to the nursing home. During an interview on [DATE] at 12:30 PM, the Assistant Administrator stated, I was notified immediately after the event that we had performed CPR on a DNR resident. We immediately began an investigation and did the required reporting. I do agree that we should have recognized that staff may not know what to do if there is incorrect paperwork. Apparently his yellow DNR form was not appropriately filled out and we did not have his wife's POA paperwork in the facility, so we waited for her to come and provide this before we made him a DNR. We should have reviewed our own policies and determined what to do. This resident was without the correct advance directive plan for three days and once we had this [the advanced directive], he was provided CPR and shouldn't have been. The investigation revealed that the order was entered incorrectly and did not populate the new advance directive for DNR in PCC. Since that time, we completed a root cause analysis, and implemented a performance improvement plan. I am monitoring the plan and it will be brought to QAPI [Quality Assurance Performance Improvement] monthly. During an interview on [DATE] at 12:45 PM, the Director of Nursing stated, I was on the day that Resident #1 coded. I found his DNR paperwork and provided this to EMS and they stopped the code. His DNR form was in a book at the nurses' station. I immediately began to look into why this happened. First, when the resident arrived staff did not verify with the POA the code status and did not review the transfer form. On admission staff did not follow our policies, they did not look at all the hospital documentation or know that they could still get an order for the DNR without the POA paperwork when the resident couldn't speak on his own behalf. Social Services did realize there was a DNR form provided but it was not correctly filled out and they were unaware of our ability to have two nurses document and get the physician's order. Once the resident's [Resident #1) wife provided the POA paperwork we obtained the order, and it was not correctly entered into PCC and the full code order was not discontinued. The day of the code blue the nurse that had obtained the DNR order just didn't remember and went to PCC to check, and he [the resident] was still listed as a full code. I interviewed all staff involved, and completed an investigation. We did an ad hoc QAPI that day, conducted a root cause analysis and formulated a performance improvement plan. We have conducted the training on advance directives, abuse and neglect, proper order entry so the correct order comes on the patients' profile. We immediately began a facility wide audit to determine that all residents had the correct advance directives and code status and have reviewed all new admissions daily. During an interview on [DATE] at 1:00 PM, Staff A, LPN, stated, I did not call or ask his wife if he was a DNR when I did his admission. I did not look at any of his paperwork like the transfer form, [from the hospital], just the discharge medication reconciliation form, that's all. I should have spoken to his wife. I was not aware that two nurses could get the form signed verbally and we could get an order for the DNR from the doctor. I should have reviewed all the admission paperwork. During an interview conducted via telephone on [DATE] at 1:30 PM, Staff B, LPN stated, I did get the order for Resident #1 on Friday, and I did get a DNR order. I did not remember that I got a DNR order when he coded three days later. I started CPR. I guess that I did not enter the order in the right spot and so it didn't show up as an order and I didn't discontinue the full code order and I should have. The Director of Nursing came in when the paramedics were here and showed them the DNR form, the yellow form, and they stopped and called the code. During an interview on [DATE] at 1:45 PM, the Social Service Director stated, I obtained his [Resident #1] paperwork for his POA. He did come to the facility with a DNR form, but it was not properly filled out and we did not have his POA paperwork, so I told his wife we could not honor the DNR until she gave us proof that she was his POA. I did interview him, but he was not really able to talk to me. His wife couldn't come because she was sick. Once she came on the 27th, I made sure that the staff knew to get an order for the DNR since she signed the yellow form. I was not aware that our policies state two nurses could obtain verbal consent and sign the form until the POA was able to. I have received the training now. During an interview on [DATE] at 2:15 PM, the Medical Director stated, I do expect staff to follow a resident or resident representative's wishes for code status. We should not perform CPR when residents do not wish for these measures. Once we identified this, we worked and found two to three weak links, the first being portal training on how to enter the right orders in the right ways so that we had the most up to date information available to all the staff. Next, we have created a manual system to prevent reoccurrences in the future so at all times we have two systems to make sure we are doing the right thing for the residents. The possible complications of CPR would include fractured ribs and a fractured sternum and would be considered traumatic should he have survived. Review of the policy and procedure titled Determination of Code Status issued in 11/2022 read, Policy: The residents' code status will be determined by a physician's order and/or validly executed State of Florida DNR order form (Florida Department of Health Do Not Resuscitate form #DH 1896) and/or documented evidence of resident wishes being in place. Procedure: 1. Upon admission the nurse completing the admission assessment will ascertain resident's desired code status (full code or DNR). In the event the resident is incapacitated or unable to communicate their wishes regarding code status, reasonable efforts will be made to contact the designated responsible party or surrogate decision maker to ascertain the resident's desired code status. 2. Upon Determination of resident/responsible party wishes, the nurse will document those wishes in the admission nursing assessment. 3. If the resident/responsible party elects a DNR, the resident and/or responsible party will sign and date the State of Florida DNR form available at: State of Florida form 1896 do not resuscitate order form. This can be done in person, via fax or scanned e-mail for resident representative not present. 4. The nurse will contact the attending physician and obtain an order for full code or DNR per resident or responsible party wishes. In the event of a DNR order given via telephone, two nurses shall witness and note such a verbal/telephone order using the State of Florida Do Not Resuscitate order form by writing and cosigning the verbal/telephone order at the bottom of the form, including the date and time the order was obtained. 6. Upon receipt of either verbal, telephone, or direct order for code status the nurse noting such order shall enter the order status into the electronic health record and validate that such order can be visualized in the record, the EMAR, and the point of care kiosk. The nurse shall check that any prior advance directive orders which exist are discontinued at the same time the new order is being entered. 7. The electronic record (including electronic chart, point of care kiosk, or EMAR) will serve as the primary source of validation of code status should a resident be found unresponsive. 9. When a DNRO [Do Not Resuscitate Order] is executed it will be made part of the medical record by being scanned into the EHR [electronic health record] under the documents section of the electronic health record. 10. A code status binder will be maintained at each nurses' station. Copies of state of the Florida DNR order forms, documentation of verbal wishes of resident, and/or physician orders shall be printed out and maintained in such binder. 12. Any resident without a signed State of Florida DNR order form, or without a physicians DNR order, or without documented verbal wishes of a desire for withholding of resuscitative measures, will be a Full code. Review of the policy and procedure titled Code Blue and CPR issued in 11/2022 read, Policy: This facility will honor the resident/resident representative wishes regarding either the provision while withholding of cardiopulmonary resuscitation (CPR), to any resident requiring such care prior to the arrival of emergency medical personnel in accordance with related physician orders, such as DNR's, and the resident's advanced directives. In the event a resident experiences cardiac arrest (cessation of pulse and/or respirations). CPR will be provided in the absence of a valid physician's orders for do not resuscitate (DNR), a state of Florida DNR order form (#DH1896) or documented verbal wishes indicating otherwise which are pending physician order. Once emergency responders arrive, emergency responders will take control of the resuscitative effort and direct all related activities until either the resuscitative effort is ceased, or the resident is transported to an emergency center. Procedure: 5. A staff member other than the one who is evaluating the resident and preparing to provide emergency care must promptly check current code status by checking the code status section of the EHR (electronic health record), EMAR [electronic medication administration record] or point of care kiosk. At that point provision or withholding of resuscitative efforts may begin. Additional CPR certified personnel when present, may assist with management of the physical efforts in resuscitation as directed by the Licensed nurse in command. Review of the policy and procedure titled, Advanced Directives issued in 11/2022 read, Policy: It will be the policy of this facility that the resident has the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive and participate in advanced care planning. Advance Directives/Advance Care planning designations will be respected in accordance with state law and facility policy. The facility submitted an acceptable Immediate Jeopardy removal plan, and the immediate jeopardy was removed. The facility's non-compliance was corrected on February 1, 2023. The facility conducted an Ad Hoc QA meeting to review of the removal plan. On [DATE], the facility conducted a house-wide full chart review of 103 of 103 resident records and systems review for DNR/advance directives, physician orders pertaining to code status/advance directives, DNRO forms scanned in records. The facility provided training on advance directives to 30 of 30 licensed nurses on [DATE]. The facility provided abuse, neglect, and advanced directive training to 119 of 122 total facility staff. The facility conducted three mock codes/drills to ensure staff understood the location of the advance directives book and the documentation of code status in the electronic medical record with a total of 24 of 30 licensed nurses. The facility started validation of the code orders in care profile as per physician order for newly admitted residents by conducting daily audits through Advance Directives Compliance Tracking Tool on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The facility conducted advance directive monitoring audits of 10 residents per facility unit, which includes monitoring DNR/full code status in PCC, physician order for DNR, care plans for DNR, and implementation of admission information regarding DNR, on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to immediately consult with the resident's physician and notify the residents' representatives when there was a change of condition for 2 of 2 residents reviewed for changes in condition, Resident #29 and #42, resulting in the residents having to be treated by IV (intravenous) antibiotic therapy due to infection. Delay in notifying the physician of a wound, critical labs, and resident change in condition due to infection can result in the spread of the infection into the deeper tissues of the body, the infection can travel through the blood to other parts of the body and could become life threatening. Findings include: 1. Review of the admission record documented Resident #29 was admitted to the facility on [DATE] with the following diagnoses: encounter for surgical aftercare following surgery on the circulatory system, atherosclerotic heart disease of native coronary artery (heart disease) with angina pectoris (chest pain), acute systolic (congestive) heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), pleural effusion (fluid that builds up between the tissue that lines the lungs and the chest due to poor pumping of the heart), acute and chronic respiratory failure (a condition in which the lungs cannot get enough oxygen into the blood or remove the carbon dioxide) with hypoxia (low oxygen levels in the blood), pneumonia, cardiac pacemaker, pressure ulcer sacral region, stage 3, hyperlipidemia (high cholesterol), type 2 diabetes mellitus, major depressive disorder, right leg below the knee amputation, essential hypertension (high blood pressure), non ST elevation myocardial infarction (a heart attack), paroxysmal atrial fibrillation (an irregular heart beat), peripheral vascular disease (a blood circulation disorder that causes the blood vessels to narrow), chronic kidney disease, and left below the knee amputation. Review of the Tissue Analytics (TA) wound care note for Resident #29 dated 8/29/2022 reads, Sacral wound 1.97 cm [centimeters] x 3.33 cm x 0.20 cm cleanse with n/s [normal saline] Med Honey, calcium alginate cover with bordered gauze, daily. In house acquired 8/23/22, Recommendation: obtain wound culture d/t [due to] increased deterioration. Recommend start Doxycycline pending wound culture results. Review of the physician order for Resident #29 dated 8/29/2022 reads, Doxycycline Hyclate 100 mg [milligrams] 1 tablet by mouth two times a day for wound infection. Start med [medication] after wound is cultured for 7 days. Review of the lab results report for Resident #29 dated 8/30/2022 titled Wound culture 1 reads, Critical result called to [Director of Nursing's (DON) name] on 9/2/2022 11:42 AM by [Laboratory technician's name]. Results were read back to caller. Site: Coccyx. Result: Heavy growth Gram Positive Cocci: Staphylococcus Aureus (isolate 1) This isolate is Methicillin Resistant (MRSA). Review of the nursing progress note for Resident #29 dated 9/2/22 at 1307 (1:07 PM) reads, ARNP [Advanced Registered Nurse Practitioner] aware of coccyx culture, awaiting final results and sensitivity for further evaluation of tx [treatment] plan. Review of the lab results report for Resident #29 dated 8/30/2022 titled Wound culture 1 reads, Report information: Collection date: 8/30/2022 02:30 [AM]; Received date: 8/30/2022 14:51 [2:51 PM]; Report date: 9/3/2022 10:08 [AM]. Final Report: Result: Heavy growth normal skin flora, heavy growth gram positive cocci. staphylococcus aureus (Isolate 1) This isolate is Methicillin Resistant (MRSA). Moderate growth gram negative rods. Morganella Morganii spp morganii (Isolate 2), Proteus mirabilis (Isolate 3) Pseudomonas aeruginosa (Isolate 4). Sensitivity Analysis: Tetracycline <=1 S for isolate 1. [Susceptible] There was no sensitivity analysis documented for additional isolates 2, 3 and 4. [A sensitivity test checks to see what kind of medicine, such as an antibiotic, will work best to treat the illness or infection]. Review of the medical record for Resident #29 does not document the physician or Advanced Practice Registered Nurse (APRN) were notified of the final culture report dated 9/3/2022 through 9/7/2022. Review of the physician order for Resident #29 dated 9/7/2022 reads, Midline/PICC [peripherally inserted central catheter] placement for IV [intravenous] ABX [antibiotics]. Review of the physician order for Resident #29 dated 9/10/2022 reads, Gentamycin Sulfate solution use 90 mg [milligrams] every 12 hours. For MRSA wounds for 10 days in 0.9% NSS [normal saline solution] 100 ml [milliliters]. Review of the document from The IV Company for Resident #29 dated 9/8/2022 reads, Consultation: Reason for consultation: Midline; reason for insertion: drugs. Post insertion data -line removal: Line insertion: Midline Insertion site: left, attempts: 1; Cephalic, blood return: positive; internal length 15; arm circumference: 33. Comments: Midline left cephalic. No complications. Time in 1333 [1:33 PM], Time out: 1353 [1:53 PM]. During an interview on 9/14/2022 at 8:05 AM, the Director of Nursing (DON) stated, I did not call the nurse practitioner with the critical lab result of the wound. I gave it to the nurse. I don't see that the critical lab result was called. The lab result should have been called. I'm not sure why it wasn't. There is no progress note and no change of condition done. We failed this resident [Resident #29]. We did not do what we should have for the resident. I did not make sure that the staff called the practitioner. I was not aware that the final culture results weren't called. We should have called the results to the nurse practitioner. During an interview on 9/14/2022 at 10:38 AM, the Advanced Practice Registered Nurse (APRN) stated, I was not notified of any critical lab results. I saw the full wound culture report the day that I ordered the midline and antibiotics because the Gentamycin covered everything that was present in the coccyx wound culture. I believe I was notified that the culture report was back on 9/7/2022. I would have changed the antibiotics to IV Gentamycin sooner had I been notified. I would have discontinued the Doxycycline on 9/3/2022 because it did not cover the other organisms. I would say this was a delay in care. He [Resident #29] definitely could have worsened without appropriate treatment and the appropriate antibiotics for his wound. I expect that all labs will be called so we can provide care that is appropriate for any given infection. During an interview on 9/15/2022 at 10:35 AM Staff F, Registered Nurse (RN) stated, I did speak with [APRN's name] on September 2, to let her know that the coccyx wound culture had MRSA, but the rest of the culture was not available. I was not on the next several days and did not call the culture reports. There is no documentation that anyone called the doctor or the practitioner. They should have. I finally called [APRN's name] and she came in and ordered the midline and the antibiotics. Review of the lab results report for Resident #29 dated 9/11/2022 reads, Gentamicin trough result: 5.4 mcg [micrograms]/ml [milliliter]. Critical lab result called to [Staff name] on 9/11/2022 1:40 PM by [Laboratory staff name]. Results were read back to caller. [Aiming for a level of < 1 mcg/mL approximately 6 hours prior to the next dose ensure there is a drug-free window in order to minimize drug accumulation within proximal tubules/major component of the kidney]. Review of the medical record for Resident #29 does not document the physician, pharmacist or APRN were notified of the critical laboratory result. Review of the lab results report for Resident #29 dated 9/12/2022 reads, Gentamycin trough result: 2.6 mcg/ml. Critical lab result called to [Staff name] on 9/13/2022 at 11:47 AM by [Laboratory Staff name]. Results were read back to caller. Review of the medical record does not document the physician, pharmacist or APRN were notified of the critical laboratory result. During an interview on 9/15/2022 at 11:15 AM the Medical Director stated I understand that the culture reports were not called to the physician or mid-level. I told them that there were two different areas, and they are independent of one another, and no one should wait for another culture of a different area to come back. This is a breach of protocol and this needs to be improved. We have much space for improvement and training and education needs to be done for the staff. We need to reach a better-quality matrix for the residents, and I think we will. All critical lab reports should be called to the physicians. During an interview on 9/15/2022 at 3:10 PM the DON stated, It does not look like we have called these results [Gentamycin trough results] to the pharmacist or the nurse practitioner. They are critical results and should be called immediately. We usually have a doctor's order to have pharmacy dose gentamicin, I don't know why we don't. I see there were two critical results and neither of them were called when they should have been. During a telephone interview on 9/16/2022 at 9:22 AM the pharmacist stated, We were not informed of the critical gentamycin trough that was completed on 9/11/2022. We did attempt to contact the facility multiple times and have notes to indicate that multiple messages were left requesting that the nursing staff call us back and they did not. I see a note that we spoke to [Staff O, Licensed Practical Nurse's name] on 9/13/2022, we recommended that the gentamycin dose get reduced to 80 mg twice a day and a repeat peak and trough be completed after the second dose. We are having a hard time maintaining communication with the nurses. The gentamycin is currently on hold until we get another peak and trough and then we will decide further dosing. The potential side effects would be damage to the eight cranial nerves which would have an effect on hearing, causing possible hearing loss and nephrotoxicity [a rapid decline in kidney function due to toxic effects of medications]. Review of the policy and procedure titled, Lab and Diagnostic Results - Clinical Protocol with an approval date of 1/27/2022 reads, Review by Nursing: 1. When test reports are reported to the facility, a nurse will first review the results. a. If staff who first receive or review lab and diagnostic test results cannot follow the remainder of this procedure for reporting and documenting the results and their implications, another nurse in the facility (supervisor, charge nurse, etc.) should follow or coordinate the procedure. 2. Before contacting the physician, the person who is to communicate results to a physician will gather, review, and organize the information and be prepared to discuss the following (to the extent that such information is available): c. Why the lab and diagnostic tests were obtained (for example, as a routine screening or follow up); to assess a condition change or recent onset of signs and symptoms, or to monitor a serum medication level; d. How test results may relate to the individual's current condition and treatment. 3. A nurse will identify the urgency of communicating, with the Attending Physician based on physician request, seriousness of any abnormality, and the individual's current condition. 4. A nurse will try to determine whether the test was done: b. To assess a condition change or recent onset of signs and symptoms. Identifying situations that warrant immediate notification: 1. Nursing staff will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results: Whether the result should be conveyed to a physician regardless of other circumstances (that is, the abnormal result is problematic regardless of any other factors); Whether the resident/patients' clinical status is unclear or he/she has signs of acute illness or condition change and is not stable or improving, or there are no previous results for comparison. Options for physician notification: 1. A physician can be notified by phone, fax voicemail, e-mail, mail, pager, or a telephone message to another person acting as the physician's agent (for example, office staff) b. Direct voice communication with the physician is the preferred means for presenting any results requiring immediate notification, especially when the resident's clinical status is unstable or current treatment needs review or clarification. Review of the policy and procedure titled Change in Condition issued on 4/1/2022 reads Policy: It will be the policy of this facility to notify the physician, family, resident, and/or responsible party/resident representative (as is applicable) of significant changes in condition and providing treatment(s) according to the residents wishes and physician orders. Procedure: 2. When a change is noted, gather pertinent data such as vital signs, weights, and other clinical observations. 4. When significant changes in skin condition or weight are noted it is appropriate to contact the physician and responsible party/resident representative if applicable to notify them and receive orders such as consultations, root cause analysis or implementation of further monitoring. 7. Contact the primary physician to update him/her to the change in condition. In the event the primary physician cannot be notified, attempt to contact the facility's medical director. 2. Record review of the admission record documented Resident #42 was admitted to the facility on [DATE] with the following diagnoses: type 2 diabetes mellitus, chronic obstructive pulmonary disease, chronic pain, generalized anxiety disorder, bipolar disorder, essential (primary) hypertension, atherosclerotic heart disease of native coronary artery (heart disease) without angina pectoris (chest pain), and primary osteoarthritis right shoulder. Review of the Nursing Progress note for Resident #42 dated 8/24/2022 at 5:49 AM authored by Staff E, Licensed Practical Nurse (LPN) reads This nurse heard noise come from pt. [patient] room. Entered pt. room visualized pt. on hands and knees at the side of the bed. Blood noted on floor, small amount of bleeding noted in right hairline, small bleeding area noted to right elbow. Assisted pt. back to bed. Bleeding to hairline stopped and steristrips applied. Bleeding area to right elbow cleansed and steristrips applied and dressing applied. Pt. denies any pain at this time. No other areas of discoloration noted at this time, ROM [range of motion] WNL [within normal limits], Vitals WNL. Neuro checks started. Left message for [Medical Doctor's name] on call service to notify, left message for Daughter [name]. Pt. resting comfortably in bed, bed in low position, call light and bedside table with fluids within reach. Review of the medical record for Resident #42 revealed no evidence of change in condition documentation, skin assessments or nursing progress notes indicating the physician or nurse practitioner were notified and wound care orders obtained. Review of the nursing progress note for Resident #42 dated 9/6/2022 at 10:45 PM reads, Swelling and redness noted to right elbow some serosanguinous discharge noted. No odor. This nurse dressed site until further evaluation. Review of the Nursing Progress note for Resident #42 dated 9/7/2022 at 6:14 AM reads, Noted that skin tear from previous fall is reddened, painful and warm to touch, with serosanguinous drainage. Call placed to [APRN's name] to notify, awaiting call back with any new orders. Dressing orders clarified and dressing in place CDI [clean, dry and intact]. Review of the Nursing Progress note for Resident #42 dated 9/7/2022 at 11:25 AM reads, Skin tear from previous fall right elbow, red, warm, and tender. ARNP did a wound culture, cleaned, and applied new dressing awaiting orders. Review of the treatment administration record for the month of August revealed no evidence of physician's orders related to care for the right elbow skin tear. Review of the treatment administration record for the month of September documented treatment to the right elbow skin tear began on 9/7/2022. There were no other orders related to care for the right elbow skin tear. Review of the physician order for Resident #42 dated 9/8/2022 reads, May insert midline with 1% lidocaine for IV ABX. Review of the physician order for Resident #42 dated 9/7/2022 reads Piperacillin Sod [sodium] - Tazobactam So [sodium] solution reconstituted 3.0-375 gm [gram], use 3.375 gram intravenously every 6 hours for infection for 10 days. Review of The IV Company document for Resident #42 dated 9/8/2022 reads Consultation: Reason for consultation: Midline: reason for insertion: drugs. Post insertion data - line removal: Line insertion: Midline Insertion site: left, attempts: 1; Basilic, blood return: positive; internal length 15; arm circumference: 32. Comments: Midline left basilic. No complications. Time in 1228 [12:28 PM], Time out: 1307 [1:07 PM]. Review of the lab results report for Resident #42 dated 9/13/2022 reads, Final Report: Microbiology report. Site: elbow right; Result: Staphylococcus aureus (isolate 1). During an interview on 9/13/2022 at 1:45 PM the DON stated, I see that there were no treatment orders in place for [Resident #42's name], after her fall. I do not see any provider notification or request for wound care orders for her skin tear. I see the culture and that she needed to have a midline and antibiotics for the infection of the skin tear. We should have asked for treatment orders, and we did not. I could see that you might consider that we did not provide her the proper care and it was part of the reason she needed the midline and antibiotics. I don't see any notes or a change of condition form in the chart where we notified the doctor or nurse practitioner until the arm was red and swollen. During an interview on 9/14/22 at 7:48 AM Resident #42 stated, I was having a lot of pain in my arm after I fell. I kept telling them, but they weren't listening. Finally, someone did and that's when they got the wound culture. No one would look at it when I asked and told them how much it was hurting me. They did not change the dressing on it at all. During an interview on 9/14/22 at 8:59 AM Staff E, Licensed Practical Nurse (LPN), stated, I did find her [Resident #42] on the floor. I heard a thud and found her on her knees on the floor. She had a skin tear and had a cut on her forehead. I assessed her and cleaned her forehead and right elbow. I was able to close the wound on her elbow with steristrips directly after she fell. I think I left a message for the nurse practitioner, but don't recall that she called back. We should follow up when a resident has any injuries and see if the practitioner wants any type of skin care done. I did not obtain any orders to treat her skin tear and I probably should have, but I did provide immediate treatment to her wounds. I did an assessment. I probably should have called the nurse practitioner back before I went off shift. During a telephone interview conducted on 9/14/2022 at 10:25 AM the APRN stated, I do not think that I was notified of the patient's fall until 9/6/2022 late in the evening, a nurse notified me that she had a red and draining arm from the skin tear. I gave orders for treatment and saw her the next day when I took a wound culture. I was not called and asked for any wound treatments prior to that time. I absolutely feel that the wound became infected due to a lack of wound care and that she would not have required additional treatments had she been provided daily wound care. I do feel this was a delay in treatment and caused a need for additional, more invasive treatments. I expect that staff will inform me of any changes in patient condition. All skin concerns should be addressed, and we should be called. During an interview conducted on 9/14/2022 at 2:10 PM the Regional Nurse Consultant stated, We have not provided change of condition notification to the providers for [Resident #42 and #29's names]. We were notified of the critical lab results for [Resident #29's name]. We did notify the provider. There is a note in the chart, but when the final culture was back, we did not call the provider. I don't see that there was information about whether the additional sensitivities were sensitive to the oral antibiotic he [Resident #29] was on. We should have called. There is no excuse that I could give you for why they weren't notified. [Resident #42's name] was not provided any wound care after the skin tear. We should have notified the physician or nurse practitioner and we should have gotten orders for wound care. I can't give you any clear reason why this was not done. She did have a need for a midline and antibiotics because the wound became infected. We did not do what we should have. Review of the policy and procedure titled Wound Care issue date of 4/1/2022 reads, Policy: It is the policy of this facility to provide assessment and identification of residents at risk of developing pressure injuries, other wounds and treatment of skin impairment. Procedure: 2. Skin will be assessed/evaluated for the presence of developing pressure injuries or other changes in skin condition on a weekly basis at least once each week or as needed by a licensed nurse. 11. Document the progression of the wound being treated. Such observations should include items size, staging (if applicable), odors, exudate, tunneling, etiology, etc. 12. Contact the physician for additional order changes as is appropriate or to notify of skin condition changes or refusals of care. The Immediate Jeopardy was removed onsite after the receipt of an acceptable immediate jeopardy removal plan. The survey team verified the facility's actions for removal of immediacy to prevent the likelihood of harm and/or possible death: Residents #29 and #42 were assessed for skin impairments and their physicians were notified on 9/13/2022. Ad Hoc QAPI [Quality Assurance Performance Improvement] was held on 9/13/2022 attended by Medical Director, Administrator, Director of Nursing, Infection Preventionist, and Social Services Director to implement a performance improvement plan. The facility has conducted root cause analysis on 9/14/2022 for delay in treatment and neglect. The facility completed skin assessments on 93 residents for any wound concerns and obtained orders for three additional residents identified with concerns. On 9/14/2022, the Administrator and Director of Nursing were educated by the Regional Director of Clinical Operations on the components of administration to include monitoring of facility systems during administrative/clinical stand up and standdown to identify areas that may rise to the level of investigating ANEMMI. By 9/16/2022, the facility trained 28 of 28 licensed nursing staff on change in condition, skin and wound care and abuse and neglect, which was verified through staff interviews.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free from medical neglect when they did not immediately consult with the resident's physician and notify the residents' representatives when there was a change of condition for 2 of 2 residents, Residents #29 and #42, resulting in a delay of care. Delay in notifying the physician of a wound, critical labs, or resident change in condition can result in the spread of infection into the deeper tissues of the body, the infection can travel through the blood to other parts of the body and could become life threatening. Findings include: 1. Review of the admission record documented Resident #29 was admitted to the facility on [DATE] with the following diagnoses: encounter for surgical aftercare following surgery on the circulatory system, atherosclerotic heart disease of native coronary artery (heart disease) with angina pectoris (chest pain), acute systolic (congestive) heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), pleural effusion (fluid that builds up between the tissue that lines the lungs and the chest due to poor pumping of the heart), acute and chronic respiratory failure (a condition in which the lungs cannot get enough oxygen into the blood or remove the carbon dioxide) with hypoxia (low oxygen levels in the blood), pneumonia, cardiac pacemaker, pressure ulcer sacral region, stage 3, hyperlipidemia (high cholesterol), type 2 diabetes mellitus, major depressive disorder, right leg below the knee amputation, essential hypertension (high blood pressure), non ST elevation myocardial infarction (a heart attack), paroxysmal atrial fibrillation (an irregular heart beat), peripheral vascular disease (a blood circulation disorder that causes the blood vessels to narrow), chronic kidney disease, and left below the knee amputation. Review of the Tissue Analytics (TA) wound care note for Resident #29 dated 8/29/2022 reads, Sacral wound 1.97 cm [centimeters] x 3.33 cm x 0.20 cm cleanse with n/s [normal saline] Med Honey, calcium alginate cover with bordered gauze, daily. In house acquired 8/23/22, Recommendation: obtain wound culture d/t [due to] increased deterioration. Recommend start Doxycycline pending wound culture results. Review of the physician order for Resident #29 dated 8/29/2022 reads, Doxycycline Hyclate 100 mg [milligrams] 1 tablet by mouth two times a day for wound infection. Start med [medication] after wound is cultured for 7 days. Review of the lab results report for Resident #29 dated 8/30/2022 titled Wound culture 1 reads, Critical result called to [Director of Nursing's (DON) name] on 9/2/2022 11:42 AM by [Laboratory technician's name]. Results were read back to caller. Site: Coccyx. Result: Heavy growth Gram Positive Cocci: Staphylococcus Aureus (isolate 1) This isolate is Methicillin Resistant (MRSA). Review of the nursing progress note for Resident #29 dated 9/2/22 at 1307 (1:07 PM) reads, ARNP [Advanced Registered Nurse Practitioner] aware of coccyx culture, awaiting final results and sensitivity for further evaluation of tx [treatment] plan. Review of the lab results report for Resident #29 dated 8/30/2022 titled Wound culture 1 reads, Report information: Collection date: 8/30/2022 02:30 [AM]; Received date: 8/30/2022 14:51 [2:51 PM]; Report date: 9/3/2022 10:08 [AM]. Final Report: Result: Heavy growth normal skin flora, heavy growth gram positive cocci. staphylococcus aureus (Isolate 1) This isolate is Methicillin Resistant (MRSA). Moderate growth gram negative rods. Morganella Morganii spp morganii (Isolate 2), Proteus mirabilis (Isolate 3) Pseudomonas aeruginosa (Isolate 4). Sensitivity Analysis: Tetracycline <=1 S for isolate 1. [Susceptible] There was no sensitivity analysis documented for additional isolates 2, 3 and 4. [A sensitivity test checks to see what kind of medicine, such as an antibiotic, will work best to treat the illness or infection]. Review of the medical record for Resident #29 does not document the physician or Advanced Practice Registered Nurse (APRN) were notified of the final culture report dated 9/3/2022 through 9/7/2022. Review of the physician order for Resident #29 dated 9/7/2022 reads, Midline/PICC [peripherally inserted central catheter] placement for IV [intravenous] ABX [antibiotics]. Review of the physician order for Resident #29 dated 9/10/2022 reads, Gentamycin Sulfate solution use 90 mg [milligrams] every 12 hours. For MRSA wounds for 10 days in 0.9% NSS [normal saline solution] 100 ml [milliliters]. Review of the document from The IV Company for Resident #29 dated 9/8/2022 reads, Consultation: Reason for consultation: Midline; reason for insertion: drugs. Post insertion data -line removal: Line insertion: Midline Insertion site: left, attempts: 1; Cephalic, blood return: positive; internal length 15; arm circumference: 33. Comments: Midline left cephalic. No complications. Time in 1333 [1:33 PM], Time out: 1353 [1:53 PM]. During an interview on 9/14/2022 at 8:05 AM, the Director of Nursing (DON) stated, I did not call the nurse practitioner with the critical lab result of the wound. I gave it to the nurse. I don't see that the critical lab result was called. The lab result should have been called. I'm not sure why it wasn't. There is no progress note and no change of condition done. We failed this resident [Resident #29]. We did not do what we should have for the resident. I did not make sure that the staff called the practitioner. I was not aware that the final culture results weren't called. We should have called the results to the nurse practitioner. During an interview on 9/14/2022 at 10:38 AM, the Advanced Practice Registered Nurse (APRN) stated, I was not notified of any critical lab results. I saw the full wound culture report the day that I ordered the midline and antibiotics because the Gentamycin covered everything that was present in the coccyx wound culture. I believe I was notified that the culture report was back on 9/7/2022. I would have changed the antibiotics to IV Gentamycin sooner had I been notified. I would have discontinued the Doxycycline on 9/3/2022 because it did not cover the other organisms. I would say this was a delay in care. He [Resident #29] definitely could have worsened without appropriate treatment and the appropriate antibiotics for his wound. I expect that all labs will be called so we can provide care that is appropriate for any given infection. During an interview on 9/15/2022 at 10:35 AM Staff F, Registered Nurse (RN) stated, I did speak with [APRN's name] on September 2, to let her know that the coccyx wound culture had MRSA, but the rest of the culture was not available. I was not on the next several days and did not call the culture reports. There is no documentation that anyone called the doctor or the practitioner. They should have. I finally called [APRN's name] and she came in and ordered the midline and the antibiotics. Review of the lab results report for Resident #29 dated 9/11/2022 reads, Gentamicin trough result: 5.4 mcg [micrograms]/ml [milliliter]. Critical lab result called to [Staff name] on 9/11/2022 1:40 PM by [Laboratory staff name]. Results were read back to caller. [Aiming for a level of < 1 mcg/mL approximately 6 hours prior to the next dose ensure there is a drug-free window in order to minimize drug accumulation within proximal tubules/major component of the kidney]. Review of the medical record for Resident #29 does not document the physician, pharmacist or APRN were notified of the critical laboratory result. Review of the lab results report for Resident #29 dated 9/12/2022 reads, Gentamycin trough result: 2.6 mcg/ml. Critical lab result called to [Staff name] on 9/13/2022 at 11:47 AM by [Laboratory Staff name]. Results were read back to caller. Review of the medical record does not document the physician, pharmacist or APRN were notified of the critical laboratory result. During an interview on 9/15/2022 at 11:15 AM the Medical Director stated I understand that the culture reports were not called to the physician or mid-level. I told them that there were two different areas, and they are independent of one another, and no one should wait for another culture of a different area to come back. This is a breach of protocol and this needs to be improved. We have much space for improvement and training and education needs to be done for the staff. We need to reach a better-quality matrix for the residents, and I think we will. All critical lab reports should be called to the physicians. During an interview on 9/15/2022 at 3:10 PM the DON stated, It does not look like we have called these results [Gentamycin trough results] to the pharmacist or the nurse practitioner. They are critical results and should be called immediately. We usually have a doctor's order to have pharmacy dose gentamicin, I don't know why we don't. I see there were two critical results and neither of them were called when they should have been. During a telephone interview on 9/16/2022 at 9:22 AM the pharmacist stated, We were not informed of the critical gentamycin trough that was completed on 9/11/2022. We did attempt to contact the facility multiple times and have notes to indicate that multiple messages were left requesting that the nursing staff call us back and they did not. I see a note that we spoke to [Staff O, Licensed Practical Nurse's name] on 9/13/2022, we recommended that the gentamycin dose get reduced to 80 mg twice a day and a repeat peak and trough be completed after the second dose. We are having a hard time maintaining communication with the nurses. The gentamycin is currently on hold until we get another peak and trough and then we will decide further dosing. The potential side effects would be damage to the eight cranial nerves which would have an effect on hearing, causing possible hearing loss and nephrotoxicity [a rapid decline in kidney function due to toxic effects of medications]. Review of the policy and procedure titled Abuse and Protection and Response Policy approval date of 1/27/2022 reads, Policy: Abuse as hereafter defined, will not be tolerated by anyone, including staff, patients, volunteers, family members or legal guardian, friends, or other individuals. The health center Administrator is responsible for assuring that patient safety, including freedom from risk of abuse holds the highest priority. Definitions: Neglect: the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Neglect occurs when facility staff fails to monitor/supervise the delivery of patient care and services to assure that care is provided as needed by the resident. Identification: Policy: Any patient event that is reported to any staff by patient family, other staff or any other person will be considered as possible abuse if it meets any of the following criteria: d. Any complaint of deprivation by an individual caregiver of goods and services necessary to maintain physical, mental, and psychological well-being to include toileting issues. Review of the policy and procedure titled, Lab and Diagnostic Results - Clinical Protocol with an approval date of 1/27/2022 reads, Review by Nursing: 1. When test reports are reported to the facility, a nurse will first review the results. a. If staff who first receive or review lab and diagnostic test results cannot follow the remainder of this procedure for reporting and documenting the results and their implications, another nurse in the facility (supervisor, charge nurse, etc.) should follow or coordinate the procedure. 2. Before contacting the physician, the person who is to communicate results to a physician will gather, review, and organize the information and be prepared to discuss the following (to the extent that such information is available): c. Why the lab and diagnostic tests were obtained (for example, as a routine screening or follow up); to assess a condition change or recent onset of signs and symptoms, or to monitor a serum medication level; d. How test results may relate to the individual's current condition and treatment. 3. A nurse will identify the urgency of communicating, with the Attending Physician based on physician request, seriousness of any abnormality, and the individual's current condition. 4. A nurse will try to determine whether the test was done: b. To assess a condition change or recent onset of signs and symptoms. Identifying situations that warrant immediate notification: 1. Nursing staff will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results: Whether the result should be conveyed to a physician regardless of other circumstances (that is, the abnormal result is problematic regardless of any other factors); Whether the resident/patients' clinical status is unclear or he/she has signs of acute illness or condition change and is not stable or improving, or there are no previous results for comparison. Options for physician notification: 1. A physician can be notified by phone, fax voicemail, e-mail, mail, pager, or a telephone message to another person acting as the physician's agent (for example, office staff) b. Direct voice communication with the physician is the preferred means for presenting any results requiring immediate notification, especially when the resident's clinical status is unstable or current treatment needs review or clarification. Review of the policy and procedure titled Change in Condition issued on 4/1/2022 reads Policy: It will be the policy of this facility to notify the physician, family, resident, and/or responsible party/resident representative (as is applicable) of significant changes in condition and providing treatment(s) according to the residents wishes and physician orders. Procedure: 2. When a change is noted, gather pertinent data such as vital signs, weights, and other clinical observations. 4. When significant changes in skin condition or weight are noted it is appropriate to contact the physician and responsible party/resident representative if applicable to notify them and receive orders such as consultations, root cause analysis or implementation of further monitoring. 7. Contact the primary physician to update him/her to the change in condition. In the event the primary physician cannot be notified, attempt to contact the facility's medical director. 2. Record review of the admission record documented Resident #42 was admitted to the facility on [DATE] with the following diagnoses: type 2 diabetes mellitus, chronic obstructive pulmonary disease, chronic pain, generalized anxiety disorder, bipolar disorder, essential (primary) hypertension, atherosclerotic heart disease of native coronary artery (heart disease) without angina pectoris (chest pain), and primary osteoarthritis right shoulder. Review of the Nursing Progress note for Resident #42 dated 8/24/2022 at 5:49 AM authored by Staff E, Licensed Practical Nurse (LPN) reads This nurse heard noise come from pt. [patient] room. Entered pt. room visualized pt. on hands and knees at the side of the bed. Blood noted on floor, small amount of bleeding noted in right hairline, small bleeding area noted to right elbow. Assisted pt. back to bed. Bleeding to hairline stopped and steristrips applied. Bleeding area to right elbow cleansed and steristrips applied and dressing applied. Pt. denies any pain at this time. No other areas of discoloration noted at this time, ROM [range of motion] WNL [within normal limits], Vitals WNL. Neuro checks started. Left message for [Medical Doctor's name] on call service to notify, left message for Daughter [name]. Pt. resting comfortably in bed, bed in low position, call light and bedside table with fluids within reach. Review of the medical record for Resident #42 revealed no evidence of change in condition documentation, skin assessments or nursing progress notes indicating the physician or nurse practitioner were notified and wound care orders obtained. Review of the nursing progress note for Resident #42 dated 9/6/2022 at 10:45 PM reads, Swelling and redness noted to right elbow some serosanguinous discharge noted. No odor. This nurse dressed site until further evaluation. Review of the Nursing Progress note for Resident #42 dated 9/7/2022 at 6:14 AM reads, Noted that skin tear from previous fall is reddened, painful and warm to touch, with serosanguinous drainage. Call placed to [APRN's name] to notify, awaiting call back with any new orders. Dressing orders clarified and dressing in place CDI [clean, dry and intact]. Review of the Nursing Progress note for Resident #42 dated 9/7/2022 at 11:25 AM reads, Skin tear from previous fall right elbow, red, warm, and tender. ARNP did a wound culture, cleaned, and applied new dressing awaiting orders. Review of the treatment administration record for the month of August revealed no evidence of physician's orders related to care for the right elbow skin tear. Review of the treatment administration record for the month of September documented treatment to the right elbow skin tear began on 9/7/2022. There were no other orders related to care for the right elbow skin tear. Review of the physician order for Resident #42 dated 9/8/2022 reads, May insert midline with 1% lidocaine for IV ABX. Review of the physician order for Resident #42 dated 9/7/2022 reads Piperacillin Sod [sodium] - Tazobactam So [sodium] solution reconstituted 3.0-375 gm [gram], use 3.375 gram intravenously every 6 hours for infection for 10 days. Review of The IV Company document for Resident #42 dated 9/8/2022 reads Consultation: Reason for consultation: Midline: reason for insertion: drugs. Post insertion data - line removal: Line insertion: Midline Insertion site: left, attempts: 1; Basilic, blood return: positive; internal length 15; arm circumference: 32. Comments: Midline left basilic. No complications. Time in 1228 [12:28 PM], Time out: 1307 [1:07 PM]. Review of the lab results report for Resident #42 dated 9/13/2022 reads, Final Report: Microbiology report. Site: elbow right; Result: Staphylococcus aureus (isolate 1). During an interview on 9/13/2022 at 1:45 PM the DON stated, I see that there were no treatment orders in place for [Resident #42's name], after her fall. I do not see any provider notification or request for wound care orders for her skin tear. I see the culture and that she needed to have a midline and antibiotics for the infection of the skin tear. We should have asked for treatment orders, and we did not. I could see that you might consider that we did not provide her the proper care and it was part of the reason she needed the midline and antibiotics. I don't see any notes or a change of condition form in the chart where we notified the doctor or nurse practitioner until the arm was red and swollen. During an interview on 9/14/22 at 7:48 AM Resident #42 stated, I was having a lot of pain in my arm after I fell. I kept telling them, but they weren't listening. Finally, someone did and that's when they got the wound culture. No one would look at it when I asked and told them how much it was hurting me. They did not change the dressing on it at all. During an interview on 9/14/22 at 8:59 AM Staff E, Licensed Practical Nurse (LPN), stated, I did find her [Resident #42] on the floor. I heard a thud and found her on her knees on the floor. She had a skin tear and had a cut on her forehead. I assessed her and cleaned her forehead and right elbow. I was able to close the wound on her elbow with steristrips directly after she fell. I think I left a message for the nurse practitioner, but don't recall that she called back. We should follow up when a resident has any injuries and see if the practitioner wants any type of skin care done. I did not obtain any orders to treat her skin tear and I probably should have, but I did provide immediate treatment to her wounds. I did an assessment. I probably should have called the nurse practitioner back before I went off shift. During a telephone interview conducted on 9/14/2022 at 10:25 AM the APRN stated, I do not think that I was notified of the patient's fall until 9/6/2022 late in the evening, a nurse notified me that she had a red and draining arm from the skin tear. I gave orders for treatment and saw her the next day when I took a wound culture. I was not called and asked for any wound treatments prior to that time. I absolutely feel that the wound became infected due to a lack of wound care and that she would not have required additional treatments had she been provided daily wound care. I do feel this was a delay in treatment and caused a need for additional, more invasive treatments. I expect that staff will inform me of any changes in patient condition. All skin concerns should be addressed, and we should be called. During an interview conducted on 9/14/2022 at 2:10 PM the Regional Nurse Consultant stated, We have not provided change of condition notification to the providers for [Resident #42 and #29's names]. We were notified of the critical lab results for [Resident #29's name]. We did notify the provider. There is a note in the chart, but when the final culture was back, we did not call the provider. I don't see that there was information about whether the additional sensitivities were sensitive to the oral antibiotic he [Resident #29] was on. We should have called. There is no excuse that I could give you for why they weren't notified. [Resident #42's name] was not provided any wound care after the skin tear. We should have notified the physician or nurse practitioner and we should have gotten orders for wound care. I can't give you any clear reason why this was not done. She did have a need for a midline and antibiotics because the wound became infected. We did not do what we should have. Review of the policy and procedure titled Wound Care issue date of 4/1/2022 reads, Policy: It is the policy of this facility to provide assessment and identification of residents at risk of developing pressure injuries, other wounds and treatment of skin impairment. Procedure: 2. Skin will be assessed/evaluated for the presence of developing pressure injuries or other changes in skin condition on a weekly basis at least once each week or as needed by a licensed nurse. 11. Document the progression of the wound being treated. Such observations should include items size, staging (if applicable), odors, exudate, tunneling, etiology, etc. 12. Contact the physician for additional order changes as is appropriate or to notify of skin condition changes or refusals of care. The Immediate Jeopardy was removed onsite after the receipt of an acceptable immediate jeopardy removal plan. The survey team verified the facility's actions for removal of immediacy to prevent the likelihood of harm and/or possible death: Residents #29 and #42 were assessed for skin impairments and their physicians were notified on 9/13/2022. Ad Hoc QAPI [Quality Assurance Performance Improvement] was held on 9/13/2022 attended by Medical Director, Administrator, Director of Nursing, Infection Preventionist, and Social Services Director to implement a performance improvement plan. The facility has conducted root cause analysis on 9/14/2022 for delay in treatment and neglect. The facility completed skin assessments on 93 residents for any wound concerns and obtained orders for three additional residents identified with concerns. On 9/14/2022, the Administrator and Director of Nursing were educated by the Regional Director of Clinical Operations on the components of administration to include monitoring of facility systems during administrative/clinical stand up and standdown to identify areas that may rise to the level of investigating ANEMMI. By 9/16/2022, the facility trained 28 of 28 licensed nursing staff on change in condition, skin and wound care and abuse and neglect, which was verified through staff interviews.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility administration failed to administer the facility in a manner that enables it to attain and maintain the highest practicable physical well-being of each resident and to prevent medical neglect when the facility failed to notify the physician of critical laboratory results, wound culture results and wound care needs resulting in a delay in care and treatment for 2 of 2 residents, Residents #29 and #42. Delay in wound care treatment can result in the spread of infection into the deeper tissues of the body, the infection can travel through the blood to other parts of the body and could become life threatening. Findings include: Review of the job description for the Administrator with an effective date of 1/17/2022 reads, Purpose of your job position: The primary purpose of your position is to direct the day-to day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to assure the highest degree of quality care can be provided to our residents at all times. Delegation of Authority: As administrator you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. Duties and responsibilities: Administrative functions: Plan, develop, organize, implement, evaluate, and direct the facility's programs and activities in accordance with guidelines issued by the VP (Vice President) of operations. Develop and maintain written policies and procedures and professional standards of practice that govern the operation of the facility. Assist department directors in the development, use, and implementation of departmental policies and procedures and professional standards of practice. Ensure that all employees, residents, visitors, and the general public follow the facility's established policies and procedures. Review of the job description for the Director of Nursing Services dated 9/9/2021 reads, Purpose of your job position: The primary purpose of your position is to plan. organize, develop, and direct the overall operation of our nursing service department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility and as may be directed by the administrator to ensure the highest degree of quality care is maintained at all times. Duties and responsibilities, Administrative functions: Plan, develop, organize, implement, evaluate, and direct the nursing service department, as well as its programs and activities, in accordance with current rules, regulations, and guidelines that govern the nursing care facilities. Develop methods for coordination of nursing services with other resident services to ensure continuity of the resident's total regime of care, develop, implement, and maintain an ongoing quality assurance program for the nursing services department, perform administrative duties such as completing medical forms, reports, evaluations, studies, charting, etc. as necessary and monitor the facility's QI (quality improvement) QM (quality management) and survey reports. Assist in developing plans of actions to correct potential or identified problem areas. 1. Review of the admission record documented Resident #29 was admitted to the facility on [DATE] with the following diagnoses: encounter for surgical aftercare following surgery on the circulatory system, atherosclerotic heart disease of native coronary artery (heart disease) with angina pectoris (chest pain), acute systolic (congestive) heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), pleural effusion (fluid that builds up between the tissue that lines the lungs and the chest due to poor pumping of the heart), acute and chronic respiratory failure (a condition in which the lungs cannot get enough oxygen into the blood or remove the carbon dioxide) with hypoxia (low oxygen levels in the blood), pneumonia, cardiac pacemaker, pressure ulcer sacral region, stage 3, hyperlipidemia (high cholesterol), type 2 diabetes mellitus, major depressive disorder, right leg below the knee amputation, essential hypertension (high blood pressure), non ST elevation myocardial infarction (a heart attack), paroxysmal atrial fibrillation (an irregular heart beat), peripheral vascular disease (a blood circulation disorder that causes the blood vessels to narrow), chronic kidney disease, and left below the knee amputation. Review of the Tissue Analytics (TA) wound care note for Resident #29 dated 8/29/2022 reads, Sacral wound 1.97 cm [centimeters] x 3.33 cm x 0.20 cm cleanse with n/s [normal saline] Med Honey, calcium alginate cover with bordered gauze, daily. In house acquired 8/23/22, Recommendation: obtain wound culture d/t [due to] increased deterioration. Recommend start Doxycycline pending wound culture results. Review of the physician order for Resident #29 dated 8/29/2022 reads, Doxycycline Hyclate 100 mg [milligrams] 1 tablet by mouth two times a day for wound infection. Start med [medication] after wound is cultured for 7 days. Review of the lab results report for Resident #29 dated 8/30/2022 titled Wound culture 1 reads, Critical result called to [Director of Nursing's (DON) name] on 9/2/2022 11:42 AM by [Laboratory technician's name]. Results were read back to caller. Site: Coccyx. Result: Heavy growth Gram Positive Cocci: Staphylococcus Aureus (isolate 1) This isolate is Methicillin Resistant (MRSA). Review of the nursing progress note for Resident #29 dated 9/2/22 at 1307 (1:07 PM) reads, ARNP [Advanced Registered Nurse Practitioner] aware of coccyx culture, awaiting final results and sensitivity for further evaluation of tx [treatment] plan. Review of the lab results report for Resident #29 dated 8/30/2022 titled Wound culture 1 reads, Report information: Collection date: 8/30/2022 02:30 [AM]; Received date: 8/30/2022 14:51 [2:51 PM]; Report date: 9/3/2022 10:08 [AM]. Final Report: Result: Heavy growth normal skin flora, heavy growth gram positive cocci. staphylococcus aureus (Isolate 1) This isolate is Methicillin Resistant (MRSA). Moderate growth gram negative rods. Morganella Morganii spp morganii (Isolate 2), Proteus mirabilis (Isolate 3) Pseudomonas aeruginosa (Isolate 4). Sensitivity Analysis: Tetracycline <=1 S for isolate 1. [Susceptible] There was no sensitivity analysis documented for additional isolates 2, 3 and 4. [A sensitivity test checks to see what kind of medicine, such as an antibiotic, will work best to treat the illness or infection]. Review of the medical record for Resident #29 does not document the physician or Advanced Practice Registered Nurse (APRN) were notified of the final culture report dated 9/3/2022 through 9/7/2022. Review of the physician order for Resident #29 dated 9/7/2022 reads, Midline/PICC [peripherally inserted central catheter] placement for IV [intravenous] ABX [antibiotics]. Review of the physician order for Resident #29 dated 9/10/2022 reads, Gentamycin Sulfate solution use 90 mg [milligrams] every 12 hours. For MRSA wounds for 10 days in 0.9% NSS [normal saline solution] 100 ml [milliliters]. Review of the document from The IV Company for Resident #29 dated 9/8/2022 reads, Consultation: Reason for consultation: Midline; reason for insertion: drugs. Post insertion data -line removal: Line insertion: Midline Insertion site: left, attempts: 1; Cephalic, blood return: positive; internal length 15; arm circumference: 33. Comments: Midline left cephalic. No complications. Time in 1333 [1:33 PM], Time out: 1353 [1:53 PM]. During an interview on 9/14/2022 at 8:05 AM, the Director of Nursing (DON) stated, I did not call the nurse practitioner with the critical lab result of the wound. I gave it to the nurse. I don't see that the critical lab result was called. The lab result should have been called. I'm not sure why it wasn't. There is no progress note and no change of condition done. We failed this resident [Resident #29]. We did not do what we should have for the resident. I did not make sure that the staff called the practitioner. I was not aware that the final culture results weren't called. We should have called the results to the nurse practitioner. During an interview on 9/14/2022 at 10:38 AM, the Advanced Practice Registered Nurse (APRN) stated, I was not notified of any critical lab results. I saw the full wound culture report the day that I ordered the midline and antibiotics because the Gentamycin covered everything that was present in the coccyx wound culture. I believe I was notified that the culture report was back on 9/7/2022. I would have changed the antibiotics to IV Gentamycin sooner had I been notified. I would have discontinued the Doxycycline on 9/3/2022 because it did not cover the other organisms. I would say this was a delay in care. He [Resident #29] definitely could have worsened without appropriate treatment and the appropriate antibiotics for his wound. I expect that all labs will be called so we can provide care that is appropriate for any given infection. During an interview on 9/15/2022 at 10:35 AM Staff F, Registered Nurse (RN) stated, I did speak with [APRN's name] on September 2, to let her know that the coccyx wound culture had MRSA, but the rest of the culture was not available. I was not on the next several days and did not call the culture reports. There is no documentation that anyone called the doctor or the practitioner. They should have. I finally called [APRN's name] and she came in and ordered the midline and the antibiotics. Review of the lab results report for Resident #29 dated 9/11/2022 reads, Gentamicin trough result: 5.4 mcg [micrograms]/ml [milliliter]. Critical lab result called to [Staff name] on 9/11/2022 1:40 PM by [Laboratory staff name]. Results were read back to caller. [Aiming for a level of < 1 mcg/mL approximately 6 hours prior to the next dose ensure there is a drug-free window in order to minimize drug accumulation within proximal tubules/major component of the kidney]. Review of the medical record for Resident #29 does not document the physician, pharmacist or APRN were notified of the critical laboratory result. Review of the lab results report for Resident #29 dated 9/12/2022 reads, Gentamycin trough result: 2.6 mcg/ml. Critical lab result called to [Staff name] on 9/13/2022 at 11:47 AM by [Laboratory Staff name]. Results were read back to caller. Review of the medical record does not document the physician, pharmacist or APRN were notified of the critical laboratory result. During an interview on 9/15/2022 at 11:15 AM the Medical Director stated I understand that the culture reports were not called to the physician or mid-level. I told them that there were two different areas, and they are independent of one another, and no one should wait for another culture of a different area to come back. This is a breach of protocol and this needs to be improved. We have much space for improvement and training and education needs to be done for the staff. We need to reach a better-quality matrix for the residents, and I think we will. All critical lab reports should be called to the physicians. During an interview on 9/15/2022 at 3:10 PM the DON stated, It does not look like we have called these results [Gentamycin trough results] to the pharmacist or the nurse practitioner. They are critical results and should be called immediately. We usually have a doctor's order to have pharmacy dose gentamicin, I don't know why we don't. I see there were two critical results and neither of them were called when they should have been. During a telephone interview on 9/16/2022 at 9:22 AM the pharmacist stated, We were not informed of the critical gentamycin trough that was completed on 9/11/2022. We did attempt to contact the facility multiple times and have notes to indicate that multiple messages were left requesting that the nursing staff call us back and they did not. I see a note that we spoke to [Staff O, Licensed Practical Nurse's name] on 9/13/2022, we recommended that the gentamycin dose get reduced to 80 mg twice a day and a repeat peak and trough be completed after the second dose. We are having a hard time maintaining communication with the nurses. The gentamycin is currently on hold until we get another peak and trough and then we will decide further dosing. The potential side effects would be damage to the eight cranial nerves which would have an effect on hearing, causing possible hearing loss and nephrotoxicity [a rapid decline in kidney function due to toxic effects of medications]. Review of the policy and procedure titled ANE (Abuse, Neglect and Exploitation) and Investigations issue date of 4/1/2022 reads Policy: It will be the policy of this facility honor resident rights and address with employees the seven (7) components regarding mistreatment, abuse, neglect, sexual misconduct, injuries of unknown source, involuntary seclusion, corporal punishment, misappropriation of resident property or funds or use of physical or chemical restraint not required to treat the residents symptoms in accordance with federal law. It will be the policy of this facility to ensure that all alleged violations of federal or state laws, which include mistreatment, neglect, abuse (verbal mental physical or sexual, injuries of undetermined source, involuntary seclusion, corporal punishment, misappropriation of resident property or funds or use of physical or chemical restraint) not in accordance with regulation to treat residents' symptoms will be reported immediately to the administrator/DNS abuse coordinator designee. Appropriate agencies will be notified in accordance with existing laws. Definitions: Neglect is the failure of the facility, 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. 3. Prevention: Staff, residents, and resident representatives will be instructed of how to identify and report concerns, events, and grievances. They will also be given the name of the facilities designated abuse contact person as well as numbers for state agencies. This will be done through resident council, family council, in service training, one to one if indicated, information posted in the facility. The facility environment will be monitored to prevent any additional ANE through: Monitoring staff actions while caring for residents. The facility will monitor reported events to determine if any pattern, trend, or frequency exists to attempt to minimize the occurrence or injury. All events will be addressed at the monthly Quality Assurance Performance Improvement (QAPI) meeting. Review of the policy and procedure titled, Lab and Diagnostic Results - Clinical Protocol with an approval date of 1/27/2022 reads, Review by Nursing: 1. When test reports are reported to the facility, a nurse will first review the results. a. If staff who first receive or review lab and diagnostic test results cannot follow the remainder of this procedure for reporting and documenting the results and their implications, another nurse in the facility (supervisor, charge nurse, etc.) should follow or coordinate the procedure. 2. Before contacting the physician, the person who is to communicate results to a physician will gather, review, and organize the information and be prepared to discuss the following (to the extent that such information is available): c. Why the lab and diagnostic tests were obtained (for example, as a routine screening or follow up); to assess a condition change or recent onset of signs and symptoms, or to monitor a serum medication level; d. How test results may relate to the individual's current condition and treatment. 3. A nurse will identify the urgency of communicating, with the Attending Physician based on physician request, seriousness of any abnormality, and the individual's current condition. 4. A nurse will try to determine whether the test was done: b. To assess a condition change or recent onset of signs and symptoms. Identifying situations that warrant immediate notification: 1. Nursing staff will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results: Whether the result should be conveyed to a physician regardless of other circumstances (that is, the abnormal result is problematic regardless of any other factors); Whether the resident/patients' clinical status is unclear or he/she has signs of acute illness or condition change and is not stable or improving, or there are no previous results for comparison. Options for physician notification: 1. A physician can be notified by phone, fax voicemail, e-mail, mail, pager, or a telephone message to another person acting as the physician's agent (for example, office staff) b. Direct voice communication with the physician is the preferred means for presenting any results requiring immediate notification, especially when the resident's clinical status is unstable or current treatment needs review or clarification. Review of the policy and procedure titled Change in Condition issued on 4/1/2022 reads Policy: It will be the policy of this facility to notify the physician, family, resident, and/or responsible party/resident representative (as is applicable) of significant changes in condition and providing treatment(s) according to the residents wishes and physician orders. Procedure: 2. When a change is noted, gather pertinent data such as vital signs, weights, and other clinical observations. 4. When significant changes in skin condition or weight are noted it is appropriate to contact the physician and responsible party/resident representative if applicable to notify them and receive orders such as consultations, root cause analysis or implementation of further monitoring. 7. Contact the primary physician to update him/her to the change in condition. In the event the primary physician cannot be notified, attempt to contact the facility's medical director. 2. Record review of the admission record documented Resident #42 was admitted to the facility on [DATE] with the following diagnoses: type 2 diabetes mellitus, chronic obstructive pulmonary disease, chronic pain, generalized anxiety disorder, bipolar disorder, essential (primary) hypertension, atherosclerotic heart disease of native coronary artery (heart disease) without angina pectoris (chest pain), and primary osteoarthritis right shoulder. Review of the Nursing Progress note for Resident #42 dated 8/24/2022 at 5:49 AM authored by Staff E, Licensed Practical Nurse (LPN) reads This nurse heard noise come from pt. [patient] room. Entered pt. room visualized pt. on hands and knees at the side of the bed. Blood noted on floor, small amount of bleeding noted in right hairline, small bleeding area noted to right elbow. Assisted pt. back to bed. Bleeding to hairline stopped and steristrips applied. Bleeding area to right elbow cleansed and steristrips applied and dressing applied. Pt. denies any pain at this time. No other areas of discoloration noted at this time, ROM [range of motion] WNL [within normal limits], Vitals WNL. Neuro checks started. Left message for [Medical Doctor's name] on call service to notify, left message for Daughter [name]. Pt. resting comfortably in bed, bed in low position, call light and bedside table with fluids within reach. Review of the medical record for Resident #42 revealed no evidence of change in condition documentation, skin assessments or nursing progress notes indicating the physician or nurse practitioner were notified and wound care orders obtained. Review of the nursing progress note for Resident #42 dated 9/6/2022 at 10:45 PM reads, Swelling and redness noted to right elbow some serosanguinous discharge noted. No odor. This nurse dressed site until further evaluation. Review of the Nursing Progress note for Resident #42 dated 9/7/2022 at 6:14 AM reads, Noted that skin tear from previous fall is reddened, painful and warm to touch, with serosanguinous drainage. Call placed to [APRN's name] to notify, awaiting call back with any new orders. Dressing orders clarified and dressing in place CDI [clean, dry and intact]. Review of the Nursing Progress note for Resident #42 dated 9/7/2022 at 11:25 AM reads, Skin tear from previous fall right elbow, red, warm, and tender. ARNP did a wound culture, cleaned, and applied new dressing awaiting orders. Review of the treatment administration record for the month of August revealed no evidence of physician's orders related to care for the right elbow skin tear. Review of the treatment administration record for the month of September documented treatment to the right elbow skin tear began on 9/7/2022. There were no other orders related to care for the right elbow skin tear. Review of the physician order for Resident #42 dated 9/8/2022 reads, May insert midline with 1% lidocaine for IV ABX. Review of the physician order for Resident #42 dated 9/7/2022 reads Piperacillin Sod [sodium] - Tazobactam So [sodium] solution reconstituted 3.0-375 gm [gram], use 3.375 gram intravenously every 6 hours for infection for 10 days. Review of The IV Company document for Resident #42 dated 9/8/2022 reads Consultation: Reason for consultation: Midline: reason for insertion: drugs. Post insertion data - line removal: Line insertion: Midline Insertion site: left, attempts: 1; Basilic, blood return: positive; internal length 15; arm circumference: 32. Comments: Midline left basilic. No complications. Time in 1228 [12:28 PM], Time out: 1307 [1:07 PM]. Review of the lab results report for Resident #42 dated 9/13/2022 reads, Final Report: Microbiology report. Site: elbow right; Result: Staphylococcus aureus (isolate 1). During an interview on 9/13/2022 at 1:45 PM the DON stated, I see that there were no treatment orders in place for [Resident #42's name], after her fall. I do not see any provider notification or request for wound care orders for her skin tear. I see the culture and that she needed to have a midline and antibiotics for the infection of the skin tear. We should have asked for treatment orders, and we did not. I could see that you might consider that we did not provide her the proper care and it was part of the reason she needed the midline and antibiotics. I don't see any notes or a change of condition form in the chart where we notified the doctor or nurse practitioner until the arm was red and swollen. During an interview on 9/14/22 at 7:48 AM Resident #42 stated, I was having a lot of pain in my arm after I fell. I kept telling them, but they weren't listening. Finally, someone did and that's when they got the wound culture. No one would look at it when I asked and told them how much it was hurting me. They did not change the dressing on it at all. During an interview on 9/14/22 at 8:59 AM Staff E, Licensed Practical Nurse (LPN), stated, I did find her [Resident #42] on the floor. I heard a thud and found her on her knees on the floor. She had a skin tear and had a cut on her forehead. I assessed her and cleaned her forehead and right elbow. I was able to close the wound on her elbow with steristrips directly after she fell. I think I left a message for the nurse practitioner, but don't recall that she called back. We should follow up when a resident has any injuries and see if the practitioner wants any type of skin care done. I did not obtain any orders to treat her skin tear and I probably should have, but I did provide immediate treatment to her wounds. I did an assessment. I probably should have called the nurse practitioner back before I went off shift. During a telephone interview conducted on 9/14/2022 at 10:25 AM the APRN stated, I do not think that I was notified of the patient's fall until 9/6/2022 late in the evening, a nurse notified me that she had a red and draining arm from the skin tear. I gave orders for treatment and saw her the next day when I took a wound culture. I was not called and asked for any wound treatments prior to that time. I absolutely feel that the wound became infected due to a lack of wound care and that she would not have required additional treatments had she been provided daily wound care. I do feel this was a delay in treatment and caused a need for additional, more invasive treatments. I expect that staff will inform me of any changes in patient condition. All skin concerns should be addressed, and we should be called. During an interview conducted on 9/14/2022 at 2:10 PM the Regional Nurse Consultant stated, We have not provided change of condition notification to the providers for [Resident #42 and #29's names]. We were notified of the critical lab results for [Resident #29's name]. We did notify the provider. There is a note in the chart, but when the final culture was back, we did not call the provider. I don't see that there was information about whether the additional sensitivities were sensitive to the oral antibiotic he [Resident #29] was on. We should have called. There is no excuse that I could give you for why they weren't notified. [Resident #42's name] was not provided any wound care after the skin tear. We should have notified the physician or nurse practitioner and we should have gotten orders for wound care. I can't give you any clear reason why this was not done. She did have a need for a midline and antibiotics because the wound became infected. We did not do what we should have. During an interview on 9/15/2022 at 1:25 PM the Director of Nursing stated, I should have reviewed and brought both concerns to QAPI [Quality Assurance and Performance Improvement] when we did not complete the skin assessments and when we needed to get midlines and antibiotics. We should have completed full house skin sweeps and identified any other concerns. Absolutely should have investigated these and brought them to QAPI. We failed the residents, and we can do much better. During an interview on 9/16/2022 at 9:05 AM the Administrator stated, I am ultimately responsible for the running of the facility, but the Director of Nursing is responsible for all the clinical operations. Review of the policy and procedure titled Wound Care issue date of 4/1/2022 reads, Policy: It is the policy of this facility to provide assessment and identification of residents at risk of developing pressure injuries, other wounds and treatment of skin impairment. Procedure: 2. Skin will be assessed/evaluated for the presence of developing pressure injuries or other changes in skin condition on a weekly basis at least once each week or as needed by a licensed nurse. 11. Document the progression of the wound being treated. Such observations should include items size, staging (if applicable), odors, exudate, tunneling, etiology, etc. 12. Contact the physician for additional order changes as is appropriate or to notify of skin condition changes or refusals of care. The Immediate Jeopardy was removed onsite after the receipt of an acceptable immediate jeopardy removal plan. The survey team verified the facility's actions for removal of immediacy to prevent the likelihood of harm and/or possible death: Residents #29 and #42 were assessed for skin impairments and their physicians were notified on 9/13/2022. Ad Hoc QAPI [Quality Assurance Performance Improvement] was held on 9/13/2022 attended by Medical Director, Administrator, Director of Nursing, Infection Preventionist, and Social Services Director to implement a performance improvement plan. The facility has conducted root cause analysis on 9/14/2022 for delay in treatment and neglect. The facility completed skin assessments on 93 residents for any wound concerns and obtained orders for three additional residents identified with concerns. On 9/14/2022, the Administrator and Director of Nursing were educated by the Regional Director of Clinical Operations on the components of administration to include monitoring of facility systems during administrative/clinical stand up and standdown to identify areas that may rise to the level of investigating ANEMMI. By 9/16/2022, the facility trained 28 of 28 licensed nursing staff on change in condition, skin and wound care and abuse and neglect, which was verified through staff interviews.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to utilize the Quality Assessment and Process Improvement (QAPI) process when the administrative staff failed to investigate, develop, and implement appropriate plans of correction to identify and correct quality deficiencies of the facility failing to notify the physician of critical laboratory results, wound culture results and wound care needs resulting in a delay in care and treatment for 2 of 2 residents, Residents #29 and #42. Delay in wound care treatment can result in the spread of infection into the deeper tissues of the body, the infection can travel through the blood to other parts of the body and could become life threatening. Findings Include: 1. Review of the admission record documented Resident #29 was admitted to the facility on [DATE] with the following diagnoses: encounter for surgical aftercare following surgery on the circulatory system, atherosclerotic heart disease of native coronary artery (heart disease) with angina pectoris (chest pain), acute systolic (congestive) heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), pleural effusion (fluid that builds up between the tissue that lines the lungs and the chest due to poor pumping of the heart), acute and chronic respiratory failure (a condition in which the lungs cannot get enough oxygen into the blood or remove the carbon dioxide) with hypoxia (low oxygen levels in the blood), pneumonia, cardiac pacemaker, pressure ulcer sacral region, stage 3, hyperlipidemia (high cholesterol), type 2 diabetes mellitus, major depressive disorder, right leg below the knee amputation, essential hypertension (high blood pressure), non ST elevation myocardial infarction (a heart attack), paroxysmal atrial fibrillation (an irregular heart beat), peripheral vascular disease (a blood circulation disorder that causes the blood vessels to narrow), chronic kidney disease, and left below the knee amputation. Review of the Tissue Analytics (TA) wound care note for Resident #29 dated 8/29/2022 reads, Sacral wound 1.97 cm [centimeters] x 3.33 cm x 0.20 cm cleanse with n/s [normal saline] Med Honey, calcium alginate cover with bordered gauze, daily. In house acquired 8/23/22, Recommendation: obtain wound culture d/t [due to] increased deterioration. Recommend start Doxycycline pending wound culture results. Review of the physician order for Resident #29 dated 8/29/2022 reads, Doxycycline Hyclate 100 mg [milligrams] 1 tablet by mouth two times a day for wound infection. Start med [medication] after wound is cultured for 7 days. Review of the lab results report for Resident #29 dated 8/30/2022 titled Wound culture 1 reads, Critical result called to [Director of Nursing's (DON) name] on 9/2/2022 11:42 AM by [Laboratory technician's name]. Results were read back to caller. Site: Coccyx. Result: Heavy growth Gram Positive Cocci: Staphylococcus Aureus (isolate 1) This isolate is Methicillin Resistant (MRSA). Review of the nursing progress note for Resident #29 dated 9/2/22 at 1307 (1:07 PM) reads, ARNP [Advanced Registered Nurse Practitioner] aware of coccyx culture, awaiting final results and sensitivity for further evaluation of tx [treatment] plan. Review of the lab results report for Resident #29 dated 8/30/2022 titled Wound culture 1 reads, Report information: Collection date: 8/30/2022 02:30 [AM]; Received date: 8/30/2022 14:51 [2:51 PM]; Report date: 9/3/2022 10:08 [AM]. Final Report: Result: Heavy growth normal skin flora, heavy growth gram positive cocci. staphylococcus aureus (Isolate 1) This isolate is Methicillin Resistant (MRSA). Moderate growth gram negative rods. Morganella Morganii spp morganii (Isolate 2), Proteus mirabilis (Isolate 3) Pseudomonas aeruginosa (Isolate 4). Sensitivity Analysis: Tetracycline <=1 S for isolate 1. [Susceptible] There was no sensitivity analysis documented for additional isolates 2, 3 and 4. [A sensitivity test checks to see what kind of medicine, such as an antibiotic, will work best to treat the illness or infection]. Review of the medical record for Resident #29 does not document the physician or Advanced Practice Registered Nurse (APRN) were notified of the final culture report dated 9/3/2022 through 9/7/2022. Review of the physician order for Resident #29 dated 9/7/2022 reads, Midline/PICC [peripherally inserted central catheter] placement for IV [intravenous] ABX [antibiotics]. Review of the physician order for Resident #29 dated 9/10/2022 reads, Gentamycin Sulfate solution use 90 mg [milligrams] every 12 hours. For MRSA wounds for 10 days in 0.9% NSS [normal saline solution] 100 ml [milliliters]. Review of the document from The IV Company for Resident #29 dated 9/8/2022 reads, Consultation: Reason for consultation: Midline; reason for insertion: drugs. Post insertion data -line removal: Line insertion: Midline Insertion site: left, attempts: 1; Cephalic, blood return: positive; internal length 15; arm circumference: 33. Comments: Midline left cephalic. No complications. Time in 1333 [1:33 PM], Time out: 1353 [1:53 PM]. During an interview on 9/14/2022 at 8:05 AM, the Director of Nursing (DON) stated, I did not call the nurse practitioner with the critical lab result of the wound. I gave it to the nurse. I don't see that the critical lab result was called. The lab result should have been called. I'm not sure why it wasn't. There is no progress note and no change of condition done. We failed this resident [Resident #29]. We did not do what we should have for the resident. I did not make sure that the staff called the practitioner. I was not aware that the final culture results weren't called. We should have called the results to the nurse practitioner. During an interview on 9/14/2022 at 10:38 AM, the Advanced Practice Registered Nurse (APRN) stated, I was not notified of any critical lab results. I saw the full wound culture report the day that I ordered the midline and antibiotics because the Gentamycin covered everything that was present in the coccyx wound culture. I believe I was notified that the culture report was back on 9/7/2022. I would have changed the antibiotics to IV Gentamycin sooner had I been notified. I would have discontinued the Doxycycline on 9/3/2022 because it did not cover the other organisms. I would say this was a delay in care. He [Resident #29] definitely could have worsened without appropriate treatment and the appropriate antibiotics for his wound. I expect that all labs will be called so we can provide care that is appropriate for any given infection. During an interview on 9/15/2022 at 10:35 AM Staff F, Registered Nurse (RN) stated, I did speak with [APRN's name] on September 2, to let her know that the coccyx wound culture had MRSA, but the rest of the culture was not available. I was not on the next several days and did not call the culture reports. There is no documentation that anyone called the doctor or the practitioner. They should have. I finally called [APRN's name] and she came in and ordered the midline and the antibiotics. Review of the lab results report for Resident #29 dated 9/11/2022 reads, Gentamicin trough result: 5.4 mcg [micrograms]/ml [milliliter]. Critical lab result called to [Staff name] on 9/11/2022 1:40 PM by [Laboratory staff name]. Results were read back to caller. [Aiming for a level of < 1 mcg/mL approximately 6 hours prior to the next dose ensure there is a drug-free window in order to minimize drug accumulation within proximal tubules/major component of the kidney]. Review of the medical record for Resident #29 does not document the physician, pharmacist or APRN were notified of the critical laboratory result. Review of the lab results report for Resident #29 dated 9/12/2022 reads, Gentamycin trough result: 2.6 mcg/ml. Critical lab result called to [Staff name] on 9/13/2022 at 11:47 AM by [Laboratory Staff name]. Results were read back to caller. Review of the medical record does not document the physician, pharmacist or APRN were notified of the critical laboratory result. During an interview on 9/15/2022 at 11:15 AM the Medical Director stated I understand that the culture reports were not called to the physician or mid-level. I told them that there were two different areas, and they are independent of one another, and no one should wait for another culture of a different area to come back. This is a breach of protocol and this needs to be improved. We have much space for improvement and training and education needs to be done for the staff. We need to reach a better-quality matrix for the residents, and I think we will. All critical lab reports should be called to the physicians. During an interview on 9/15/2022 at 3:10 PM the DON stated, It does not look like we have called these results [Gentamycin trough results] to the pharmacist or the nurse practitioner. They are critical results and should be called immediately. We usually have a doctor's order to have pharmacy dose gentamicin, I don't know why we don't. I see there were two critical results and neither of them were called when they should have been. During a telephone interview on 9/16/2022 at 9:22 AM the pharmacist stated, We were not informed of the critical gentamycin trough that was completed on 9/11/2022. We did attempt to contact the facility multiple times and have notes to indicate that multiple messages were left requesting that the nursing staff call us back and they did not. I see a note that we spoke to [Staff O, Licensed Practical Nurse's name] on 9/13/2022, we recommended that the gentamycin dose get reduced to 80 mg twice a day and a repeat peak and trough be completed after the second dose. We are having a hard time maintaining communication with the nurses. The gentamycin is currently on hold until we get another peak and trough and then we will decide further dosing. The potential side effects would be damage to the eight cranial nerves which would have an effect on hearing, causing possible hearing loss and nephrotoxicity [a rapid decline in kidney function due to toxic effects of medications]. During an interview on 9/15/2022 at 1:25 PM the Director of Nursing stated, I should have reviewed and brought both concerns to QAPI when we did not complete the skin assessments and when we needed to get midlines and antibiotics. We should have completed full house skin sweeps and identified any other concerns. Absolutely we should have investigated these and brought them to QAPI. We failed the residents, and we can do much better. Review of the policy and procedure titled Quality Assurance and Performance Improvement Program the last approval date of 12/7/2022 reads, Policy Statement: The facility shall develop, implement, and maintain an ongoing facility wide quality assurance and performance improvement program that builds on the quality assessment and assurance program to actively pursue quality of care and quality of life goals. Policy interpretation and implementation the primary purpose of the quality assurance and performance improvement plan is to establish data- driven, facility wide processes that improve the quality of care, quality of life and clinical outcomes of our residents. Five strategic elements: 3. feedback, data systems and monitoring. A. Systems are in place to monitor care and services. B. Systems are designed to incorporate feedback from caregivers, residence, family, and staff as appropriate. C. Care processes and outcomes are monitored using performance indicators. These performance indicators are measured against quality benchmarks and targets that the facility has established. D. Adverse events are tracked, monitored, and investigated as they occur. E. Action plans are implemented to prevent recurrence of adverse events. QAPI action steps: 13. Gathering and using QAPI data in an organized and meaningful way. Areas that may be appropriate to monitor and evaluate include a. clinical outcomes: pressure ulcers, infections, medication use, pain, falls, etc. 14. Set measurable goals for improvement that may include percentage of reductions (or increases) from the measured baseline of a particular goal. 16. Recognizing patterns in systems of care that can be associated with quality problems. 17. Prioritizing identified quality issues based on risk of harm and frequency of occurrence and determining which will become the focus of PIPS [Performance Improvement Plans].18. Planning, conducting and documenting PIPS.19. Conducting root cause analysis to identify the issues that contribute to recognized problems. 20. Taking systematic action targeted at the root causes of identified problems. This encompasses the utilization of corrective actions that provides significant and meaningful steps to improve processes and do not depend on staff to simply do the right thing. Review of the policy and procedure titled ANE (Abuse, Neglect and Exploitation) and Investigations issue date of 4/1/2022 reads Policy: It will be the policy of this facility honor resident rights and address with employees the seven (7) components regarding mistreatment, abuse, neglect, sexual misconduct, injuries of unknown source, involuntary seclusion, corporal punishment, misappropriation of resident property or funds or use of physical or chemical restraint not required to treat the residents symptoms in accordance with federal law. It will be the policy of this facility to ensure that all alleged violations of federal or state laws, which include mistreatment, neglect, abuse (verbal mental physical or sexual, injuries of undetermined source, involuntary seclusion, corporal punishment, misappropriation of resident property or funds or use of physical or chemical restraint) not in accordance with regulation to treat residents' symptoms will be reported immediately to the administrator/DNS abuse coordinator designee. Appropriate agencies will be notified in accordance with existing laws. Definitions: Neglect is the failure of the facility, 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. 3. Prevention: Staff, residents, and resident representatives will be instructed of how to identify and report concerns, events, and grievances. They will also be given the name of the facilities designated abuse contact person as well as numbers for state agencies. This will be done through resident council, family council, in service training, one to one if indicated, information posted in the facility. The facility environment will be monitored to prevent any additional ANE through: Monitoring staff actions while caring for residents. The facility will monitor reported events to determine if any pattern, trend, or frequency exists to attempt to minimize the occurrence or injury. All events will be addressed at the monthly Quality Assurance Performance Improvement (QAPI) meeting. Review of the policy and procedure titled, Lab and Diagnostic Results - Clinical Protocol with an approval date of 1/27/2022 reads, Review by Nursing: 1. When test reports are reported to the facility, a nurse will first review the results. a. If staff who first receive or review lab and diagnostic test results cannot follow the remainder of this procedure for reporting and documenting the results and their implications, another nurse in the facility (supervisor, charge nurse, etc.) should follow or coordinate the procedure. 2. Before contacting the physician, the person who is to communicate results to a physician will gather, review, and organize the information and be prepared to discuss the following (to the extent that such information is available): c. Why the lab and diagnostic tests were obtained (for example, as a routine screening or follow up); to assess a condition change or recent onset of signs and symptoms, or to monitor a serum medication level; d. How test results may relate to the individual's current condition and treatment. 3. A nurse will identify the urgency of communicating, with the Attending Physician based on physician request, seriousness of any abnormality, and the individual's current condition. 4. A nurse will try to determine whether the test was done: b. To assess a condition change or recent onset of signs and symptoms. Identifying situations that warrant immediate notification: 1. Nursing staff will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results: Whether the result should be conveyed to a physician regardless of other circumstances (that is, the abnormal result is problematic regardless of any other factors); Whether the resident/patients' clinical status is unclear or he/she has signs of acute illness or condition change and is not stable or improving, or there are no previous results for comparison. Options for physician notification: 1. A physician can be notified by phone, fax voicemail, e-mail, mail, pager, or a telephone message to another person acting as the physician's agent (for example, office staff) b. Direct voice communication with the physician is the preferred means for presenting any results requiring immediate notification, especially when the resident's clinical status is unstable or current treatment needs review or clarification. Review of the policy and procedure titled Change in Condition issued on 4/1/2022 reads Policy: It will be the policy of this facility to notify the physician, family, resident, and/or responsible party/resident representative (as is applicable) of significant changes in condition and providing treatment(s) according to the residents wishes and physician orders. Procedure: 2. When a change is noted, gather pertinent data such as vital signs, weights, and other clinical observations. 4. When significant changes in skin condition or weight are noted it is appropriate to contact the physician and responsible party/resident representative if applicable to notify them and receive orders such as consultations, root cause analysis or implementation of further monitoring. 7. Contact the primary physician to update him/her to the change in condition. In the event the primary physician cannot be notified, attempt to contact the facility's medical director. 2. Record review of the admission record documented Resident #42 was admitted to the facility on [DATE] with the following diagnoses: type 2 diabetes mellitus, chronic obstructive pulmonary disease, chronic pain, generalized anxiety disorder, bipolar disorder, essential (primary) hypertension, atherosclerotic heart disease of native coronary artery (heart disease) without angina pectoris (chest pain), and primary osteoarthritis right shoulder. Review of the Nursing Progress note for Resident #42 dated 8/24/2022 at 5:49 AM authored by Staff E, Licensed Practical Nurse (LPN) reads This nurse heard noise come from pt. [patient] room. Entered pt. room visualized pt. on hands and knees at the side of the bed. Blood noted on floor, small amount of bleeding noted in right hairline, small bleeding area noted to right elbow. Assisted pt. back to bed. Bleeding to hairline stopped and steristrips applied. Bleeding area to right elbow cleansed and steristrips applied and dressing applied. Pt. denies any pain at this time. No other areas of discoloration noted at this time, ROM [range of motion] WNL [within normal limits], Vitals WNL. Neuro checks started. Left message for [Medical Doctor's name] on call service to notify, left message for Daughter [name]. Pt. resting comfortably in bed, bed in low position, call light and bedside table with fluids within reach. Review of the medical record for Resident #42 revealed no evidence of change in condition documentation, skin assessments or nursing progress notes indicating the physician or nurse practitioner were notified and wound care orders obtained. Review of the nursing progress note for Resident #42 dated 9/6/2022 at 10:45 PM reads, Swelling and redness noted to right elbow some serosanguinous discharge noted. No odor. This nurse dressed site until further evaluation. Review of the Nursing Progress note for Resident #42 dated 9/7/2022 at 6:14 AM reads, Noted that skin tear from previous fall is reddened, painful and warm to touch, with serosanguinous drainage. Call placed to [APRN's name] to notify, awaiting call back with any new orders. Dressing orders clarified and dressing in place CDI [clean, dry and intact]. Review of the Nursing Progress note for Resident #42 dated 9/7/2022 at 11:25 AM reads, Skin tear from previous fall right elbow, red, warm, and tender. ARNP did a wound culture, cleaned, and applied new dressing awaiting orders. Review of the treatment administration record for the month of August revealed no evidence of physician's orders related to care for the right elbow skin tear. Review of the treatment administration record for the month of September documented treatment to the right elbow skin tear began on 9/7/2022. There were no other orders related to care for the right elbow skin tear. Review of the physician order for Resident #42 dated 9/8/2022 reads, May insert midline with 1% lidocaine for IV ABX. Review of the physician order for Resident #42 dated 9/7/2022 reads Piperacillin Sod [sodium] - Tazobactam So [sodium] solution reconstituted 3.0-375 gm [gram], use 3.375 gram intravenously every 6 hours for infection for 10 days. Review of The IV Company document for Resident #42 dated 9/8/2022 reads Consultation: Reason for consultation: Midline: reason for insertion: drugs. Post insertion data - line removal: Line insertion: Midline Insertion site: left, attempts: 1; Basilic, blood return: positive; internal length 15; arm circumference: 32. Comments: Midline left basilic. No complications. Time in 1228 [12:28 PM], Time out: 1307 [1:07 PM]. Review of the lab results report for Resident #42 dated 9/13/2022 reads, Final Report: Microbiology report. Site: elbow right; Result: Staphylococcus aureus (isolate 1). During an interview on 9/13/2022 at 1:45 PM the DON stated, I see that there were no treatment orders in place for [Resident #42's name], after her fall. I do not see any provider notification or request for wound care orders for her skin tear. I see the culture and that she needed to have a midline and antibiotics for the infection of the skin tear. We should have asked for treatment orders, and we did not. I could see that you might consider that we did not provide her the proper care and it was part of the reason she needed the midline and antibiotics. I don't see any notes or a change of condition form in the chart where we notified the doctor or nurse practitioner until the arm was red and swollen. During an interview on 9/14/22 at 7:48 AM Resident #42 stated, I was having a lot of pain in my arm after I fell. I kept telling them, but they weren't listening. Finally, someone did and that's when they got the wound culture. No one would look at it when I asked and told them how much it was hurting me. They did not change the dressing on it at all. During an interview on 9/14/22 at 8:59 AM Staff E, Licensed Practical Nurse (LPN), stated, I did find her [Resident #42] on the floor. I heard a thud and found her on her knees on the floor. She had a skin tear and had a cut on her forehead. I assessed her and cleaned her forehead and right elbow. I was able to close the wound on her elbow with steristrips directly after she fell. I think I left a message for the nurse practitioner, but don't recall that she called back. We should follow up when a resident has any injuries and see if the practitioner wants any type of skin care done. I did not obtain any orders to treat her skin tear and I probably should have, but I did provide immediate treatment to her wounds. I did an assessment. I probably should have called the nurse practitioner back before I went off shift. During a telephone interview conducted on 9/14/2022 at 10:25 AM the APRN stated, I do not think that I was notified of the patient's fall until 9/6/2022 late in the evening, a nurse notified me that she had a red and draining arm from the skin tear. I gave orders for treatment and saw her the next day when I took a wound culture. I was not called and asked for any wound treatments prior to that time. I absolutely feel that the wound became infected due to a lack of wound care and that she would not have required additional treatments had she been provided daily wound care. I do feel this was a delay in treatment and caused a need for additional, more invasive treatments. I expect that staff will inform me of any changes in patient condition. All skin concerns should be addressed, and we should be called. During an interview conducted on 9/14/2022 at 2:10 PM the Regional Nurse Consultant stated, We have not provided change of condition notification to the providers for [Resident #42 and #29's names]. We were notified of the critical lab results for [Resident #29's name]. We did notify the provider. There is a note in the chart, but when the final culture was back, we did not call the provider. I don't see that there was information about whether the additional sensitivities were sensitive to the oral antibiotic he [Resident #29] was on. We should have called. There is no excuse that I could give you for why they weren't notified. [Resident #42's name] was not provided any wound care after the skin tear. We should have notified the physician or nurse practitioner and we should have gotten orders for wound care. I can't give you any clear reason why this was not done. She did have a need for a midline and antibiotics because the wound became infected. We did not do what we should have. Review of the policy and procedure titled Wound Care issue date of 4/1/2022 reads, Policy: It is the policy of this facility to provide assessment and identification of residents at risk of developing pressure injuries, other wounds and treatment of skin impairment. Procedure: 2. Skin will be assessed/evaluated for the presence of developing pressure injuries or other changes in skin condition on a weekly basis at least once each week or as needed by a licensed nurse. 11. Document the progression of the wound being treated. Such observations should include items size, staging (if applicable), odors, exudate, tunneling, etiology, etc. 12. Contact the physician for additional order changes as is appropriate or to notify of skin condition changes or refusals of care. The Immediate Jeopardy was removed onsite after the receipt of an acceptable immediate jeopardy removal plan. The survey team verified the facility's actions for removal of immediacy to prevent the likelihood of harm and/or possible death: Residents #29 and #42 were assessed for skin impairments and their physicians were notified on 9/13/2022. Ad Hoc QAPI [Quality Assurance Performance Improvement] was held on 9/13/2022 attended by Medical Director, Administrator, Director of Nursing, Infection Preventionist, and Social Services Director to implement a performance improvement plan. The facility has conducted root cause analysis on 9/14/2022 for delay in treatment and neglect. The facility completed skin assessments on 93 residents for any wound concerns and obtained orders for three additional residents identified with concerns. On 9/14/2022, the Administrator and Director of Nursing were educated by the Regional Director of Clinical Operations on the components of administration to include monitoring of facility systems during administrative/clinical stand up and standdown to identify areas that may rise to the level of investigating ANEMMI. By 9/16/2022, the facility trained 28 of 28 licensed nursing staff on change in condition, skin and wound care and abuse and neglect, which was verified through staff interviews.