**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 resident's representative when there was a critical laboratory result that required a change in medication for 1 of 2 residents reviewed for change in condition in a total sample of 38 residents, Resident #69. The resident was transferred to a higher level of care and did not survive. This facility failure resulted in Immediate Jeopardy. The Immediate Jeopardy began on [DATE]. The facility Administrator was informed of the Immediate Jeopardy on [DATE] at 5:03 PM. The Immediate Jeopardy was ongoing at the time of the exit on [DATE]. Findings: Cross reference to F600. Review of Resident #69's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including right femur fracture (a broken bone in the right thigh) s/p (status post) ORIF (Open Reduction and Internal Fixation), dementia, hyperlipidemia (high cholesterol levels), depression, anemia, and hypertension (high blood pressure). Review of Resident #69's Minimum Data Set (MDS), Comprehensive admission assessment dated [DATE], revealed a BIMS (Brief Interview for Mental Status) Score of 2 (Severe Cognitive Impact). Review of the physician orders for Resident #69 dated [DATE] read, BMP [Basic Metabolic Profile] CBC [Complete Blood Count], u/a [urinalysis], C&S [Culture and Sensitivity] one time only for weakness for 3 days. Review of the physician orders for Resident #69 dated [DATE] read, Levaquin [Levofloxacin, an antibiotic] Tablet 500 mg [milligrams] give 1 tablet by mouth in the morning for UTI [Urinary Tract Infection] Tx [treatment] for 10 days. Review of the physician encounter note for Resident #69 dated [DATE] at 1:00 AM authored by APRN (Advanced Practice Registered Nurse) read, Chief complaint/Nature of Presenting Illness: UTI. History of presenting illness: Urinalysis and culture showing E. Coli [Escherichia coli], sensitivity to follow, patient started on Levaquin for treatment of UTI. Patient is more alert today and his white count is trending down. Review of the urine culture and sensitivity report for Resident #69 read, Collection Date: [DATE], 04:00 [4 AM], received Date: [DATE], 17:17 [5:17 PM], Reported Date: [DATE], 12:02 [12:02 PM]. Site: clean catch. Result > 100,000 CFU [Colony Forming Unit) ml (per milliliter) gram negative rods, Escherichia Coli. This isolate is Extended Spectrum Beta-Lactamase (ESBL) producing microorganism [this is an enzyme produced by the bacteria that makes it harder to treat with antibiotics]. Critical result called to [Staff A's name] on [DATE], 12:02 PM by [Lab Employee's name]. Results were read back to caller. Result: Escherichia Coli (Isolate 1). Sensitivity Analysis: Isolate 1. Levofloxacin >=8. R=Resistant. [Resistance happens when germs like bacteria develop the ability to defeat the drugs designed to kill them]. Review of the nursing progress note for Resident #69 dated [DATE] at 3:16 PM authored by Staff A, Licensed Practical Nurse (LPN), read, Narrative: Res [resident] lethargic this shift. Poor appetite noted, couldn't complete therapy today. Res [respirations] even and unlabored. No sob [shortness of breath] or cough noted. Resting comfortably at this time. Review of Resident #69's clinical records revealed no documentation indicating the physician or resident representative was notified of the UTI or critical lab results. Review of the physician encounter note for Resident #69 dated [DATE] read, Chief complaint/Nature of Presenting Problem: UTI/ESBL. History of Present Illness: Patient was started on Levaquin for E. coli urinary tract infection. However, complete culture and sensitivity showing E. coli ESBL. I do not see where this was called to the on call provider, organism is resistant to Levaquin. Patient has no complaints of dysuria [pain or difficult urination], no reports of fever or chills. Plan: Discontinue Levaquin, may insert midline [a long intravenous catheter placed in the arm for intravenous antibiotic administration], Ertapenem [an antibiotic] 1 g [gram] daily x 10 days, Probiotic [a nutritional supplement made up of live bacteria] twice daily x 14 days, continue Percocet [a medication for pain], PT/OT [Physical Therapy/Occupational Therapy] skilled nursing, follow up with psych. Review of the nursing progress note for Resident #69 dated [DATE] at 4:15 PM authored by Staff B, RN, read, Earlier today resident seen by [APRN's name]. New orders for midline and IV [intravenous] Ertapenem daily x 10 days for UTI. Called for midline placement, labs drawn today and later critical BUN [Blood Urea Nitrogen] of 110 noted. All labs called to [APRN's name]. New order to send to ER [Emergency Room] for evaluation due to ARF [Acute Renal Failure]. Family updated. Resident transported to [Name of Hospital]. Review of the physician orders for Resident #69 dated [DATE] read, Transfer to the ER, dx [diagnosis] ARF. Review of the hospital emergency department notes for Resident #69 dated [DATE] authored by [Medical Doctor's name] read, Clinical impression: Primary impression: Sepsis [a life-threatening medical emergency when the body has an extreme response to infection], Secondary Impression: Hypernatremia [high level of sodium in the blood], AKI [acute kidney Injury], anemia, dehydration. discharge date [DATE], DC [discharge] back to ALF [Assisted Living Facility] with hospice. Resident #69 died on [DATE]. During an interview on [DATE] at 3:35 PM, the Director of Nursing (DON) stated, I was not aware of any problems with [Resident #69's name]. I was not aware that he had a urine culture reported and not called to the physician. I was not aware that the resident had an ESBL UTI that was not being treated with the correct antibiotic. I need to investigate this to determine what actually happened. If this happened, it is not representative of what we do and is not acceptable. I see this is a very serious problem if we didn't notify the on-call physician, but maybe the staff just forgot to document that they called them. I will look into this and get back to you. During an interview on [DATE] at 8:05 AM, the DON stated, We did not notify anyone about this urine culture result. I spoke to the nurse, and she cannot remember whether she did a text to a provider, and I am trying to see if there is a way that we can find out. We should have called the physician or nurse practitioner. It is a nursing standard of care to call a physician with critical laboratory results. We did not do this. There is no documentation in the chart that anyone was called. He [Resident #69] has dementia and we should have notified his family also when the lab result came back. During an interview on [DATE] at 11:32 AM, the APRN stated, I did see this resident [Resident #69] on [DATE] and did know that the urine culture was E. coli, but the sensitivities were not back at the time that I saw him, so there was no need to change antibiotics at that time. I would absolutely expect that I should be notified that the resident had an ESBL UTI and that the antibiotic was not appropriate for the organism. If I had been notified, I would have ordered the midline and the IV antibiotics on [DATE] the day the sensitivities were back. This resident had a very complex course prior to his being treated at the rehab center. I expect staff to call me with any critical lab results and let me know them. I'm not sure why they did not call and let someone know. It does take some time to get a midline in and get the antibiotics ordered. This can take time, but I would have placed the orders. During a telephone interview on [DATE] at 7:40 AM, Staff A, LPN, stated, I really can't remember whether I called the doctor or [APRN's name] not really. I remember that [APRN's name] the nurse practitioner came in that day. He knew the resident had E. coli in his urine. I don't think the results were back for what the sensitivity was. I was called by the lab, and they did give me the results. I really don't remember if I called [APRN's name], but if I didn't chart that I made the call then, I guess I didn't. When the lab calls with critical results, we are supposed to call the doctor and the family, but I don't know if I did or not. The resident was lethargic. I think I documented that. I should have called. That is the policy to call the doctor with critical lab results. I don't know why I didn't. I should have called the family and done a change of condition notification. During a telephone interview on [DATE] at 7:55 AM, Staff B, RN, stated, I did take care of [Resident #69's name] the day he went to the hospital [[DATE]]. I know he was out to the hospital related to his BUN being through the roof. It was very high. I called [APRN's name], the provider and told him he needs to go to the ER, and I called the family and let them know that he was going. He was very thin and not responding much, he would look at me, but he was not talking or responding to questions, but he was opening his eyes. I thought, Oh boy, this poor guy, he is in bad shape. During an interview on [DATE] at 1:26 PM, the Medical Director stated I am now aware of the situation with [Resident #69's name]. The administrator and the DON informed me of the concerns yesterday or the day before related to his BUN and needing to be sent out to the Emergency Department and his not having appropriate treatment for his UTI. I will be reviewing the documentation to see where the break down occurred, whether it was the provider or the nursing staff that didn't respond as they should have. This is harm when a resident needs hospitalization. There is a process that definitely needs to be fixed, a process that broke down. This is an environment unlike the hospital. We are not here even daily. We are dependent much more on the nursing staff to recognize complex problems or situations and alert us when we need to know something. I expect the nursing staff to respond and to understand that calling culture results and critical labs, that these notifications are time sensitive and must be done immediately for the welfare of the patients. We need to be aware of and fix any situation that will cause a patient to have to go out to the hospital because of our actions or inaction. Review of the facility policy and procedure titled Laboratory-Testing and Reporting with the last revision date of 11/2021 read, Purpose: To assure physician ordered diagnostic tests are performed, and to assure test results are promptly reported to the physician/clinician. Standards: 4. A nurse is responsible for monitoring all test results received. 5. Test results are promptly reported to the physician/clinician who ordered them (or another clinician on call) and their response documented in the medical record. 7. The licensed nurse is responsible for documenting physician/clinician notification in the residents medical record. Review of the facility policy and procedure titled Physician/Clinician/Family Responsible Party Notification for Change in Condition with a revision date of 10/2020, and last approval date of [DATE] read, Purpose: To ensure that medical/psychological care problems are communicated to the attending physician/clinician and family/resident representative in a timely, efficient and effective manner. Policy: 1. The facility must immediately inform the resident; consult with the resident's physician/clinician; and notify, consistent with his or her authority, the resident's representative when there is: a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). 2. When making notification as listed above, the facility must ensure that all pertinent information is documented in the resident's medical record. and appropriate information is communicated to the receiving health care institution or provider. 6. If the resident is not capable of making decisions, facility staff must contact the designated resident representative, consistent with his or her authority, to make required decisions, but the resident must still be told what is happening to him or her.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a 200 Hall tour on [DATE] at 9:40 AM, the surveyor observed a family member loudly discussing with a staff member, later identified as Staff C, LPN, the lack of assistance with getting a urinary catheter drainage bag replacement. The family member stated, I can get them on Amazon. Why can't you get them? Review of Resident #36's admission record revealed the resident was admitted on [DATE] with diagnoses including right femur fracture (broken bone in the thigh) and IMN (intermedullary nail; a rod used as a long-bone fracture fixation) placement, chronic obstructive pulmonary disease (a chronic lung disease), and obstructive and reflux uropathy (a condition when the flow of urine is blocked and causes urine to back up into the kidneys), s/p (status post) suprapubic catheter (a tube that drains urine from the bladder that is inserted through the abdomen). Review of Resident #36's MDS (Minimum Data Set), Comprehensive Quarterly assessment dated [DATE], revealed a BIMS (Brief Interview for Mental Status) Score of 15 (Intact Cognition). Review of the physician order for Resident #36 dated [DATE] read, May reinforce or use alternative containment method until replacement supplies arrive. During an interview on [DATE] at 9:48 AM, Resident #36 was frowning and speaking rapidly and loudly as she stated, My catheter bag has been leaking for several days. I have a suprapubic catheter that was put in on [DATE] and the bag has been leaking quite a while and when I reported it to a nurse, they put it in a zip lock bag, and it is still leaking and getting on my leg. During an observation on [DATE] at 9:56 AM, Resident #36's room had a strong odor of urine, which became more pronounced when the resident lifted her sheets and blankets to reveal an adult brief placed between the catheter bag and the resident's leg. The odor intensified when she opened the brief. There was a plastic zip lock bag with a urinary catheter bag floating in clear yellow liquid. The urinary catheter bag was labeled that it could hold 600 ml (milliliters) and contained approximately 200 milliliters of yellow fluid. The plastic zip lock bag contained approximately the same amount of yellow fluid. The catheter bag was covered entirely with the clear yellow fluid and floating in the plastic bag. There was approximately one inch separation at the seam of the catheter bag observed at the 400 ml marking on the left side of the catheter bag. During an interview on [DATE] at 9:56 AM, Resident #36 stated, I am very upset. My catheter has been leaking for many days and the staff will not help me. I have been telling them for a long time that my catheter was leaking, and they told me I was imagining it. I knew I wasn't as I was getting wet and sometimes the staff would ask me if I did something to make the catheter leak. I tried to tell them that the bag was leaking. They say it started Friday, but it didn't. It was going on before then. On Friday, they finally saw it was leaking and they put it in this plastic bag. This smells so awful and if I lift my covers, it smells so bad. They finally put it in a diaper when I kept getting wet to try to stop that. This is so embarrassing. My daughter in law has been trying to get them to fix this. They say they don't have the right kind of bag to put on it. I want them to fix this because I keep getting wet and it really seems bad. I have told all the nurses that this is happening. I just can't understand what the problem is. Why it can't be changed. I had surgery. There is this urinal that's hanging beside my head. I have to lay on my back and so I turn the urinal around so it's not right in my face. During an interview on [DATE] at 10:06 AM, Staff C, LPN, assigned to the 200 Hall, entered Resident #36's room and saw the catheter bag and zip lock baggie. She confirmed the catheter bag with 200 ml was floating in a zip lock bag with 250 ml of urine. Staff C stated she was flabbergasted, and it shouldn't be like this. Review of the physician order for Resident #36 dated [DATE] at 2:24 PM read, Send to [Name of Hospital] non emergent due to suprapubic catheter one time only for suprapubic catheter leaking. Review of the nursing progress notes for Resident #36 dated [DATE] at 2:24 PM authored by Staff C, LPN, read, Catheter bag was empty. Line was cleaned and opening around abdomen was cleaned and covered with drain sponges. Daughter-in-law handed cell phone to nurse. Was instructed by [name] and [MD's name] to send resident to [Name of Hospital] non-emergency for catheter to be changed out. Called 911 and sent resident out to [Name of Hospital]. Daughter-in-law at her side. Supervisor [Staff D's name] was advised. Review of the nursing progress note for Resident #36 dated [DATE] at 4:15 PM authored by Staff D, LPN, read, Additional information for Friday [DATE]. Pinpoint leak noted to urine drainage bag, because of the type of catheter inserted needs a special bag, spoke to MD [Medical Doctor] regarding getting urology appt [appointment] ASAP and will try to get bag as soon as possible. Orders given for urology appt and to secure and maintain drainage system. Review of the nursing progress note for Resident #36 dated [DATE] at 7:09 PM read, Daughter phoned to inform that resident will be held overnight and procedure will happen tomm [tomorrow]. Review of the Medical Certification For Medicaid Long-Term Care Services and Patient Transfer Form dated [DATE] revealed Resident #36 was transferred from [Name of Hospital] back to the facility with a primary diagnosis of suprapubic catheter malfunction. Review of Resident #36's receiving hospital's laboratory results dated [DATE] read, Laboratory Test Results: Collection Time: [DATE] at 17:20 [5:20 PM]. Ur [Urine] Leukocyte Esterase: Result: Large. Urine RBC [Red Blood Cells]: Result: 10-15. Urine WBC [White Blood Cells]: Result: > [greater than] 100 A, normal reference 0 [zero, it could be a sign of infection. WBCs help your body fight germs]. Urine Bacteria: Result: Many. Review of the receiving hospital's discharge medication list dated [DATE] at 1:33 PM read, Cephalexin (Trade Name: Keflex) [used to treat infections caused by bacteria. It's often given to treat the urinary tract] 500 MG Oral every 8 hours. During an interview on [DATE] at 2:10 PM, the Director of Nursing (DON) stated, I expect the staff to notify me of any issues outside of the norm. I was aware that we were not able to get the supply of the proper catheter bags for [Resident #36's name]. I think we ordered them, but I am not sure when. I found out the order was not placed until today. I know we had an order from the doctor to contain it as best we could until we received the right supplies. I was not aware that the leak in the bag was so bad that it would have the catheter bag floating in urine. That is a very big infection control problem. I was not aware that the leak worsened over the weekend. The staff should have called the doctor if they could not contain the leak with what we have here. I would expect the staff to have let the doctor know. During an interview on [DATE] at 8:45 AM, Staff D, LPN, stated, I became aware of the catheter for [Resident #36's name] having a pinpoint leak on Friday morning. I was instructed to order a new bag, but some type of emergency came up and I forgot to place the order. I realized that I didn't do it Sunday night, but thought to myself, it's okay. It was just a pinpoint leak. During an interview on [DATE] at 10:45 AM, Staff I, Certified Nursing Assistant (CNA), confirmed she usually takes care of Resident #36 daily. Staff I stated she noticed that on Friday morning, [DATE], the catheter had a drip-drip-drip leak. Staff I stated she told the nurse, Staff C, who told her to empty the bag and she would take care of it. During an interview on [DATE] at 2:15 PM, Staff C, LPN, stated, I was not told the amount of urine that was draining and that there was a large hole in the catheter bag. I was not aware that it was draining so much that it would leak out of the zip lock bag that we placed the catheter in on Friday when we saw that it was leaking. It was a small leak on Friday, not the large tear in the catheter bag that I saw yesterday. I am horrified that no one told me how bad it was. The catheter bag should not have been floating in urine. That is a very big risk for infection for the resident. I just was not told by the nurse I got report from. I would have assessed it sooner and I would have let the doctor know that we could not contain the urine and something else needed to be done. I told the Unit Manager on Friday, and she is the one who put it in the plastic bag or told me to. I didn't put it inside the brief. During a telephone interview on [DATE] at 1:00 PM, Staff J, LPN, stated, I worked the second shift over the weekend and remembered caring for [Resident #36's name]. [Staff C's name] told me she was concerned about [Resident #36's name] as the resident's catheter bag had a tear in the seam about ½ cm [centimeter] and the resident was agitated and upset. The catheter bag did have a pretty large hole in it, and I tried to tape it closed but found urine and tape don't mix. I didn't really think about calling the doctor. They already knew that it had a hole in it. It was leaking and was in a plastic bag. I can't remember if it was in any brief. During an interview on [DATE] at 1:15 PM, the Medical Director stated, I did give the order to attempt to contain the urine as best they could, but I was not aware that it was not the usual catheter bag and that it wasn't positioned for gravity flow. I had no idea that it was lateral to the patient's bladder allowing it to freely flow back into the bladder. That would certainly create a higher risk for infection. I would expect someone with some level of competency to make an informed decision to take care of the problem, to recognize that it was a problem and take care of it for the safety of the patient. Even if that meant additional call to the provider and sending the patient out to the hospital for this to be resolved. The staff should have called the provider or me back when they could not contain the urine safely. I would have expected to be called. This setting is different than acute care. They don't have supplies at their fingertips like the hospitals do, but we must do the right thing for the patient. The staff might have started off with the right intentions however, it didn't turn out that way. Definitely not! It is a big concern when our failure to act results in a patient needing to be hospitalized or has any adverse outcome. Review of the facility policy and procedure titled Abuse, Neglect and Misappropriation of Resident Property with the last revision date of 6/2021 read, Purpose: The policy's purpose is to ensure that resident rights are protected by providing a method for investigation and reporting of allegations of mistreatment, neglect, abuse, including injuries of unknown source, unusual occurrences, and misappropriation of resident property. Definitions: Neglect: This occurs on an individual basis when a resident is not cared for in one or more areas. Neglect is also lack of attentiveness, carelessness or the failure to provide timely, consistent, safe, adequate and appropriate services, treatment and care, including but not limited to: nutrition, medication, therapies, and activities of daily living. The absence of reasonable accommodations of individual needs and preferences may result in neglect. And, neglect is the failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. Examples: an action or lack of action that actually harms a resident such as: - Failing to provide personal hygiene resulting in embarrassment, depression, poor self-esteem, self-isolation, or physical harm that requires medical treatment beyond an ER/physician evaluation. - Staff failing to identify, assess, monitor, and respond to a resident suffering an acute condition. Based on observation, interview, and record review, the facility failed to ensure the residents were free from neglect by not notifying the resident's physician of a change in condition related to critical laboratory results, Resident #69, and for not ensuring proper medical equipment supplies for a suprapubic catheter, Resident #36, for 2 of 8 residents, in a total sample of 38 residents. Resident #69 had a serious urinary tract infection, was transferred to a higher level of care for further treatment because the critical laboratory results were not reported to the physician. Resident #69 did not survive. This facility failure to ensure Resident #69 was free from neglect resulted in Immediate Jeopardy. The Immediate Jeopardy began on [DATE]. The facility Administrator was informed of the Immediate Jeopardy on [DATE] at 5:03 PM. The Immediate Jeopardy was ongoing at the time of the exit on [DATE]. Findings: Cross reference to F580. 1. Review of Resident #69's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including right femur fracture (a broken bone in the right thigh) s/p (status post) ORIF (Open Reduction and Internal Fixation), dementia, hyperlipidemia (high cholesterol levels), depression, anemia, and hypertension (high blood pressure). Review of Resident #69's Minimum Data Set (MDS), Comprehensive admission assessment dated [DATE], revealed a BIMS (Brief Interview for Mental Status) Score of 2 (indicating severe cognitive impairment). Review of the physician orders for Resident #69 dated [DATE] read, BMP [Basic Metabolic Profile] CBC [Complete Blood Count], u/a [urinalysis], C&S [Culture and Sensitivity] one time only for weakness for 3 days. Review of the physician orders for Resident #69 dated [DATE] read, Levaquin [Levofloxacin, an antibiotic] Tablet 500 mg [milligrams] give 1 tablet by mouth in the morning for UTI [Urinary Tract Infection] Tx [treatment] for 10 days. Review of the physician encounter note for Resident #69 dated [DATE] at 1:00 AM authored by APRN (Advanced Practice Registered Nurse) read, Chief complaint/Nature of Presenting Illness: UTI. History of presenting illness: Urinalysis and culture showing E Coli [Escherichia coli], sensitivity to follow, patient started on Levaquin for treatment of UTI. Patient is more alert today and his white count is trending down. Review of the urine culture and sensitivity report for Resident #69 read, Collection Date: [DATE], 04:00 [4 AM], received Date: [DATE], 17:17 [5:17 PM], Reported Date: [DATE], 12:02 [12:02 PM]. Site: clean catch. Result > 100,000 CFU [Colony Forming Unit) ml (per milliliter) gram negative rods, Escherichia Coli. This isolate is Extended Spectrum Beta-Lactamase (ESBL) producing microorganism [this is an enzyme produced by the bacteria that makes it harder to treat with antibiotics]. Critical result called to [Staff A's name] on [DATE], 12:02 PM by [Lab Employee's name]. Results were read back to caller. Result: Escherichia Coli (Isolate 1). Sensitivity Analysis: Isolate 1. Levofloxacin >=8. R=Resistant. [Resistance happens when germs like bacteria develop the ability to defeat the drugs designed to kill them]. Review of the nursing progress note for Resident #69 dated [DATE] at 3:16 PM authored by Staff A, Licensed Practical Nurse (LPN), read, Narrative: Res [resident] lethargic this shift. Poor appetite noted, couldn't complete therapy today. Res [respirations] even and unlabored. No sob [shortness of breath] or cough noted. Resting comfortably at this time. Review of Resident #69's clinical records revealed no documentation indicating the physician or resident representative was notified of the UTI or critical lab results. Review of the physician encounter note for Resident #69 dated [DATE] read, Chief complaint/Nature of Presenting Problem: UTI/ESBL. History of Present Illness: Patient was started on Levaquin for E. coli urinary tract infection. However, complete culture and sensitivity showing E. coli ESBL. I do not see where this was called to the on call provider, organism is resistant to Levaquin. Patient has no complaints of dysuria [pain or difficult urination], no reports of fever or chills. Plan: Discontinue Levaquin, may insert midline [a long intravenous catheter placed in the arm for intravenous antibiotic administration], Ertapenem [an antibiotic] 1 g [gram] daily x 10 days, Probiotic [a nutritional supplement made up of live bacteria] twice daily x 14 days, continue Percocet [a medication for pain], PT/OT [Physical Therapy/Occupational Therapy] skilled nursing, follow up with psych. Review of the nursing progress note for Resident #69 dated [DATE] at 4:15 PM authored by Staff B, RN, read, Earlier today resident seen by [APRN's name]. New orders for midline and IV [intravenous] Ertapenem daily x 10 days for UTI. Called for midline placement, labs drawn today and later critical BUN [Blood Urea Nitrogen] of 110 noted. All labs called to [APRN's name]. New order to send to ER [Emergency Room] for evaluation due to ARF [Acute Renal Failure]. Family updated. Resident transported to [Name of Hospital]. Review of the physician orders for Resident #69 dated [DATE] read, Transfer to the ER, dx [diagnosis] ARF. Review of the hospital emergency department notes for Resident #69 dated [DATE] authored by [Medical Doctor's name] read, Clinical impression: Primary impression: Sepsis [a life-threatening medical emergency when the body has an extreme response to infection], Secondary Impression: Hypernatremia [high level of sodium in the blood], AKI [acute kidney Injury], anemia, dehydration. discharge date [DATE], DC [discharge] back to ALF [Assisted Living Facility] with hospice. Resident #69 died on [DATE]. During an interview on [DATE] at 3:35 PM, the Director of Nursing (DON) stated, I was not aware of any problems with [Resident #69's name]. I was not aware that he had a urine culture reported and not called to the physician. I was not aware that the resident had an ESBL UTI that was not being treated with the correct antibiotic. I need to investigate this to determine what actually happened. If this happened, it is not representative of what we do and is not acceptable. I see this is a very serious problem if we didn't notify the on-call physician, but maybe the staff just forgot to document that they called them. I will look into this and get back to you. During an interview on [DATE] at 8:05 AM, the DON stated, We did not notify anyone about this urine culture result. I spoke to the nurse, and she cannot remember whether she did a text to a provider, and I am trying to see if there is a way that we can find out. We should have called the physician or nurse practitioner. It is a nursing standard of care to call a physician with critical laboratory results. We did not do this. There is no documentation in the chart that anyone was called. He [Resident #69] has dementia and we should have notified his family also when the lab result came back. During an interview on [DATE] at 11:32 AM, the APRN stated, I did see this resident [Resident #69] on [DATE] and did know that the urine culture was E. coli, but the sensitivities were not back at the time that I saw him, so there was no need to change antibiotics at that time. I would absolutely expect that I should be notified that the resident had an ESBL UTI and that the antibiotic was not appropriate for the organism. If I had been notified, I would have ordered the midline and the IV antibiotics on [DATE] the day the sensitivities were back. This resident had a very complex course prior to his being treated at the rehab center. I expect staff to call me with any critical lab results and let me know them. I'm not sure why they did not call and let someone know. It does take some time to get a midline in and get the antibiotics ordered. This can take time, but I would have placed the orders. During a telephone interview on [DATE] at 7:40 AM, Staff A, LPN, stated, I really can't remember whether I called the doctor or [APRN's name] not really. I remember that [APRN's name] the nurse practitioner came in that day. He knew the resident had E. coli in his urine. I don't think the results were back for what the sensitivity was. I was called by the lab, and they did give me the results. I really don't remember if I called [APRN's name], but if I didn't chart that I made the call then, I guess I didn't. When the lab calls with critical results, we are supposed to call the doctor and the family, but I don't know if I did or not. The resident was lethargic. I think I documented that. I should have called. That is the policy to call the doctor with critical lab results. I don't know why I didn't. I should have called the family and done a change of condition notification. During a telephone interview on [DATE] at 7:55 AM, Staff B, RN, stated, I did take care of [Resident #69's name] the day he went to the hospital [[DATE]]. I know he was out to the hospital related to his BUN being through the roof. It was very high. I called [APRN's name], the provider and told him he needs to go to the ER, and I called the family and let them know that he was going. He was very thin and not responding much, he would look at me, but he was not talking or responding to questions, but he was opening his eyes. I thought, Oh boy, this poor guy, he is in bad shape. During an interview on [DATE] at 1:26 PM, the Medical Director stated I am now aware of the situation with [Resident #69's name]. The administrator and the DON informed me of the concerns yesterday or the day before related to his BUN and needing to be sent out to the Emergency Department and his not having appropriate treatment for his UTI. I will be reviewing the documentation to see where the break down occurred, whether it was the provider or the nursing staff that didn't respond as they should have. This is harm when a resident needs hospitalization. There is a process that definitely needs to be fixed, a process that broke down. This is an environment unlike the hospital. We are not here even daily. We are dependent much more on the nursing staff to recognize complex problems or situations and alert us when we need to know something. I expect the nursing staff to respond and to understand that calling culture results and critical labs, that these notifications are time sensitive and must be done immediately for the welfare of the patients. We need to be aware of and fix any situation that will cause a patient to have to go out to the hospital because of our actions or inaction. Review of the facility policy and procedure titled Laboratory-Testing and Reporting with the last revision date of 11/2021 read, Purpose: To assure physician ordered diagnostic tests are performed, and to assure test results are promptly reported to the physician/clinician. Standards: 4. A nurse is responsible for monitoring all test results received. 5. Test results are promptly reported to the physician/clinician who ordered them (or another clinician on call) and their response documented in the medical record. 7. The licensed nurse is responsible for documenting physician/clinician notification in the residents medical record. Review of the facility policy and procedure titled Physician/Clinician/Family Responsible Party Notification for Change in Condition with a revision date of 10/2020, and last approval date of [DATE] read, Purpose: To ensure that medical/psychological care problems are communicated to the attending physician/clinician and family/resident representative in a timely, efficient and effective manner. Policy: 1. The facility must immediately inform the resident; consult with the resident's physician/clinician; and notify, consistent with his or her authority, the resident's representative when there is: a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). 2. When making notification as listed above, the facility must ensure that all pertinent information is documented in the resident's medical record. and appropriate information is communicated to the receiving health care institution or provider. 6. If the resident is not capable of making decisions, facility staff must contact the designated resident representative, consistent with his or her authority, to make required decisions, but the resident must still be told what is happening to him or her.