Based on interviews, record reviews, and policy and procedure reviews, the facility failed to ensure residents were free from medical neglect by failing to implement policies and procedures for neglect, resident change in condition or status, and resident transportation safety for facility operated vehicles when the facility transportation driver failed to notify the facility licensed medical staff of a resident change in condition. Resident #1, while being transported to the facility in the facility transport van after attending a physician appointment, stated she was out of oxygen, that she needed oxygen, was short of breath, and experiencing chest pain. The facility transportation driver pulled off the interstate, did not notify the facility licensed medical staff, asked Resident #1 if she wanted to return to the hospital/health facility, the resident declined, stating she was okay. The transportation driver did not notify the facility licensed medical staff of the resident declining medical care and services and continued to transport Resident #1 back to the facility. Resident #1 suffered cardiac arrest and did not survive. The facility's failure to implement their policies and procedures for Resident #1 led to a determination of Immediate Jeopardy at a scope and severity of isolated, (J). The Nursing Home Administrator was notified of the Immediate Jeopardy on January 19, 2024, at 12:13 PM. The Immediate Jeopardy began on January 3, 2024, and was removed on site on January 19, 2024. Review of the Cleveland Clinic documentation titled, Hypoxia read, Hypoxia is low levels of oxygen in your body tissues. It causes symptoms like confusion, restlessness, difficulty breathing, rapid heart rate, and bluish skin. Many chronic heart and lung conditions can put you at risk for hypoxia. Hypoxia can be life-threatening. If you are experiencing symptoms of hypoxia, call 911 or go to the nearest ER [emergency room]. Hypoxia should be treated right away to prevent permanent organ damage. (My.clevelandclinic.org/health/diseases/23063-hypoxia accessed on 1/18/2024) Findings include: Review of the facility medical record for Resident #1 documented the resident was admitted with diagnoses of acute on chronic combined systolic congestive and diastolic congestive heart failure (with combined congestive heart failure in systolic, ventricles cannot produce enough pressure in the contraction phase to push blood into circulation, diastolic the ventricles cannot relax, expand, or fill with enough blood), RSV (respiratory syncytial virus - is the most common cause of lower respiratory tract infections), pneumonia unspecified organism, dysphasia following cerebral infarction (an area of dead tissue in the cerebrum caused by an insufficiency for arterial or venous blood flow - resulting in an impairment in the production of speech resulting from brain disease or damage) paroxysmal atrial fibrillation (rapid, erratic heart rate begins suddenly and then stops on its own within seven days), acute myocardial infarction (heart attack), hemiplegia (paralysis of one side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infarction affecting left nondominant side, repeated falls, ischemic cardiomyopathy (damaged heart muscle from a lack of blood flow), anemia, atherosclerotic heart disease of native coronary artery without angina pectoris (silent heart ischemia), presence of automatic implantable cardiac defibrillator (a pacemaker with the ability to recognize abnormally fast cardiac rhythm and provide an immediate treatment which can be in the form of shock therapy) presence of coronary angioplasty implant and graft (creates a new path for blood to flow around a blocked or partially blocked artery), retinal detachment left eye, occlusion and stenosis of unspecified carotid artery (the narrowing of the carotid arteries), major depressive disorder, idiopathic peripheral autonomic neuropathy (nerve damage when the cause can't be determined), peripheral vascular disease (reduced circulation of blood to a body part other than the brain or heart), essential primary hypertension (high blood pressure), hyperlipidemia, acquired absence of right leg above the knee, acquired absence of left leg below the knee, chronic obstructive pulmonary disease with acute exacerbation (sudden worsening in airway function and respiratory symptoms in people with COPD), non ST elevation myocardial infarction (a type of involving partial blockage of one of the heart arteries, causing reduced flow of oxygen-rich blood to the heart muscle), type 2 diabetes mellitus with other circulatory complications, and acute respiratory failure with hypoxia (impairment of gas exchange between the lungs and the blood causing a state in which oxygen is not available in sufficient amounts). Review of the physician orders dated 11/02/2023 Oxygen 3 liters PRN [as needed]. Review of the nursing progress note dated 1/03/2024 at 1430 [2:30 PM] read, Resident was being transported from an appointment when the transport driver witnessed resident having a medical event. She was lowered to the floor of the transport vehicle, lying sideways with her stumps facing the windshield and her head facing the wall. 911 was called, the facility director and MD [Medical Doctor] were notified. She was transferred into an ambulance to be transported to [name of a local hospital]. Multiple attempts made by staff via telephone to reach family. Review of the nursing progress note dated 1/03/2024 at 1530 [3:30 PM] read, Resident transported via TR [Timberridge] transportation van to appointment at [name of the eye center] at the [location of the eye center that is 48.3 miles from the facility; approximately a one-hour drive] at Approx [approximately] 8:45 AM for a 9:30 AM appointment time. Accompanied by driver. Notification made by driver when enroute to return to the facility that resident c/o [complaint of] shortness of breath and chest pain, driver then pulled over to assist resident and called 911. Driver states that he assisted her into a rescue position to assure her comfort and safety until EMS [Emergency Medical Services] arrived. EMS arrived & escorted resident to [name of local hospital]. Call received from [name of local hospital] to make notification to the facility of the resident passing. Administration notified daughter of event and hospitalization. During an interview on 1/16/2024 at 9:35 AM the Administrator stated, I'm not really sure about everything that happened, or what was done. I'm sorry I was on vacation and just need to get myself up to speed with everything that has been done. [The Administrator was notified of the event on 1/3/2024 at 2:02 PM]. During an interview on 1/16/2024 at 10:10 AM the Director of Nursing (DON) stated, I took [Staff A name's] statement the day of the event and it was that [Resident #1's name] told him that she was out of oxygen, and he pulled over and asked her if she wanted to go to the hospital and she said no she was fine. So, he came back to Ocala and when he saw her in the wheelchair, the wheelchair was tilted, and she was slumped to her left side. He immediately pulled over and called 911. He did follow the policy for transporting, when he recognized a medical emergency, he called 911. I don't think that he saw her lack of oxygen as an emergency. We don't know if the oxygen was out or not. He wouldn't know how to change an oxygen tank. We did not send any other tanks with her. But she is awake, alert and she stated she didn't want to go so that is what he did, he honored her right to refuse to go to the hospital. I don't know exactly what transport drivers have in education about emergencies. He is not able to assess a resident, he does not have medical training to do that. During an interview on 1/16/2023 at 11:30 AM the Administrator, in the presence of the DON stated, [Staff A's name] was transporting [Resident #1's name] to her eye appointment, and she stated, I think I'm out of oxygen, he pulled over and asked her if she wanted to go to the hospital and she said no, because she has a BIMS [Brief Interview for Mental Status] of 15 [this score means cognition is intact], it was her right to refuse to go. We have no way of knowing whether the oxygen tank was empty or not. We don't know whether this contributed to the event. But once he did recognize an emergency, he did follow our policy for transportation and did call 911. [Staff A's name] was trained on transport, and he followed the training. He is not cardiopulmonary resuscitation [CPR] trained to my knowledge. We did not, after the investigation, think that we needed to QAPI [Quality Assurance and Performance Improvement] this, she was of sound mind and competent to make her decision not to get medical treatment. We did not do an Adhoc [from the Latin and means for this] QAPI related to this. We did not do a Root Cause Analysis [RCA] to determine if there were any other factors or breaks. She had the right to refuse treatment, it was her right to do that. We do plan on discussing this during our next QAPI on the 25th. During an interview on 1/16/2024 at 2:00 PM the Assistant Director of Nursing (ADON) stated, I did not take care of her [Resident #1]. I was on the back end of the process, meaning I received the calls from the Driver and the hospital that there was a medical event during transportation of [Resident #1's name]. I did not speak with the nurse or the tech that took care of her before she left. All nurses should assess a resident before they leave. When we send a resident out with oxygen, we should assess the tank before they leave. I can't say that I know exactly how long the oxygen tanks are good for. I don't know if any other tanks went with the resident when she left. I'm not sure if the driver would even know how to change the oxygen tanks if they ran out of oxygen. During an interview on 1/16/2024 at 2:40 PM Staff C, Certified Nursing Assistant (CNA) stated, Depending on how early the appointment is 11-7 [shift] will get a resident up and dressed and start getting them breakfast, if it's a later appointment I will do that. She [Resident #1] was already up and had eaten when I got in [at 7:00 AM], she was in her wheelchair. I just made sure her oxygen tank was full. She always used her oxygen, all the time, whether she was in bed or out of it. She would always pull the nasal cannula down on her chin because her nose would dry out and then put it back in. I did not provide any extra tanks for her transport that day. I actually didn't see her leave that morning, so I don't know what time she left out of the building that day. When residents go to an appointment the nurses see them and give them the paperwork to go to the appointment with them. I think they make sure the oxygen is full before transport takes them. She seemed fine that morning her usual self. During an interview on 1/16/2024 at 3:07 PM, Staff B, Licensed Practical Nurse (LPN) stated, I was just coming on shift when I saw her [Resident #1]. I work starting at 7:00 [AM]. She was already dressed and up in her wheelchair. I gave her the envelope for the appointment. She was wearing the oxygen when I saw her. She always used oxygen, she didn't ever take off her oxygen, like she didn't use it PRN [as needed], she used it continuously. I did not assess her oxygen level when I saw her. I don't know how much was in the tank [oxygen]. Typically, I will check oxygen before residents go but I never saw her leave. I have no idea when she left the building. I saw her at 7:30 [AM] or so and that's the last time I saw her. I did not provide any further oxygen tanks for her to transport with. It is my usual habit to check and verify that the oxygen is full. We do sometimes send patients to Gainesville for appointments, most were in the area for her. I do not know how long oxygen tanks are good for. I should have made sure to see her oxygen tank. Not everyone that goes out to an appointment uses oxygen. During a telephone interview on 1/16/2024 at 6:00 PM, Staff A, Transport Driver stated, I brought [Resident #1's name] up to her doctor's appointment in Gainesville and then she wanted to get something to eat so I brought her to the food court in the mall. [Name of mall] up there in Gainesville. That was where her doctor is, in the mall. We ate and then got in the van, we had just gotten on I [Interstate] 75 from [street location] where the mall is when she said, 'I think I'm out of oxygen. I need some oxygen' and I asked her if she were {sic} okay. She told me she was short of breath. I did pull off 75 and asked but she said she didn't want any medical help. She said 'No I'm okay' to me and so I just drove on down to Ocala. She was talking to me, and I would glance up into the mirror and she would be fidgeting with stuff. It was just after I got off 75 on 200 just before [name of a restaurant] that I saw her slumped in the wheelchair. She had not complained of any shortness of breath or chest pain, she was just slumped over, not conscious at all. I pulled off and called 911. I couldn't adjust her in the chair, so I unbuckled her and got her to the floor, after that the paramedics came. I am a floor technician, that's my job and I also drive residents to their appointments. Not everyone uses oxygen when they go. I really don't know nothing about that, nothing about oxygen. I don't know how to change an oxygen tank. I have been doing the driving for a few years now, I think, since 2008. I can't really remember what type of training I got then about it. I know I need to make sure the chairs are strapped in and that if I have any kind of a medical emergency that I pull over and call 911. I do not have any CPR training. I haven't gotten no additional training after this happened. I did not call any of the nurses about the oxygen being out. I just tried to bring her back. During an interview on 1/17/2024 at 12:29 PM Staff D, Certified Nursing Assistant/Unit Secretary stated, I was assisting her because she was running late, so I called the doctor's office to see if it was okay to be there late. She wanted me to check. I went to get her at her doorway. I told her it was okay for her to be there later. I walked alongside her; she wanted me to pull up her blanket. I looked at her oxygen tank and it was at green when I saw her. I didn't truly know if it was completely full. I helped load her in the van. During an interview conducted on 1/17/2024 at 1:22 PM the Medical Doctor/Medical Director, stated, I was under the understanding that she [Resident #1] was at an appointment and eating a [name of restaurant] sandwich. She told the driver she thought that she was out of oxygen, and he asked her if she wanted to go to the hospital and she said no. I do think she was stubborn, and I don't know if he could have convinced her to go. I don't think we could force her to go. The driver is not trained to assess residents. She was a sick lady with an EF [Ejection Fraction] of 20-25% [an indicator of heart strength. It measures the amount of oxygen-rich blood pumped out to the body with each heartbeat. An EF of 20% is about one-third of the normal ejection fraction. The heart is not pumping all the oxygen-rich blood the body needs], had an ACB [aortocoronary bypass, a surgery that creates a new path for blood to flow around a blocked or partially blocked artery in the heart], AICD [automatic implanted cardioverter-defibrillator, a device that helps when there is a sudden loss of all heart activity, a condition called cardiac arrest], recent RSV [respiratory syncytial virus, inflammation partially or completely blocks the airways] and pneumonia, also very severe heart disease and peripheral vascular disease. She was using her oxygen and did need it all the time because of these things. She was hospitalized , I think, five times last year. Her oxygen was PRN because sometimes she was not compliant in wearing it. But she did need the oxygen based on her condition. But I understand that it was her right not to wear it if she didn't want to. Review of the nursing progress notes for the period of 9//2023 through 1/02/2024 documented two occurrences of Resident #1 having concerns with oxygen. Dated 10/17/2023 at 17:41 [5:41 PM] read, While assisting resident back to bed this afternoon. Resident oxygen released from the nose. When placing it back in nose resident took it out and placed in one nares. Attempted to place back explained to her that it wasn't in correctly. Resident replied 'I only keep it in one side because it makes me sneeze.' Explained to her that she is not receiving the correct amount of oxygen but continue to place in one nares. Dated 11/13/2023 at 20:25 [8:25 PM] Patient has her O2 [oxygen] cannula out of her nose due to soreness in nostrils. Declines to wear a mask. During an interview on 1/17/2024 at 4:05 PM the Administrator stated, I don't want to determine what [Staff A's name] perceived or did not perceive. He determined that she was fine, he stated that she did not want to go to the hospital, and he thought she was fine. I know that when she had an actual emergency, he did call 911. I can't say that her shortness of breath and chest pain was an emergency to [Staff A's name]. He offered and she stated she did not want to go to the hospital. It was her right to refuse. When asked the Administrator declined to answer if [Staff A's name] was able to assess the resident and able to determine if Resident #1's name was having a medical emergency. During an interview on 1/18/2023 at 10:09 AM the DON stated, I was here when [the Administrator's name] got a phone call from [Staff A's name]. He was on the side of the road near [restaurant's name]. That is the only call we got from [Staff A's name] that I know about. [Resident #1's name] was transported to [local hospital name]. I was here when [Staff A's name] got back, and he was very upset, shook up. The oxygen tank, well, I didn't look at the regulator when [Staff A's name] returned. I just heard it running, it was making a sound. I did not photograph the oxygen tank and I did not look to see whether it was empty or not. I can't say the tank was empty because I wasn't there, but she refused care all the time. So, it's not unusual for her to refuse to do things. I don't know if she had capacity because I was not there with her. I was not in the van with [Staff A's name] so I can't say that I know that she had shortness of breath or chest pain. I wasn't there. But if she did per my Administrator's interview, then no one but [Staff A's name] was in the van with the resident. He is not able to notify her of the consequences of not getting assessed, he would not be able to explain to her that being without oxygen would or could have her in more problems or what the result of not getting medical help would be. But we can't say she was out of oxygen, we don't know that, and we did not look at the oxygen gauge when he returned. So, therefore I can't say that anything happened with her oxygen, or that she was in any distress during the ride. I only have the statement that he gave me, and he thought she was alright. I wasn't called by [Staff A's name] about any chest pain or shortness of breath, so I can't tell you what I would have said to him. If a resident is short of breath and having chest pain, I would tell them to get a nurse to evaluate the resident if they were in the building. During an interview on 1/18/2024 at 10:20 AM the Administrator stated, All the information that I documented during my interview with [Staff A's name] was accurate, he did state that she complained of chest pain and shortness of breath the first time he pulled the van over. He did not call me, or anyone else about the resident at that time, he asked the resident who has the capacity to self-determine if she wanted to go to the hospital and she declined. So, he brought her back here. He told me she was fidgeting and conversing with him during the trip. He did not tell me that she complained of pain when getting off 75, he told me exactly what I wrote. It was around 2 o'clock when [Staff A's name] called me, it was so jumbled, he was frantic and upset. The information I understood at that time [Resident #1's name] required and was sent to the hospital. I can't say because I wasn't with her that she had a medical emergency any sooner than [Staff A's name] recognized it, I was not there. I think that he followed our policies and procedures. I don't think he is able to discuss the consequences of not going to the hospital. But according to [Staff A's name] she was fine during the transport, and he did what he was supposed to do when she was slumped in the chair. During an interview on 1/19/2024 at 1:50 PM Staff A, Transportation Driver /Floor Technician stated, She [Resident #1] had chest pain and shortness of breath up in Gainesville and I asked but she said no she didn't want to go to the doctors, back to there at the doctors. I did not call anyone when she had that pain. I got no training on emergencies like that. I knew that I should call if we needed to call 911. I didn't know that this was a problem, that that might cause her to die. It's been terrible. I feel so badly about it all, it is just awful, every time I talk about this I just get feeling sad all over again. I never did ask her again if she wanted to go to the hospital, just that one time. I didn't talk much to her on the way home, but I would glance up and I would see that she was fidgeting in her chair, she was awake and when I glanced in Ocala, she was all slumped over and the chair was tilted a little, she was tilted to her side. I had a hard time after I pulled over getting her pulled in her seat, so I unbuckled her and moved her to the floor. She couldn't talk to me at all. She didn't tell me that she was short of breath or having any chest pain again after being in Gainesville. That's the only time she said that. She did not say it on the off ramp here in Ocala, she wasn't saying anything. Well, I did know that it was serious her having pain and feeling that way, but she just said she didn't want to go. I just wasn't trained to call for anything but an emergency. I didn't think this was that type of an emergency. I'm not wanting to be a driver anymore. Review of the facility time-line documented: 8:49 AM Resident observed by [Staff D's name, CNA/Unit Secretary prior to departing facility for her appointment. [Staff D's name] states she verified that [Resident #1's name's] oxygen e-tank was full at time of departure. 8:55 AM Resident was loaded into the Timberridge transportation van in her wheelchair. Both [Resident #1's name] and her chair were secured. 8:55 - 9:45 AM Resident enroute to her appointment, no signs and symptoms of distress noted. 12:50 PM resident requested to stop for lunch prior to returning to the transportation van and returning to the facility. At this time the driver states he did not notice any signs of distress. 1:00 PM resident is loaded back into the facility van and both she and her chair were secured prior to getting on to the Interstate. Resident stated she believed her oxygen may have been out. Driver immediately suggested that he return her to the health facility to be evaluated. Resident declined. Driver continued to monitor resident during transport. 1:40 PM: Resident complained of chest pain and shortness of breath. Driver immediately pulled over called 911 EMS arrived and assumed responsibility of resident's care. [Approximately 4 hours and 51 minutes after exit from the facility]. 2:02 PM Administrator notified. Review of a handwritten statement by Staff A, Transportation Driver/Floor Technician dated 1/03/2024 as transcribed by the DON read, He stated that while transporting [Resident #1's name] back from her eye appointment [Resident #1's name] was fidgeting with her wheelchair and stated she was out of oxygen. He offered to return her to health facility and she declined. I looked back in the rearview mirror she was fidgeting again she was leaned over to the right side chair was tilted I pulled over and called 911. Review of the job description titled, Van Driver: General description: under general supervision, performs various tasks relating to the transport of residents and passenger vans. Typical duties/responsibilities: operates a passenger van safely and efficiently. Follows commonly scheduled routes or responds to requests from facility supervisor or management for unscheduled pickups or drop offs. Assist residents in boarding and exiting vehicle. Loads and unloads luggage, packages, or other items. Transmits and receives messages per cell phone. Monitors traffic and weather conditions and notifies facility supervisor of potential problems. Reports accidents or other safety situations to facility supervisor. Treats all residents and other persons in a courteous friendly and professional manner. Also, may be required to perform other related duties as requested. Essential functions: Must be able to perform other duties as necessary to ensure resident safety. Review of Resident #1's care plan read, Focus: [Resident #1's name] is at risk for return to hospital due to SOB [shortness of breath], falls, CHF [congestive heart failure], COPD, RSV, PNA [pneumonia]. Interventions: Monitor labs and diagnostic test, monitor/document/report PRN any signs and symptoms of CAD [coronary artery disease], chest pain or pressure especially with activity, heartburn, nausea, vomiting, shortness of breath, excessive sweating, dependent edema, changes in cap [capillary] refill, color/warmth of extremities, new or worsening agitation/delusions, notify MD as indicated. Focus: [Resident #1's name] has congestive heart failure. Interventions: check breath sounds and monitor/document for labored breathing, monitor/document for use of accessory muscles while breathing, check vital signs every shift, notify MD of significant abnormalities, encourage adequate nutrition, offer small frequent feedings, give cardiac medications as ordered, incentives spirometer as ordered, Lasix 40 milligram every two days BID [twice a day] for CHF, monitor/document/report PRN any s/sx [signs and symptoms] of congestive heart failure, periorbital edema, SOB upon exertion, cool skin, dry cough, distended neck veins, weakness, weight gain unrelated to intake, crackles and wheezes upon auscultation, OXYGEN SETTINGS: per MD orders, weigh per MD orders/ facility policy. Focus: [Resident #1' name] is on diuretic therapy related to CHF. Interventions: Administer diuretic medications as ordered by physician. Focus: [Resident #1's name] is on anticoagulant therapy r/t a-fib [atrial fibrillation - an irregular heart rhythm], h/o [history of] cva [cerebral vascular accident], pvd [peripheral vascular disease. Interventions: Administer anticoagulant medications as ordered by physician. Review of the [Name of oxygen suppler] Standard Invoices dated 1/05/2024 and 1/16/2024 documented the number of cylinders delivered with a material number of OX USPEAWBPLUS [OX USPEAWBPLUS USP (United States Pharmacopeia) Medical Grade Oxygen, Size E High Pressure Aluminum Medical Cylinder With Walk-O2 [oxygen]-Bout® Regulator, VIPR 1 [valve with integrated pressure regulator]. Review of the document provided by the facility titled, Approximate Hours Of Service For Oxygen Tanks under E Tanks read, Liter flow per minute - 3. Full Cylinder 2,000 lbs. [pounds] 3 ¼ hours. Review of the policy and procedure titled, Resident Transportation Safety (Facility Operated Vehicles) read, Policy: Facility operated vehicles used for the purpose of resident transportation will be operated in a manner that will minimize the risk of injury to residents and staff . 9. Each van/facility operated vehicle shall have a telecommunication (cell phone) available to the driver to ensure proper emergency communication. No driver shall use a telecommunication devise while the van is in motion. 10. The driver of the van facility operated vehicle is to report any accident or incident (even if there is no injury or property damage) to the facility administrator and to law enforcement as required by law. 11. If an accident or incident occurs involving a resident that results in suspected or confirmed injury to the resident or if there is a medical emergency involving a resident, emergency service should be requested by calling 911. The administrator is to be notified as soon as possible after requesting assistance for the resident. The administrator is to be notified as soon as possible after requesting assistance for the resident. The van/facility operated vehicle should wait at the location for emergency services to arrive. Review of the policy and procedure titled, Facility Operated Vehicle read, Policy: This policy is designed to maximize employee and resident safety and minimize risk of injuries and property damage. Procedure . 8. Facility operated vehicles shall have a telecommunication system available to the driver(s) to ensure proper emergency communications. Review of the policy and procedure titled, Abuse, Neglect, Exploitation & Misappropriation read, Policy: It is the policy of this facility to take appropriate steps to prevent abuse (be it verbal, sexual, physical or mental), neglect, exploitation and misappropriation and the occurrence of an injury of unknown source, and to ensure that all alleged violations of Federal and/or State laws are reported immediately to the Administrator, the Risk Manager, the Social Service Director, and the Director of Nursing. Procedure: The facility shall take steps to prevent, detect, and report suspected maltreatment: 7. Investigation: A thorough investigation will be conducted. The Abuse Coordinator/designee will initiate the procedures for conducting the investigation. The investigation will include: a. They type of allegation, b. What occurred, when, where and to whom? By whom? Get a physical description or identify the alleged perpetrator if possible, c. Describe the injury and any treatment, d. Interview witnesses separately; interview caregivers, roommates; get statements; observe/document demeanor; include names, addresses, and phone numbers of actual witnesses .f. Obtain signed statement from alleged perpetrator, if possible .h. Describe action taken to protect resident .l. If neglect is alleged, identify staff, length of time, and outcome to resident .o. Review any meds that may cause resident to bruise easily or be R/T [related to] nature of the injury .q. Review nurse's notes and other records for information about the incident. Upon completion of the investigation, the facility should prepare a summary report of the findings and conclusions, including any actions taken by the facility. 8. Corrective action: The facility shall make all reasonable efforts to determine the cause of the suspected maltreatment and take corrective action consistent with the investigation findings to eliminate any ongoing danger to the resident or other residents. Definitions: Neglect: Neglect is 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. Review of the policy and procedure titled, Nursing - Change in a Residents Condition or Status read, Policy: The facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the residence medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). In the event of a medical emergency, the facility will notify the attending physician and/or call 911 according to the resident's advanced directives. The Immediate Jeopardy (IJ) was removed on site on 1/19/24, after the receipt of an acceptable IJ removal plan. Review of the Removal Plan dated 1/19/24 documented the facility has initiated the following steps[TRUNCATED]

Based on interviews, resident record reviews, and review of the policies and procedures, the facility administration failed to administer the facility in a manner that enables it to use its resources effectively and efficiently to attain and maintain the highest practicable physical well-being of each resident and to prevent medical neglect when the facility failed to implement policies and procedures for neglect, resident change in condition or status, and resident transportation safety for facility operated vehicles; the facility transportation driver failed to notify the facility licensed medical staff of a resident change in condition. Resident #1, while being transported to the facility in the facility transport van after attending a physician appointment, stated she was out of oxygen, that she needed oxygen, was short of breath, and experiencing chest pain. The facility transportation driver pulled off the interstate, did not notify the facility licensed medical staff, asked Resident #1 if she wanted to return to the hospital/health facility, the resident declined, stating she was okay. The transportation driver did not notify the facility licensed medical staff of the resident declining medical care and services and continued to transport Resident #1 back to the facility. Resident #1 suffered cardiac arrest and did not survive. The facility's failure to implement their policies and procedures for Resident #1 led to a determination of Immediate Jeopardy at a scope and severity of isolated, (J). The Nursing Home Administrator was notified of the Immediate Jeopardy on January 19, 2024, at 12:13 PM. The Immediate Jeopardy began on January 3, 2024, and was removed on site on January 19, 2024. Review of the Cleveland Clinic documentation titled, Hypoxia read, Hypoxia is low levels of oxygen in your body tissues. It causes symptoms like confusion, restlessness, difficulty breathing, rapid heart rate, and bluish skin. Many chronic heart and lung conditions can put you at risk for hypoxia. Hypoxia can be life-threatening. If you are experiencing symptoms of hypoxia, call 911 or go to the nearest ER [emergency room]. Hypoxia should be treated right away to prevent permanent organ damage. (My.clevelandclinic.org/health/diseases/23063-hypoxia accessed on 1/18/2024) Findings include: Review of the Position Description Administrator read, Basic Function: Responsible for directing the overall operation of the facilities activities in accordance with current applicable federal, state and local standards, guidelines and regulations and as directed by the governing board and for ensuring that the highest degree of quality patient/resident care is maintained at all times. Characteristic Duties and Responsibilities: Essential Functions: 1. Establish and direct the implementation of written policies and procedures that reflect the goals and objectives of the facility. (Includes personnel policies, patient/resident care policies, procedure manuals, position descriptions, etc.) 2. Assist in the development and implementation of departmental policies and procedures, and establish a rapport in and between departments so that each can see the importance of teamwork. 3. Ensure that all personnel, patients/residents, visitors, and the general public follow established policies and procedures. 4. Interpret the facility's policies and procedures to personnel, patients/residents, family members, visitors, etc. as may become necessary. 5. Review policies and procedures periodically, at least annually, and make changes as necessary to ensure compliance with current regulations are being continually maintained. 6. Ensure that patients'/residents' rights to fair and equitable treatment, self-determination, individuality, privacy, property and civil rights, including the right to wage complaints, are well established and maintained at all times .Marginal Functions: 1. Responsible for the overall quality assessment and improvement program and the coordination of quality assessment and improvement activities . 9. Review and check competence of the work force and make necessary adjustments/corrections as required or that may become necessary. Review of the Position Description Director of Nursing (DON) read, Basic Function: Responsible for effective overall management of the Nursing Department and coordination with other disciplines to provide quality care to all patients/residents. Characteristic Duties and Responsibilities: Essential Functions: 1. Supports and practices the philosophy, objectives and standards of the Department of Nursing and participates in the revision of these as necessary to ensure quality care to all patients/residents. 2. Coordinates interdisciplinary patient/resident care management efforts .6. Ensures a safe and sanitary environment for patients/residents, employees, and visitors .8. Assumes full responsibility for the operation and management of the facility in the temporary absence of the Facility Administrator or as directed by the Administrator .Coordinates interdisciplinary patient/resident care management efforts. 1. Provides direction as to format and approach to patient/resident care management. 2. Ensures implementation of resident care planning format to comply with patients/residents needs and various regulatory agency requirement. 3. Coordinate requirements and cooperates with all other departments in providing a favorable physical, social, and emotional environment for all patients/residents. Review of the Medical Director Services Agreement read, 3. Medical Director of Facility. During the Term, Physician agrees to serve as Medical Director for Facility: During the Term, Physician agrees to perform services identified on Exhibit A attached hereto and incorporated herein by reference. Review of Exhibit A, Medical Director Services read, 1. Visit facility as often as needed to effectively perform the services which shall be at least once monthly and document each visit in writing. 2. Develop, implement, and evaluate resident care policies, procedures and guidelines, based on the current standards of practice, and collaborate with Facility leadership, staff, and other practitioners and consultants regarding the following: a. admissions, discharges, infection control, safety, restraints, fall risks, pain management, significant weight loss or gain, psychotropic medications, physician privileges and practices, responsibilities of non-physician health care workers and other aspects of residence care to ensure adequate and comprehensive services. b. accidents and incidents, use of medications, use and release of clinical information, ancillary services such as laboratory, radiology, and pharmacy and overall quality of care. c. providing a continuity of care and an adequate medical record system. d. the safe and effective use of medications to meet the needs of residents; . k. medical and clinical concerns and issues that affect resident care, medical care, or quality of life, or are related to the provision of services by physicians or other licensed healthcare practitioners .5. Advise and consult with the Facility Administrator regarding: a. Facility's ability to meet the residents' needs and opportunities for future resident care programs .f. improving performance of medical services as an integral part of improving Facility's performance. 6. Direct and Coordinate: a. the medical care in Facility and ensure that Facility is providing appropriate care as required. Review of the Position Description Assistant Director of Nursing read, Basic Function: Assists the Director of Nursing in the overall management of the Department of Nursing .Characteristic Duties and Responsibilities: Essential Functions: 1. Assist in ensuring quality nursing care to all residents/patients. Supports and practice the philosophy nursing objectives and standards of the Department of Nursing .5. Assists in ensuring a safe and sanitary environment for patients/residents, employees and visitors . Minimum Performance Standards: Assist in ensuring quality nursing care to all patients/residents. Supports and practices the philosophy, nursing objectives and standards of the Department of Nursing. Performance in the following areas is acceptable when: 2. Participates in the implementation of the patient/resident care planning process to comply with patient/resident needs and regulatory agency requirements. Review of the facility medical record for Resident #1 documented the resident was admitted with diagnoses of acute on chronic combined systolic congestive and diastolic congestive heart failure (with combined congestive heart failure in systolic, ventricles cannot produce enough pressure in the contraction phase to push blood into circulation, diastolic the ventricles cannot relax, expand, or fill with enough blood), RSV (respiratory syncytial virus - is the most common cause of lower respiratory tract infections), pneumonia unspecified organism, dysphasia following cerebral infarction (an area of dead tissue in the cerebrum caused by an insufficiency for arterial or venous blood flow - resulting in an impairment in the production of speech resulting from brain disease or damage) paroxysmal atrial fibrillation (rapid, erratic heart rate begins suddenly and then stops on its own within seven days), acute myocardial infarction (heart attack), hemiplegia (paralysis of one side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infarction affecting left nondominant side, repeated falls, ischemic cardiomyopathy (damaged heart muscle from a lack of blood flow), anemia, atherosclerotic heart disease of native coronary artery without angina pectoris (silent heart ischemia), presence of automatic implantable cardiac defibrillator (a pacemaker with the ability to recognize abnormally fast cardiac rhythm and provide an immediate treatment which can be in the form of shock therapy) presence of coronary angioplasty implant and graft (creates a new path for blood to flow around a blocked or partially blocked artery), retinal detachment left eye, occlusion and stenosis of unspecified carotid artery (the narrowing of the carotid arteries), major depressive disorder, idiopathic peripheral autonomic neuropathy (nerve damage when the cause can't be determined), peripheral vascular disease (reduced circulation of blood to a body part other than the brain or heart), essential primary hypertension (high blood pressure), hyperlipidemia, acquired absence of right leg above the knee, acquired absence of left leg below the knee, chronic obstructive pulmonary disease with acute exacerbation (sudden worsening in airway function and respiratory symptoms in people with COPD), non ST elevation myocardial infarction (a type of involving partial blockage of one of the heart arteries, causing reduced flow of oxygen-rich blood to the heart muscle), type 2 diabetes mellitus with other circulatory complications, and acute respiratory failure with hypoxia (impairment of gas exchange between the lungs and the blood causing a state in which oxygen is not available in sufficient amounts). Review of the physician orders dated 11/02/2023 Oxygen 3 liters PRN [as needed]. Review of the nursing progress note dated 1/03/2024 at 1430 [2:30 PM] read, Resident was being transported from an appointment when the transport driver witnessed resident having a medical event. She was lowered to the floor of the transport vehicle, lying sideways with her stumps facing the windshield and her head facing the wall. 911 was called, the facility director and MD [Medical Doctor] were notified. She was transferred into an ambulance to be transported to [name of a local hospital]. Review of the nursing progress note dated 1/03/2024 at 1530 [3:30 PM] read, Resident transported via TR [Timberridge] transportation van to appointment at [name of the eye center] at the [location of the eye center that is 48.3 miles from the facility; approximately a one-hour drive] at Approx [approximately] 8:45 AM for a 9:30 AM appointment time. Accompanied by driver. Notification made by driver when enroute to return to the facility that resident c/o [complaint of] shortness of breath and chest pain, driver then pulled over to assist resident and called 911. Driver states that he assisted her into a rescue position to assure her comfort and safety until EMS [Emergency Medical Services] arrived. EMS arrived & escorted resident to [name of local hospital]. Call received from [name of local hospital] to make notification to the facility of the resident passing. Administration notified daughter of event and hospitalization. During an interview on 1/16/2024 at 9:35 AM the Administrator stated, I'm not really sure about everything that happened, or what was done. I'm sorry I was on vacation and just need to get myself up to speed with everything that has been done. [The Administrator was notified of the event on 1/3/2024 at 2:02 PM]. During an interview on 1/16/2024 at 10:10 AM the Director of Nursing (DON) stated, I took [Staff A name's] statement the day of the event and it was that [Resident #1's name] told him that she was out of oxygen, and he pulled over and asked her if she wanted to go to the hospital and she said no she was fine. So, he came back to Ocala and when he saw her in the wheelchair, the wheelchair was tilted, and she was slumped to her left side. He immediately pulled over and called 911. He did follow the policy for transporting, when he recognized a medical emergency, he called 911. I don't think that he saw her lack of oxygen as an emergency. We don't know if the oxygen was out or not. He wouldn't know how to change an oxygen tank. We did not send any other tanks with her. But she is awake, alert and she stated she didn't want to go so that is what he did, he honored her right to refuse to go to the hospital. I don't know exactly what transport drivers have in education about emergencies. He is not able to assess a resident, he does not have medical training to do that. During an interview on 1/16/2023 at 11:30 AM the Administrator, in the presence of the DON, stated, [Staff A's name] was transporting [Resident #1's name]to her eye appointment, and she stated, I think I'm out of oxygen, he pulled over and asked her if she wanted to go to the hospital and she said no, because she has a BIMS [Brief Interview for Mental Status] of 15 [this score means cognition is intact], it was her right to refuse to go. We have no way of knowing whether the oxygen tank was empty or not. We don't know whether this contributed to the event. But once he did recognize an emergency, he did follow our policy for transportation and did call 911. [Staff A's name] was trained on transport, and he followed the training. He is not cardiopulmonary resuscitation [CPR] trained to my knowledge. During an interview on 1/16/2024 at 2:00 PM the Assistant Director of Nursing (ADON) stated, I did not take care of her [Resident #1]. I was on the back end of the process, meaning I received the calls from the Driver and the hospital that there was a medical event during transportation of [Resident #1's name]. I can't say that I know exactly how long the oxygen tanks are good for. During an interview on 1/16/2024 at 3:07 PM, Staff B, Licensed Practical Nurse (LPN) stated, I was just coming on shift when I saw her [Resident #1]. I work starting at 7:00 [AM]. She was already dressed and up in her wheelchair. She always used oxygen, she didn't ever take off her oxygen, like she didn't use it PRN, she used it continuously. I do not know how long oxygen tanks are good for. During a telephone interview on 1/16/2024 at 6:00 PM, Staff A, Transport Driver stated, I brought [Resident #1's name] up to her doctor's appointment in Gainesville and then she wanted to get something to eat so I brought her to the food court in the mall. [Name of mall] up there in Gainesville. That was where her doctor is, in the mall. We ate and then got in the van, we had just gotten on I [Interstate] 75 from [street location] where the mall is when she said, 'I think I'm out of oxygen. I need some oxygen' and I asked her if she were {sic} okay. She told me she was short of breath. I did pull off 75 and asked but she said she didn't want any medical help. She said 'No, I'm okay' to me and so I just drove on down to Ocala. She was talking to me, and I would glance up into the mirror and she would be fidgeting with stuff. It was just after I got off 75 on 200 just before [name of a restaurant] that I saw her slumped in the wheelchair. She had not complained of any shortness of breath or chest pain, she was just slumped over, not conscious at all. I pulled off and called 911. I couldn't adjust her in the chair, so I unbuckled her and got her to the floor, after that the paramedics came. I am a floor technician, that's my job and I also drive residents to their appointments. Not everyone uses oxygen when they go. I really don't know nothing about that, nothing about oxygen. I don't know how to change an oxygen tank. I have been doing the driving for a few years now, I think, since 2008. I can't really remember what type of training I got then about it. I know I need to make sure the chairs are strapped in and that if I have any kind of a medical emergency, that I pull over and call 911. I do not have any CPR training. I haven't gotten no additional training after this happened. I did not call any of the nurses about the oxygen being out. I just tried to bring her back. During an interview conducted on 1/17/2024 at 1:22 PM the Medical Doctor/Medical Director, stated, I was under the understanding that she [Resident #1] was at an appointment and eating a [name of restaurant] sandwich. She told the driver she thought that she was out of oxygen, and he asked her if she wanted to go to the hospital and she said no. I do think she was stubborn, and I don't know if he could have convinced her to go. I don't think we could force her to go. The driver is not trained to assess residents. She was a sick lady with an EF [Ejection Fraction] of 20-25% [an indicator of heart strength. It measures the amount of oxygen-rich blood pumped out to the body with each heartbeat. An EF of 20% is about one-third of the normal ejection fraction. The heart is not pumping all the oxygen-rich blood the body needs], had an ACB [aortocoronary bypass, a surgery that creates a new path for blood to flow around a blocked or partially blocked artery in the heart], AICD [automatic implanted cardioverter-defibrillator, a device that helps when there is a sudden loss of all heart activity, a condition called cardiac arrest], recent RSV [respiratory syncytial virus, inflammation partially or completely blocks the airways] and pneumonia, also very severe heart disease and peripheral vascular disease. She was using her oxygen and did need it all the time because of these things. During an interview on 1/17/2024 at 4:05 PM the Administrator stated, I don't want to determine what [Staff A's name] perceived or did not perceive. He determined that she was fine, he stated that she did not want to go to the hospital, and he thought she was fine. I know that when she had an actual emergency, he did call 911. I can't say that her shortness of breath and chest pain was an emergency to [Staff A's name]. He offered and she stated she did not want to go to the hospital. It was her right to refuse. When asked the Administrator declined to answer if [Staff A's name] was able to assess the resident and able to determine if Resident #1's name was having a medical emergency. During an interview on 1/18/2023 at 10:09 AM the DON stated, I was here when [the Administrator's name] got a phone call from [Staff A's name]. He was on the side of the road near [restaurant's name]. That is the only call we got from [Staff A's name] that I know about. [Resident #1's name] was transported to [local hospital name]. I was here when [Staff A's name] got back, and he was very upset, shook up. The oxygen tank, well, I didn't look at the regulator when [Staff A's name] returned. I just heard it running, it was making a sound. I did not photograph the oxygen tank and I did not look to see whether it was empty or not. I can't say the tank was empty because I wasn't there, but she refused care all the time. So, it's not unusual for her to refuse to do things. I don't know if she had capacity because I was not there with her. I was not in the van with [Staff A's name] so I can't say that I know that she had shortness of breath or chest pain. I wasn't there. But if she did per my Administrator's interview, then no one but [Staff A's name] was in the van with the resident. He is not able to notify her of the consequences of not getting assessed, he would not be able to explain to her that being without oxygen would or could have her in more problems or what the result of not getting medical help would be. But we can't say she was out of oxygen, we don't know that, and we did not look at the oxygen gauge when he returned. So, therefore I can't say that anything happened with her oxygen, or that she was in any distress during the ride. I only have the statement that he gave me, and he thought she was alright. I wasn't called by [Staff A's name] about any chest pain or shortness of breath, so I can't tell you what I would have said to him. If a resident is short of breath and having chest pain, I would tell them to get a nurse to evaluate the resident if they were in the building. During an interview on 1/18/2024 at 10:20 AM the Administrator stated, All the information that I documented during my interview with [Staff A's name] was accurate, he did state that she complained of chest pain and shortness of breath the first time he pulled the van over. He did not call me, or anyone else about the resident at that time, he asked the resident who has the capacity to self-determine if she wanted to go to the hospital and she declined. So, he brought her back here. He told me she was fidgeting and conversing with him during the trip. He did not tell me that she complained of pain when getting off 75, he told me exactly what I wrote. It was around 2 o'clock when [Staff A's name] called me, it was so jumbled, he was frantic and upset. The information I understood at that time [Resident #1's name] required and was sent to the hospital. I can't say because I wasn't with her that she had a medical emergency any sooner than [Staff A's name] recognized it, I was not there. I think that he followed our policies and procedures. I don't think he is able to discuss the consequences of not going to the hospital. But according to [Staff A's name] she was fine during the transport, and he did what he was supposed to do when she was slumped in the chair. During an interview on 1/19/2024 at 1:50 PM Staff A, Transportation Driver /Floor Technician stated, She [Resident #1] had chest pain and shortness of breath up in Gainesville and I asked but she said no she didn't want to go to the doctors, back to there at the doctors. I did not call anyone when she had that pain. I got no training on emergencies like that. I knew that I should call if we needed to call 911. I didn't know that this was a problem, that that might cause her to die. I never did ask her again if she wanted to go to the hospital, just that one time. I didn't talk much to her on the way home, but I would glance up and I would see that she was fidgeting in her chair, she was awake and when I glanced in Ocala, she was all slumped over and the chair was tilted a little, she was tilted to her side. I had a hard time after I pulled over getting her pulled in her seat, so I unbuckled her and moved her to the floor. She couldn't talk to me at all. She didn't tell me that she was short of breath or having any chest pain again after being in Gainesville. That's the only time she said that. She did not say it on the off ramp here in Ocala, she wasn't saying anything. Well, I did know that it was serious her having pain and feeling that way, but she just said she didn't want to go. I just wasn't trained to call for anything but an emergency. I didn't think this was that type of an emergency. Review of the facility time-line documented: 8:49 AM Resident observed by [Staff D's name, CNA/Unit Secretary prior to departing facility for her appointment. [Staff D's name] states she verified that [Resident #1's name's] oxygen e-tank was full at time of departure. 8:55 AM Resident was loaded into the Timberridge transportation van in her wheelchair. Both [Resident #1's name] and her chair were secured. 8:55 - 9:45 AM Resident enroute to her appointment, no signs and symptoms of distress noted. 12:50 PM resident requested to stop for lunch prior to returning to the transportation van and returning to the facility. At this time the driver states he did not notice any signs of distress. 1:00 PM resident is loaded back into the facility van and both she and her chair were secured prior to getting on to the Interstate. Resident stated she believed her oxygen may have been out. Driver immediately suggested that he return her to the health facility to be evaluated. Resident declined. Driver continued to monitor resident during transport. 1:40 PM: Resident complained of chest pain and shortness of breath. Driver immediately pulled over called 911 EMS arrived and assumed responsibility of resident's care. [Approximately 4 hours and 51 minutes after exit from the facility]. 2:02 PM Administrator notified. Review of a handwritten statement by Staff A, Transportation Driver/Floor Technician dated 1/03/2024 as transcribed by the DON read, He stated that while transporting [Resident #1's name] back from her eye appointment [Resident #1's name] was fidgeting with her wheelchair and stated she was out of oxygen. He offered to return her to health facility and she declined. I looked back in the rearview mirror she was fidgeting again she was leaned over to the right side chair was tilted I pulled over and called 911. Review of the job description titled, Van Driver: General description: under general supervision, performs various tasks relating to the transport of residents and passenger vans. Typical duties/responsibilities: Transmits and receives messages per cell phone. Reports accidents or other safety situations to facility supervisor . Review of Resident #1's care plan read, Focus: [Resident #1's name] is at risk for return to hospital due to SOB [shortness of breath], falls, CHF [congestive heart failure], COPD, RSV, PNA [pneumonia]. Interventions: Monitor labs and diagnostic test, monitor/document/report PRN any signs and symptoms of CAD [coronary artery disease], chest pain or pressure especially with activity, heartburn, nausea, vomiting, shortness of breath, excessive sweating, dependent edema, changes in cap [capillary] refill, color/warmth of extremities, new or worsening agitation/delusions, notify MD as indicated. Focus: [Resident #1's name] has congestive heart failure. Interventions: check breath sounds and monitor/document for labored breathing, monitor/document for use of accessory muscles while breathing, check vital signs every shift, notify MD of significant abnormalities, encourage adequate nutrition, offer small frequent feedings, give cardiac medications as ordered, incentives spirometer as ordered, Lasix 40 milligram every two days BID [twice a day] for CHF, monitor/document/report PRN any s/sx [signs and symptoms] of congestive heart failure, periorbital edema, SOB upon exertion, cool skin, dry cough, distended neck veins, weakness, weight gain unrelated to intake, crackles and wheezes upon auscultation, OXYGEN SETTINGS: per MD orders, weigh per MD orders/ facility policy. Focus: [Resident #1' name] is on diuretic therapy related to CHF. Interventions: Administer diuretic medications as ordered by physician. Focus: [Resident #1's name] is on anticoagulant therapy r/t a-fib [atrial fibrillation - an irregular heart rhythm], h/o [history of] cva [cerebral vascular accident], pvd [peripheral vascular disease. Interventions: Administer anticoagulant medications as ordered by physician. Review of the [Name of oxygen suppler] Standard Invoices dated 1/05/2024 and 1/16/2024 documented the number of cylinders delivered with a material number of OX USPEAWBPLUS [OX USPEAWBPLUS USP (United States Pharmacopeia) Medical Grade Oxygen, Size E High Pressure Aluminum Medical Cylinder With Walk-O2 [oxygen]-Bout® Regulator, VIPR 1 [valve wiht integrated pressure regulator]. Review of the document provided by the facility titled, Approximate Hours Of Service For Oxygen Tanks under E Tanks read, Liter flow per minute - 3. Full Cylinder 2,000 lbs. [pounds] 3 ¼ hours. Review of the policy and procedure titled, Resident Transportation Safety (Facility Operated Vehicles) read, Policy: Facility operated vehicles used for the purpose of resident transportation will be operated in a manner that will minimize the risk of injury to residents and staff . 9. Each van/facility operated vehicle shall have a telecommunication (cell phone) available to the driver to ensure proper emergency communication. No driver shall use a telecommunication devise while the van is in motion. 10. The driver of the van facility operated vehicle is to report any accident or incident (even if there is no injury or property damage) to the facility administrator and to law enforcement as required by law. 11. If an accident or incident occurs involving a resident that results in suspected or confirmed injury to the resident or if there is a medical emergency involving a resident, emergency service should be requested by calling 911. The administrator is to be notified as soon as possible after requesting assistance for the resident. The van/facility operated vehicle should wait at the location for emergency services to arrive. Review of the policy and procedure titled, Facility Operated Vehicle read, Policy: This policy is designed to maximize employee and resident safety and minimize risk of injuries and property damage. Procedure . 8. Facility operated vehicles shall have a telecommunication system available to the driver(s) to ensure proper emergency communications. Review of the policy and procedure titled, Abuse, Neglect, Exploitation & Misappropriation read, Policy: It is the policy of this facility to take appropriate steps to prevent abuse (be it verbal, sexual, physical or mental), neglect, exploitation and misappropriation and the occurrence of an injury of unknown source, and to ensure that all alleged violations of Federal and/or State laws are reported immediately to the Administrator, the Risk Manager, the Social Service Director, and the Director of Nursing. Procedure: The facility shall take steps to prevent, detect, and report suspected maltreatment: 7. Investigation: A thorough investigation will be conducted. The Abuse Coordinator/designee will initiate the procedures for conducting the investigation. The investigation will include: a. They type of allegation, b. What occurred, when, where and to whom? By whom? Get a physical description or identify the alleged perpetrator if possible, c. Describe the injury and any treatment, d. Interview witnesses separately; interview caregivers, roommates; get statements; observe/document demeanor; include names, addresses, and phone numbers of actual witnesses .f. Obtain signed statement from alleged perpetrator, if possible .h. Describe action taken to protect resident .l. If neglect is alleged, identify staff, length of time, and outcome to resident .o. Review any meds that may cause resident to bruise easily or be R/T [related to] nature of the injury .q. Review nurse's notes and other records for information about the incident. Upon completion of the investigation, the facility should prepare a summary report of the findings and conclusions, including any actions taken by the facility.

Based on interviews, resident record reviews, and review of policies and procedures, the facility failed to utilize the Quality Assessment and Performance Improvement (QAPI) process to investigate, develop and implement an effective performance improvement plan (PIP) when the facility transportation driver failed to notify the facility licensed medical staff of a resident change in condition. Resident #1, while being transported to the facility in the facility transport van after attending a physician appointment, stated she was out of oxygen, that she needed oxygen, was short of breath, and experiencing chest pain. The facility transportation driver pulled off the interstate, did not notify the facility licensed medical staff, asked Resident #1 if she wanted to return to the hospital/health facility, the resident declined, stating she was okay. The transportation driver did not notify the facility licensed medical staff of the resident declining medical care and services and continued to transport Resident #1 back to the facility. Resident #1 suffered cardiac arrest and did not survive. The facility's failure to develop and implement appropriate plans of action to identify and correct process failures of providing emergency care and services for Resident #1 led to a determination of Immediate Jeopardy at a scope and severity of isolated (J). The Nursing Home Administrator was notified of the Immediate Jeopardy on January 19, 2024, at 12:13 PM. The Immediate Jeopardy began on January 3, 2024, and was removed on site on January 19, 2024. Review of the Cleveland Clinic documentation titled, Hypoxia read, Hypoxia is low levels of oxygen in your body tissues. It causes symptoms like confusion, restlessness, difficulty breathing, rapid heart rate, and bluish skin. Many chronic heart and lung conditions can put you at risk for hypoxia. Hypoxia can be life-threatening. If you are experiencing symptoms of hypoxia, call 911 or go to the nearest ER [emergency room]. Hypoxia should be treated right away to prevent permanent organ damage. (My.clevelandclinic.org/health/diseases/23063-hypoxia accessed on 1/18/2024) Findings include: Review of the facility medical record for Resident #1 documented the resident was admitted with diagnoses of acute on chronic combined systolic congestive and diastolic congestive heart failure (with combined congestive heart failure in systolic, ventricles cannot produce enough pressure in the contraction phase to push blood into circulation, diastolic the ventricles cannot relax, expand, or fill with enough blood), RSV (respiratory syncytial virus - is the most common cause of lower respiratory tract infections), pneumonia unspecified organism, dysphasia following cerebral infarction (an area of dead tissue in the cerebrum caused by an insufficiency for arterial or venous blood flow - resulting in an impairment in the production of speech resulting from brain disease or damage) paroxysmal atrial fibrillation (rapid, erratic heart rate begins suddenly and then stops on its own within seven days), acute myocardial infarction (heart attack), hemiplegia (paralysis of one side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infarction affecting left nondominant side, repeated falls, ischemic cardiomyopathy (damaged heart muscle from a lack of blood flow), anemia, atherosclerotic heart disease of native coronary artery without angina pectoris (silent heart ischemia), presence of automatic implantable cardiac defibrillator (a pacemaker with the ability to recognize abnormally fast cardiac rhythm and provide an immediate treatment which can be in the form of shock therapy) presence of coronary angioplasty implant and graft (creates a new path for blood to flow around a blocked or partially blocked artery), retinal detachment left eye, occlusion and stenosis of unspecified carotid artery (the narrowing of the carotid arteries), major depressive disorder, idiopathic peripheral autonomic neuropathy (nerve damage when the cause can't be determined), peripheral vascular disease (reduced circulation of blood to a body part other than the brain or heart), essential primary hypertension (high blood pressure), hyperlipidemia, acquired absence of right leg above the knee, acquired absence of left leg below the knee, chronic obstructive pulmonary disease with acute exacerbation (sudden worsening in airway function and respiratory symptoms in people with COPD), non ST elevation myocardial infarction (a type of involving partial blockage of one of the heart arteries, causing reduced flow of oxygen-rich blood to the heart muscle), type 2 diabetes mellitus with other circulatory complications, and acute respiratory failure with hypoxia (impairment of gas exchange between the lungs and the blood causing a state in which oxygen is not available in sufficient amounts). On 1/3/2024 at approximately 8:45 AM, Resident #1 was transported to a 9:30 AM appointment by a facility transport driver, Staff A, in the facility van to a medical appointment 48.3 miles from the facility. Resident #1 had one oxygen e-tank. Following the appointment, the Staff A and Resident #1 had lunch in the mall where the medical appointment was. On the return trip home, after just getting on the interstate, Resident #1 told Staff A that she thought she was out of oxygen. When Staff A asked if she was okay, Resident #1 said she was short of breath and had chest pain but did not want medical help. Staff A continued on toward the facility. The transport driver saw her fidgeting in her chair. When Staff A pulled off the interstate to go to the facility, he noticed Resident #1 was slumped in her chair. Staff A called 911 at approximately 1:40 PM. [Approximately 4 hours and 51 minutes after exit from the facility]. (Cross Reference F600) During an interview on 1/16/2024 at 9:35 AM the Administrator stated, I'm not really sure about everything that happened, or what was done. I'm sorry I was on vacation and just need to get myself up to speed with everything that has been done. [The Administrator was notified of the event on 1/3/2024 at 2:02 PM]. During an interview on 1/16/2023 at 11:30 AM the Administrator, in the presence of the DON stated, [Staff A's name] was transporting [Resident #1's name]to her eye appointment, and she stated, I think I'm out of oxygen, he pulled over and asked her if she wanted to go to the hospital and she said no, because she has a BIMS [Brief Interview for Mental Status] of 15 [this score means cognition is intact], it was her right to refuse to go. We have no way of knowing whether the oxygen tank was empty or not. We don't know whether this contributed to the event. But once he did recognize an emergency, he did follow our policy for transportation and did call 911. [Staff A's name] was trained on transport, and he followed the training. He is not cardiopulmonary resuscitation [CPR] trained to my knowledge. We did not, after the investigation, think that we needed to QAPI [Quality Assurance and Performance Improvement] this, she was of sound mind and competent to make her decision not to get medical treatment. We did not do an Ad Hoc [from the Latin and means for this] QAPI related to this. We did not do a Root Cause Analysis [RCA] to determine if there were any other factors or breaks. She had the right to refuse treatment, it was her right to do that. We do plan on discussing this during our next QAPI on the 25th. Review of the policy and procedure titled, Quality Management read, Vision Statement: This facility will create a caring and nurturing environment, focused on professionalism and excellence in service delivery. The facility strives to be the provider of choice as well as the employer of choice in our community. Purpose: Through quality assurance and performance improvement (QAPI), the facility will take a proactive approach to continually improving care and services for our residents. The facility will involve residents, staff, and other partners to realize our vision of being both the provider and the employer of choice in this community. To do this, all employees will participate in ongoing QAPI efforts to support our mission of providing quality focused care, one resident at a time. Guiding Principles: The facility will use QAPI to make decisions and improve the day-to-day operations. QAPI will include all employees, every department, and all services provided. QAPI focuses on systems and processes, rather than individuals. The facility will have a culture that encourages, rather than punishes, staff who identify errors or system breakdowns . The facility will make decisions based on data, which will include the input and experiences of caregivers, residents, health care partners, families and other stakeholders. The facility will set goals for performance and measures progress toward those goals. The desired outcome of QAPI in the facility is to improve quality of care and the enhanced quality of life of our residents. Policy: The Administrator is responsible for the quality assessment and assurance committee for the facility. The facility will have an internal Quality Assurance and Performance Improvement Program designed to provide a comprehensive approach to ensuring high quality care and services. The QA&A [Quality Assurance & Assessment] Committee, referred to as the QAPI Committee, will meet at least monthly and will utilize the 5 Elements of QAPI which are: 1. Design and scope - ongoing program and is comprehensive, dealing with the full range of services offered by the facility. The QAPI program will address all systems of care and management practices, aiming for safety and high quality while emphasizing autonomy and choice in daily life for residents. It utilizes the best available evidence to define and measure goals. 2. Governance and Leadership - the governing body (administration of the facility) will develop a culture of seeking input from facility staff, residents, and families while assuring adequate resources to conduct QAPI efforts. QAPI will be a priority and will include setting expectations around safety, quality, rights, choice, and respect by balancing safety with resident-centered rights and choice. 3. Feedback, Data Systems and Monitoring - the facility will put systems in place to monitor care and services through the use of multiple sources. Feedback systems will incorporate input from staff, residents, families, and others. Performance Indicators will monitor a wide range of care and outcomes and findings will be compared to benchmarks or targets established for performance. 4. Performance Improvement Projects (PIP's) - involves gathering information systematically and intervening for improvement with a written work plan by the project team and a timeline. 5. Systematic Analysis and Systematic Action - the facility will model and promote systems thinking, practice root cause analysis and take action at the systems level. Composition and duties of the QAPI Committee: the facility administrator and Department Leaders will create an environment that promotes quality improvement and involves all caregivers. The residents, families and staff will be encouraged to bring quality concerns forward to the Committee without fear of reprisal. The committee will be expected to build effective teamwork among departments and caregivers, emphasizing effective communication across shifts and between departments. The Committee is comprised of: Medical Director, Administrator (serving as Chairperson), Director of Nursing, Risk Manager, Safety Committee Leader, Care Plan Coordinator, Activity Director, Social Service Director, Food Service Manager, Maintenance Supervisor, Laundry/Housekeeping Supervisor, Infection Control Preventionist, Other Facility Staff, Guests or Designees as indicated. 2. The Committee will identify opportunities for improvement as well as recommend, implement, monitor and evaluate changes. The Committee will address all systems of care and management practices, aiming for safety and high quality while emphasizing autonomy and choice in daily life for residents. It utilizes the best available evidence to define and measure goals. 3. The Committee will obtain data from multiple sources, including Performance Indicators which are benchmarked, and will incorporate input from staff, residents, families, and others as appropriate. 4. The Committee will charter Performance Improvement Projects (PIP's) to provide concentrated efforts to address a particular problem areas identified in one part of the facility or facility wide. The facility conducts PIPs to examine and improve care or services by gathering information systematically to clarify issues and intervening for improvement. 5. The facility will be proficient in the use of Root Cause Analysis to determine how identified problems may be caused or exacerbated and will look across all involved systems to prevent future events and promote sustained improvement programs. 6. Once the root cause has been established, changes or corrective actions tightly linked to the root cause will be implemented. These changes or corrective measures should offer long term solutions to the problem, and must be achievable, objective, and measurable. 7. The Committee will review Performance Improvement Projects each month to monitor and provide feedback to sustain continuous improvement. The Immediate Jeopardy (IJ) was removed on site on 01/19/2024, after the receipt of an acceptable IJ removal plan. Review of the Removal Plan dated 01/19/2024 documented the facility has initiated the following steps to ensure proper utilization of the QAPI process. 1/17/24 Ad Hoc QAPI meeting held to discuss a resident change in status while being transported from a Physician appointment. QAPI committee completed root cause analysis with the following findings: Facility did not ensure resident was supplied with sufficient oxygen (E tanks) for the duration of the trip. Facility failed to educate driver to notify the facility or emergency personnel of any changes in resident status at the time of the change. QAPI committee completed: All staff education on abuse and neglect. Oxygen Transportation Education for LPNs and RNs. Transport Driver education to call emergency personnel in the even {sic} of any resident change of status. Transportation Driver training in American Heart Association CPR, First Aide and Transportation Safety. Transportation Policies and Procedure update for RN, LPN, Drivers, Administrative Staff. An Ad Hoc QAPI meeting was held again on 1/19/24 to review the IJ template and approved the final remediation plan. The plan was approved as written. Facility alleges compliance with immediate jeopardy removal on 1/19/24. Review of the Internal Risk Management and Quality Assurance Performance Improvement Program Meeting Minutes dated 1/17/24 documented the Administrator, DON, Medical Director, Care Plan Coordinator, Activity Director, Social Service Director, CDM/Food Service Director, Maintenance Supervisor, Laundry/HKPG [housekeeping], Infection Control Preventionist and four additional staff members signed as attending the meeting. On the agenda of the meeting was resident change in status while being transported from a physician's appointment. Review of the Root Cause Analysis (RCA): TR - Transport documented it was completed dated 01/17/2024. Review of the In-Service Record titled, Re-Education on Resident Transportation Safety Policies and Procedures documented five (5) staff signed as having attended the training completed on 01/19/2024. Three staff were transport drivers, the other two staff members consisted of the Human Resource Director and the Maintenance Director. During interviews it was stated they attended for the education of the required training. The Maintenance Director oversees the transport drivers. Review of the American CPR Care Association cards documented 3 of 3 transportation drivers completed AED, Adult, Child, Infant CPR & AED Training (BLS) on 01/18/2024. Review of the In-Service Record dated 1/5/2024-ongoing, completed 1/19/2024, titled, Oxygen Safety, Ensure that residents leaving the facility with oxygen have a full tank per MD [Medical Doctor] orders documented 67 licensed staff, 32 CNAs [Certified Nursing Assistants], the Maintenance Director, and Human Resource Director signed as attending the training. Review of the In-Service Record documented the [NAME] Clerk signed attending training titled, Transportation Arrangements. Observations were conducted on 01/19/2024 of two residents, being administered oxygen, being transported to physician appointments. A check list was completed for the residents and a licensed nurse attended with each transport. Review of the Internal Risk Management and Quality Assurance Performance Improvement Program Meeting Minutes dated 01/19/2024 documented the Administrator, Director of Nursing, Medical Director, Infection Control Preventionist, and an additional staff person, was in attendance and the Removal Plan was approved. Interviews were conducted with two of three of the transportation drivers, the Maintenance Director, the Human Resources Director, regarding transportation safety policy and procedures and oxygen tanks and safety. Interviews were conducted with 24 CNAs, and 16 licensed who stated they had completed training on abuse, neglect, exploitation, oxygen safety, and the oxygen tanks.