**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to effectively collaborate with a hospice agency to ensure prompt recognition and timely treatment of uncontrolled agitation for 1 of 1 terminally ill resident reviewed for hospice services, (#88); failed to appropriately prevent and treat self-inflicted wounds, (#88) and ensure skin evaluation and wound treatments were done according to professional standards, (#37), for 2 of 4 residents reviewed for non-pressure skin conditions, out of a total sample of 44 residents. The facility's failure to maintain ongoing communication with the hospice agency regarding the severity, frequency, and outcomes of unmanaged anxiety and agitation caused actual physical and psychosocial harm for resident #88, who suffered symptoms that were inconsistent with the resident's and his representatives' choice and goal for comfort at the end of life. Findings: 1. Review of the medical record revealed resident #88 was admitted to the facility on [DATE] with a primary diagnosis of brain cancer and additional diagnoses including depression, weakness, and history of prostate cancer, chemotherapy and radiation. Review of the Minimum Data Set (MDS) admission assessment with assessment reference date (ARD) of 5/30/23 revealed resident #88 was admitted to the facility from the community. The document revealed resident #88 was sometimes understood, with limited ability to make concrete requests, and responded adequately to simple, direct communication only. The resident's Brief Interview for Mental Status (BIMS) score was 8, which indicated he had moderate cognitive impairment. The MDS assessment showed the resident exhibited physical and other behavioral symptoms which significantly interfered with his care and participation in activities on one to three days in the 7-day look back period. The document indicated the resident also rejected evaluation or care that was necessary to achieve his goals for health and well-being. Resident #88 was totally dependent on two or more staff members for transfers and he required extensive assistance of two or more staff members for bed mobility and toilet use. The resident required extensive assistance of one staff member for dressing, eating, and personal hygiene. He did not walk during the 7-day look back period and was unsteady during surface-to-surface transfers, such as between the bed and wheelchair, and was only able to stabilize with staff assistance. The MDS assessment showed the resident did not use any mobility devices during the look back period and had no falls since admission to the facility. The document showed the resident had no ulcers, wounds, or other skin problems, and he had a chronic condition that might result in a life expectancy of less than six months for which he received hospice care and services. The MDS Quarterly assessment with ARD of 8/26/23 revealed resident #88's BIMS score decreased to 5 which indicated severe cognitive impairment. The document showed the resident made vocal complaints of pain on one to two days in the 7-day look back period, and continued to receive hospice care and services. The MDS assessment revealed resident #88 had two or more falls with no injury since the previous assessment, and sustained skin tears. His medications during the look back period included daily anti-anxiety and anti-depressant drugs, and narcotic pain medication on two days. Review of the medical record revealed resident #88 had a care plan for a terminal prognosis of brain cancer and hospice services initiated on 6/12/23. The goals were the resident's comfort would be maintained, he would be free of anxiety, and he would receive hospice service support for end of life care. The care plan interventions included contact information for the hospice agency and instructed nursing staff to work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met [and] work with nursing staff to provide maximum comfort for the resident. Resident #88 had a care plan for cognitive impairments related to brain cancer initiated on 5/31/23. The interventions included instructions to cue, reorient, and supervise resident #88 as needed, and keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. A care plan for risk for potential impairment to skin integrity related to fragile skin and self-picking at skin was initiated on 6/12/23. The goal was resident #88 would maintain or develop clean and intact skin. The interventions included avoid scratching, keep fingernails short, educate resident and caregivers on causative factors, follow protocols for treatment of injury, and identify/document potential causative factors and eliminate/resolve where possible. Review of the Skilled Nursing Facility Integrated Plan of Care (undated) revealed resident #88 was a hospice patient who lived in a skilled nursing facility as his home and his condition was expected to decline. The goal was resident #88's choice for comfort care would be respected and supported, and his care would be coordinated between the facility and the hospice agency. The interventions indicated the facility was responsible for provision of the resident's day to day care needs and comfort. The document indicated the hospice nurse would visit at a minimum once weekly and as needed, with 24-hour on-call availability of hospice services. Review of the medical record revealed resident #88's hospice agency provided a Facility Patient Instruction form with names and contact information for the resident's hospice team including his nurse, chaplain, aide, and social worker. The document indicated facility staff should contact the hospice agency for any unmanaged symptoms, all patient falls, any change in condition, any new orders, and patient or family concerns. On 9/11/23 at 10:29 AM, Licensed Practical Nurse (LPN) E stood at the medication cart in the hallway. Resident #88 sat in a recliner covered with a sheet, adjacent to the wall in a nearby alcove. He exhibited agitated behavior and confused conversation, and he was not easily comforted or distracted. LPN E explained the resident was not in his room as he was at risk for falls. She stated when she arrived at about 8:00 AM, she was informed the resident fell on the overnight shift at about 6:00 AM. The resident had multiple scabs and open areas covering all extremities, and there was dried blood noted on the sheet that covered the chair. LPN E stated she was informed the resident picked at his skin and removed protective sleeves and long pants that were provided. On 9/11/23 at 10:59 AM and 11:38 AM, Certified Nursing Assistant (CNA) B confirmed she was assigned to care for resident #88. She stated he continuously pinched and picked at his skin, but she did not know what interventions were in place to protect the areas. She explained she did not care for the resident regularly, but she worked on other assignments on the unit and felt if he was not well medicated, he displayed this level of agitation and needed to be watched continuously. On 9/11/23 at 11:13 AM, while LPN E attended to another resident in a room located in the alcove, resident #88 sat upright in the recliner and weakly attempted to stand. LPN E hurriedly ran to the partially open door, reminded the resident to stay seated, and returned to care for the other resident. There were no other staff members in or near the hallway, and resident #88 remained agitated, restless, and confused. He was noted to have auditory hallucinations, and repeatedly called for and responded to unseen persons. On 9/11/23 at 11:35 AM, resident #88 was observed seated on the floor in the alcove, approximately six feet away from the recliner. The Central Supply staff pushed the recliner towards the resident and then assisted the Risk Manager (RM) and a Certified Nursing Assistant (CNA) to pick resident #88 up off floor and lift him back into the recliner. The RM tried to reorient and distract the resident who continued asking for unknown persons and became increasingly confused and belligerent. On 9/11/23 at 12:22 PM, resident #88 remained in a recliner in the hallway. His brow was furrowed, he had a tense facial expression, repeatedly called out, and continued to exhibit restlessness and agitation. The Hospice Nurse stood beside the recliner and explained she was in the facility for a routine weekly visit and had never before seen him this agitated. She was informed the resident's assigned CNA stated he was often agitated. The Hospice Nurse confirmed facility staff never informed her the resident experienced episodes of extreme agitation. She said, The facility never tells me anything. The Hospice Nurse stated the facility did not communicate well with the hospice agency, especially regarding the resident's falls. She stated as soon as she arrived and assessed the resident she called the hospice physician and obtained an order for an immediate dose of Ativan 1 milligram (mg) for agitation, which was given about 15 minutes ago. On 9/11/23 at 1:36 PM, resident #88 was in his recliner with his eyes closed and he had a relaxed facial expression. The Hospice nurse acknowledged the anti-anxiety medication was effective. She stated during her regular weekly visits, the resident was usually calm and she would only find out about falls when someone informed her during the visit. The Hospice Nurse explained there had been no Unit Manager on the [NAME] Wing for several months and there was a constant rotation of nurses and CNAs on the unit. She stated those circumstance made it challenging to obtain accurate, thorough information on resident #88's status. The Hospice Nurse acknowledged she spoke with the psychiatric nurse practitioner in August 2023 when she noted some agitation during one of her visits, and the resident received an order for a scheduled anti-anxiety medication. The Hospice Nurse stated she was not informed of any changes in condition or unmanaged symptoms or behaviors until she spoke with one of the resident's representatives about three weeks ago. She stated the representative, not the facility, informed her resident #88 was experiencing hallucinations. When asked about the resident's skin-picking and open wounds, the Hospice Nurse explained the resident should wear long pants to protect his legs and a gauze wrap and/or protective sleeves on his arms. She emphasized that collaboration between hospice and the facility was important to treat the resident's symptoms quickly and properly and to keep him calm and safe. The Hospice Nurse expressed frustration and disappointment that the facility had not communicated ongoing, significant behaviors to her, as she would have addressed the issues with the hospice interdisciplinary group, including the hospice physician, as she did today. She explained she just completed arrangements for the resident to be transferred to a higher level of care, the Hospice Inpatient Unit, for unmanaged symptoms. On 9/11/23 at 1:48 PM, CNA B informed the Hospice Nurse that resident #88's agitated behavior as observed today was not uncommon. She explained the resident often yelled, screamed, and crawled on the floor. CNA B confirmed she had never reported the behaviors to hospice staff who visited as she was not even aware the resident received hospice services. On 9/11/23 at 4:51 PM, LPN E stated on arrival this morning, the Hospice Nurse assessed resident #88 and obtained a physician order to increase his anti-anxiety medication from Ativan 0.5 mg every six hours as needed to Ativan 1 mg every eight hours. LPN E acknowledged resident #88 was now calm and the increased dosage was effective. When asked to explain how she addressed the resident's escalating agitation that morning, LPN E stated he received a dose of Ativan at 5:30 AM, and since it was ordered every six hours, she was not able to give another dose until 11:30 AM. She acknowledged she did not call the attending physician or hospice to report the resident's agitation. She said, I didn't call hospice because I really don't know him. She explained she could not say that his behavior was a condition that required physician or hospice notification. Review of the medical record revealed a progress note written by the Hospice Nurse on 9/11/23. The document indicated resident #88 was agitated, yelling, and attempting to get out of his recliner when she arrived for her visit. The Hospice Nurse collaborated with her supervisor and the decision was made to transfer the resident to the Hospice Inpatient Unit for management of hallucinations and agitation. On 9/12/23 at 1:00 PM, in a telephone interview, resident #88's cousin explained he was the resident's first emergency contact and primary caregiver at home before he was admitted to the facility. He stated the Hospice Nurse communicated with him via phone after each weekly visit to update him on his cousin's status. He recalled during the last care conference meeting held by phone on 8/29/23, the nurse informed him they would try to get through the meeting very quickly as the facility had to prepare for an impending storm. He recalled discussions about the resident's safety related to getting out of bed and falling, but there was no mention of agitation. The resident's cousin stated on Sunday 9/03/23, a friend visited the facility and noted the resident had significantly increased confusion and agitation, and was even uncharacteristically belligerent during personal care. He recalled they spoke to the Risk Manager who assured them he would contact the Hospice Nurse. The resident's cousin said, I would think if he did this every day they would call. He did 42 days of chemo[therapy] and 33 days of radiation. I was with him for all of that. He has been through a lot. The cousin stated the worst thing was for the resident to be uncomfortable and agitated. On 9/12/23 at 11:31 AM, in a telephone interview, resident #88's friend stated he was the second emergency contact and visited the facility regularly. He explained he observed his friend's agitation and interactions with staff that were not his usual behavior, such as combativeness and bad language during care. The resident's friend stated staff got agitated too, and one occasion a CNA actually asked him to help change the resident's brief because of the behavior. The friend stated he had a hard time getting information about the resident's care and medication changes from the facility. He explained a common response from nurses was that they were new and could not answer questions as it was their first time caring for the resident. Resident #88's friend stated there was no apparent continuity of care. On 9/13/23 at approximately 10:57 AM, the facility's Administrator and Risk Manager completed a review of 12 of the 13 falls resident #88 had since admission. The Administrator acknowledged the common root cause for the resident's falls was his diagnosis of brain cancer which led to increasing lack of safety awareness, confusion, and agitated behavior as his disease progressed. The Administrator was informed the Hospice Nurse stated the hospice agency was not made aware of the resident's falls until she was in the facility for her weekly visits, and she reported there was inadequate communication from facility staff regarding resident #88's symptom of agitation. The Administrator stated he believed the facility's Director of Nursing (DON) and Assistant Director of Nursing (ADON) collaborated with hospice agencies. The Administrator expressed dissatisfaction with the response from some hospice agencies, and stated the facility was currently exploring the alternative of a palliative care program. The Risk Manager acknowledged on 9/11/23 he observed resident #88 with significant agitation. He confirmed the assigned nurse should have called the hospice agency to report the unmanaged symptom and inform the hospice that anti-anxiety medication the resident received was not effective. On 9/13/23 at 1:53 PM, the Staffing Coordinator explained resident #88's behavior had worsened over time and made him more likely to fall. She recalled several nurses and CNAs on all shifts had reported concerns regarding their ability to properly monitor resident #88. She stated the facility's administration, therapy, social services, and nursing management staff were aware of the issue as they regularly discussed the resident's impulsive behaviors in daily stand-down meetings. On 9/14/23 at 8:00 AM, the hospice agency's Director of Clinical Services (DCS) confirmed resident #88 was at the Inpatient Unit with admitting diagnoses of anxiety and agitation. She explained the hospice agency expected good collaboration and coordination of care with the skilled nursing facilities where hospice patients resided. The DCS stated hospice staff were available to respond to patients' needs 24 hours daily, and they expected notification at the time of every fall as the hospice had to complete an event report and follow up. She said, We definitely expect to be informed of increased agitation. She explained if informed timely, the hospice staff could have added medications to manage his symptoms, started continuous care with a hospice nurse at the bedside, increased the hospice aide visits from two to five times weekly, and/or asked the hospice physician to collaborate with the attending physician. The DCS was informed of the facility Administrator's concerns regarding responsiveness of hospice staff. She stated she would have wanted and expected feedback from the facility if the hospice response was not adequate. The DCS acknowledged the purpose of hospice care was to manage symptoms to prevent them from escalating out of control and causing distress to the patient. She stated skin-picking was associated with anxiety and agitation and daily interventions should include protective sleeves and long pants. On 9/14/23 at 9:10 AM, the Lead MDS Coordinator stated the facility's goal was to involve the hospice care team to ensure continuity of care and the best outcome possible for terminally ill residents and their families. She explained the facility provided most of the care for hospice residents including assessments, medication administration, and personal care. The Lead MDS Coordinator confirmed facility staff were expected to contact the hospice agency for medication adjustments and changes in condition. She acknowledged the facility's interdisciplinary team (IDT) discussed resident #88's disease progression and how it affected his cognition and behaviors including picking at his skin. The Lead MDS Coordinator validated skin-picking is a sign of anxiety and agitation. She reviewed the resident's care plans and validated his skin integrity care plan discussed the problem but the interventions did not include use of protective sleeves, gauze wrapping or use of long pants to protect the resident's skin. Review of the medical record with the Lead MDS Coordinator revealed no physician orders or associated documentation on the Treatment Administration Record to indicate staff were to apply protective coverings to resident #88's extremities or monitor and treat the open areas. On 9/14/23 at 10:29 AM, the DON confirmed her expectation was staff would communicate with hospice personnel when they arrived for a visit and before they left the facility. She acknowledged nurses should notify the hospice agency if a resident had medication management needs or had a change in condition. The DON was informed the hospice nurse stated she was not informed of resident #88's falls when they occurred; instead, she found out about them only during her weekly visits. The DON stated falls were probably not a change in condition for this resident. She was not aware if any nurse or member of nursing management communicated with the hospice agency regarding the possibility of continuous care for management of the resident's increased agitation prior to 9/11/23. On 9/14/23 at 12:36 PM, in a telephone interview with the hospice agency's DCS, she stated she reviewed the 24-hour call log from June to September 2023 and there was no record of any calls from the facility regarding resident #88's anxiety, agitation, falls, the need for additional staff support and/or a request for a nursing visit between scheduled weekly Hospice Nurse visits. On 9/14/23 at 2:00 PM, Registered Nurse (RN) G recalled once she was assigned to resident #88 when he fell. She stated he had hallucinations and tried to get something off the floor. RN G explained she followed the facility's protocols and notified the physician and resident's representative of the incident, but did not notify the hospice agency. She said, I would not have called for the fall, I have never called hospice for falls. I would call for a deterioration in condition. I took care of him when he was agitated. Because it was ongoing , I would imagine that [hospice] knew about it. On 9/14/23 at 3:24 PM, in a telephone interview, LPN H stated she was not sure, but thought resident #88 received hospice services. She acknowledged he was confused, required constant redirection, was often anxious, and picked at his skin. LPN H confirmed the hospice agency should be notified of increased agitation, but stated she never did that as he had medication available. On 9/14/23 at 3:53 PM, the Weekend Nursing Supervisor described resident #88's usual behavior as disruptive and agitated. He acknowledged any facility nurse could have called the hospice agency and asked for a hospice nurse to come out and assess the resident. The Weekend Nursing Supervisor confirmed resident #88 had multiple scabbed and open areas on all extremities, and there was one wound on the resident's lower leg that was concerning as it appeared to be possibly infected. He stated about a week ago, he swabbed it and placed the swab in a tube. He explained he asked the assigned nurse to notify the hospice agency and send the specimen to the lab for testing. The Weekend Supervisor was informed the hospice agency did not receive any calls from the facility regarding a wound, and there was no physician order to send the specimen to the lab. The Weekend Supervisor acknowledged he did not follow up. The facility's policy and procedure for Hospice Programs dated 1/25/23 revealed the facility contracted hospice services. The document indicated a coordinated plan of care between the facility, hospice agency and resident/family will be developed and shall include directives for managing pain and other uncomfortable symptoms. Review of the Facility Assessment Tool dated 6/05/23 revealed the facility could meet the needs of residents with cancer diagnoses and provide care and services related to activities of daily living, mobility, fall prevention, mental health and behavior, medications, person-centered care, and special needs such as hospice care. The document indicated staff would be educated on identification of change in condition and .how to determine if symptoms represent problems in need of intervention. The Facility Assessment revealed staff competencies included person-centered care to include end-of-life care. 2. Review of the medical record revealed resident #37 was admitted to the facility on [DATE] with diagnoses including stroke, hypertension, constipation, and overactive bladder. Review of the MDS admission assessment with ARD of 8/02/23 revealed resident #37 had a BIMS score of 14 which indicated she was cognitively intact. The document showed she did not exhibit inattention, disorganized thinking, or altered level of consciousness, and did not reject assistance with ADLs during the 7-day look back period. The resident required extensive assistance from one staff member for bed mobility, dressing,toilet use, and personal hygiene. The MDS assessment revealed resident #37 had pressure ulcers, but no other wounds or skin problems. Review of the medical record revealed a care plan for risk for skin impairment. The goal was the resident would maintain or develop clean and intact skin. The interventions included keep skin clean and dry, and use caution during transfers and bed mobility. Review of the Order Summary Report and Treatment Administration Record for September 2023 revealed resident #37 had a physician order dated 8/10/23 and discontinued on 9/05/23 for performance of a visual weekly skin check every Wednesday morning. The medical record did not contain an active order for weekly skin checks. Review of the medical record revealed a Skin Observation note dated 9/07/23 regarding resident #37's new skin condition, an open area on her coccyx. An interdisciplinary team note dated 9/08/23 revealed resident #37 used her phone to call 911 for a transfer to hospital, reason she wanted to go home and stop holding me hostage. A nursing note dated 9/08/23 at 3:18 PM revealed the resident returned from the hospital at baseline status with no new orders. On 9/11/23 at 10:40 AM, resident #37's left hand rested at her side, on top of the sheet. A large, thick, white, adhesive bordered gauze pad covered the dorsal surface of her left hand. There was an area of dark drainage, approximately 1 centimeter (cm) in diameter, noted at the center of the dressing. The dressing was not dated or initialed. On 9/12/23 at 11:43 AM, the undated, soiled dressing remained on resident #37's left hand. When asked what happened to her hand, she could not recall what type of injury she had, and where or when it occurred. The resident stated she only remembered that someone placed the dressing on her hand. On 9/12/23 at 11:52 AM, RN A was asked to assess resident #37's left hand. She confirmed there was dark drainage under the dressing and verified there was no date to indicate how long it had been in place. She attempted to lift a corner of the dressing but the adhesive was tightly stuck to the resident's thin, fragile skin. RN A went to the treatment cart and returned with a wipe that she used to moisten and slowly peel back the dressing. RN A confirmed the wound on the resident's hand appeared to be a skin tear that measured approximately 2 cm x 1 cm, and there was dried blood on edge of the wound. RN A stated there were no treatment orders for resident #37 in the electronic medical record and the offgoing nurse did not mention that the resident had an injury. On 9/13/23 at 12:20 PM, ADON P stated nurses should report any new injury to the Unit Manager and follow the facility's change in condition policy and procedures. She confirmed there was no documentation in the medical record regarding resident #37's left hand injury or dressing, and the ongoing investigation had not yet yielded any information. Review of the facility's policy and procedures for Change in Resident's Condition or Status, dated 1/25/23, revealed the physician should be notified of any accident, incident, or injury of unknown origin involving a resident. On 9/13/23 at 2:23 PM, the facility's Risk Manager confirmed resident #37 returned from the hospital a few days before the dressing was brought to the facility's attention. He explained the dressing might have been applied in the hospital as according to the description, it did not seem like facility stock. The Risk Manager stated on return from the hospital, the assigned nurse was expected to conduct a skin evaluation and document the findings. He explained the attending physician should be notified of any issues and appropriate orders obtained.