**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to protect the resident's right to be free from neglect related to proper use of mechanical lifts during transfers for two residents (#14 and #4) out of 21 residents dependent on mechanical lifts for transfers. The facility neglected to properly assess Resident #14 for the use of a mechanical lift and failed to educate staff to implement proper transfer methods, resulting in a major injury that occurred on 05/12/2025 resulting in Resident #14 being transferred to a higher level of care and required surgical repair of a spiral comminuted fracture of the right femur. The facility's neglect resulted in physical pain and psychosocial suffering for Resident #14. This neglect created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Resident #14 and Resident #4 and resulted in the determination of Immediate Jeopardy on 05/12/2025. The findings of Immediate Jeopardy were determined to be removed on 06/13/2025 and the severity and scope was reduced to a D after verification of removal of immediacy of harm. Findings Included: 1. Review of Resident #14's Information Record, dated 06/11/2025, revealed Resident #14 was originally admitted to the facility on [DATE] with diagnoses of primary osteoarthritis, dementia, need for assistance with personal care, cognitive communication deficit. Review of the admission Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. Section C0100 showed the resident is rarely/never understood. Review of Resident #14's physician orders, dated 05/12/2025, showed the resident had an active order to send resident to the emergency room (ER) for evaluation and treatment of right hip pain, one time, only for one day. Review of Resident #14's Kardex (a document used by staff with specific instructions for a resident's care needs) showed transferring Functional Abilities (GG): Bed-to-Chair Transfer, sit-to stand (mechanical lift). The Kardex was updated during the survey on 6/11/2025 showing the resident was totally dependent on staff for transferring, requiring a mechanical lift with two staff assistance for transfers. A review of the Care Plan for Resident #14 revealed a Focus: [Resident #14] has limited physical mobility related to disease process, senile degeneration of brain Weakness, initiated on 12/25/2025. The goal showed Resident #14 will remain free of complication related to immobility, including contractures, thrombus formation, skin-breakdown, fall related to injury through next review date, initiated 12/25/2025 and revised on 06/09/2025. The interventions showed Resident #14 was non-weight bearing, initiated on 06/10/2025. Review of a Change in Condition form, dated 05/12/2025, showed Resident #14's right hip appeared displaced, she had decreased functional mobility compared to her baseline, and experienced new pain. Her non-verbal signs of pain were described as screaming. Resident #14 was transported to the hospital on [DATE] by emergency transport. Review of a local hospital record, dated 5/12/2025, showed Resident #14 to be a [AGE] year-old female who resides at [Name of Facility] with history of dementia presented to the local hospital emergency room with chief complaint of right lower extremity pain after falling out of bed, X-rays taken in the emergency room revealed a displaced spiral subtrochanteric fracture of the right femur with severe osteopenia, also questionable right inferior pubic rami fracture noted as well. Plan for open reduction and internal fixation of the right femur. Review of a local hospital radiology report, dated 5/12/2025, showed: X-ray of the hip unilateral with pelvis when performed; 2-3 view Comparison: No prior. Findings noted: Spiral comminuted fracture in the subtrochanteric portion of the right femur which spirals into the proximal shaft and is displaced and impacted with the proximal portion of the femur rotated laterally. Questionable fracture of the inferior public ramus on the right. Review of a local hospital operative report, dated 5/12/2025, revealed Resident #14 had an open reduction and internal fixation of right hip subtrochanteric fracture with [Medical Equipment Company] 340 x 10 millimeters (mm) intramedullary (IM) rod with 95 millimeters proximal lag screw and 45 millimeters (mm) distal set screw .Incision was irrigated with antibiotic solution. Closure was performed with #1 [Surgical Suture] for the fascial [connective tissue that surrounds and supports bones, muscles, nerves, blood vessels, and organs throughout the body.] closure, 2-0 [Surgical Suture] subcutaneous, and standard skin staples. Xeroform dry dressing was applied. A review of a local hospital progress note, dated 5/19/2025, showed Resident #14 was hospitalized due to a right hip fracture after a fall from bed at the patient's nursing home. She underwent right hip open reduction and internal fixation (ORIF) on 5/13/2025. Resident #14 had intermittently elevated temperatures since 5/13/2025 with no infectious source identified. Acute intertrochanteric fracture of the right femur with varus angulation and mild displacement. Lesser trochanteric avulsion fragment is mildly displaced. No dislocation. No other fractures are identified. Moderate right and mild left hip arthrosis. Conclusion: Acute fracture of the right hip. A review of the Physician Order Summary Report for Resident #14, dated 06/12/2025, revealed the following: -Weekly Skin Sweeps, every day shift, every Tue (Tuesday) for skin observation. -Acetaminophen Oral Tablet (Acetaminophen) Give 1000 milligram (mg) by mouth every 12 hours related to Abnormal Posture: Pain Disorder with related psychological facture - Assess resident for pain every shift; Non-pharmacological interventions: 1 = relaxations, 2 = light touch, 3 = I (pharmaceutical name), 4 = exercise, 5 = music, 6 = N/A, 7= other see progress note. Document corresponding code and pain level in supplemental documentation every shift for monitor - start on 5/21/2025, -Eliquis Oral Tablet 2.5 milligram (mg) (Apixaban) Give 1 tablet by mouth two times a day for status post (s/p) surgery - started on 5/21/2025 -Tramadol Hydrochloride Oral Tablet 50 mg (Tramadol HCI) Give 1 tablet by mouth every 4 hours as needed for pain - started on 5/20/025 - Right Hip Staples: gently cleanse area, dry, cover with long border dressing every shift for Infection Preventions - Start 05/24/2025 - Non-Weight Bearing for 3 weeks every shift for wound care for 21 days. Review of the Medical Administration Records (MAR) for Resident #14, dated May and June 2025, showed Resident #14's pain levels were assessed after she was admitted back to the facility on every shift. The review showed Tramadol was administered on May 27th with a pain level marked 7 out of 10; on May 28th pain level was marked as 7 out of 10; and on June 3rd the pain level was marked as 6 out of 10, meaning the pain levels were very strong keeping Resident #14 from doing things. Source: https://healthy.kaiserpermanente.org/health-wellness/health-encyclopedia/he.learning-about-the-0-to-10-pain-scale.abs0043 An interview was conducted on 6/10/2025 at 12:08 p.m. with Staff F, Certified Nursing Assistant (CNA) /Restorative Aide. He stated the resident was dependent on transfers with two-person assistance using the mechanical lift. He stated he assisted Staff Q, CNA, with transferring Resident #14 using a mechanical lift to get her in and out of bed in the morning and afternoon on the day she was sent to the hospital (5/12/25). He stated when they got the resident up in the morning, there was nothing wrong with her leg, but when they transferred her back into bed, he noticed something wrong with her leg. He said, her leg looked out of place. He stated he called the Assistant Director of Nursing (ADON) immediately to check the resident out. During an interview conducted on 06/10/2025 at 12:24 p.m. with Staff L, Licensed Practical Nurse (LPN), she stated she was familiar with Resident #14 and was usually the nurse assigned to the resident. She stated when she arrived at work, Resident #14 was being sent out to the hospital for evaluation. She stated she went down to the resident's room to check on her. When she arrived at the room, Staff F, CNA asked her if the resident had any pain the day before. She reported the resident was just fine and there was nothing unusual going on with her yesterday. Staff L, LPN said, When I touched Resident #14's leg, [the resident] yelled out like she was in pain. She stated the resident screamed out in pain and said, Lord, it hurts. Staff L, LPN said the resident returned back to the facility with thirty-nine staples in her right leg. Staff L, LPN said, To be honest, I don't know what happened to her because she was just fine the day before. An interview was conducted on 06/10/2025 at 1:01 p.m. with Resident #14's Primary Care Provider (PCP). He stated he was notified the resident was going to the ER. The PCP said, It's kind of sketchy what happened to her. He stated that the chief complaint note from the hospital showed that she had fallen at the facility, but no one told him that was what happened. He stated these types of fracture happen a lot with very frail elderly people, whenever they have a fall or do a sharp turn and then fall. He said he did not look at the radiology report to see what type of fracture the resident had sustained. During an interview conducted on 06/10/2025 at 1:23 p.m. with the ADON, she stated she remembered coming down the hall when she heard Resident #14 yelling. The ADON said she stopped and was getting ready to knock on the door as Staff Q, CNA, opened the door to tell her she needed to check the resident out. The ADON stated as she entered the room, Staff F, CNA was in the room and the mechanical lift was next to the bed. She stated when she looked over at Resident #14, she noticed her right hip bulging out of place and swollen. She said she immediately went to get the Director of Nurses (DON). The ADON said the DON came to the room, did a visual assessment on Resident #14, and had her send the resident out to the local hospital for further evaluation. She stated she received a call from the resident's family member asking what happened to [Resident #14]. The ADON stated the family member reported having to sign consent because the resident had to have surgery due to a fracture. An interview was conducted on 06/10/2025 at 1:54 p.m. with the DON and the Nursing Home Administrator (NHA). The DON reviewed her statement and said she noted at approximately 1400 (2 p.m.) on 5/12/2025, the ADON came to the administrator's office reporting an emergency. The DON stated she went down to the resident's room, and the assigned 7:00 a.m. to 3:00 p.m. CNA showed her Resident #14's right hip, which appeared to be swollen and appeared to be a different size than the left hip. The NHA stated Resident #14 appeared to be in pain in the right hip. The DON stated she gave the ADON the directive to send the resident to the hospital ASAP (as soon as possible). The DON made recommendations to notify the provider and the [family member]. The NHA stated they were shocked when the [family member] called the DON and stated the resident needed to have surgery. The NHA stated they contacted the hospital to get an update on her status and to request records to see what type of fracture the resident had suffered. The NHA stated when they got the hospital medical records, it was noted the resident had suffered a fracture due to a fall. The NHA stated they interviewed everyone who worked on the unit that day and gathered information from the resident roommate. The NHA stated the Emergency Medical Services (EMS) Run Report came back two weeks later, showing nursing had reported the resident had right hip pain related to a fall. The NHA stated there was a discrepancy on the reporting, as he had interviewed his nurses and no one said the resident had fallen. The NHA stated they were under the impression that it was the sling or pressure from the mechanical lift that was the cause of her dislocated hip. The DON stated she did not have a good answer as to who was responsible for assessing residents for use of mechanical lift and sling sizes. The DON said, The aides are familiar with the residents, so they know what size sling to use on a resident. The DON stated typically when the CNA goes through orientation, another aide provides the new CNA with training on using the mechanical lift. She stated she and the ADON interviewed the resident's roommate, who reported not having noticed anything different with Resident #14 and not seeing the resident on the floor. The DON stated she interviewed the CNAs, and they stated they assisted Resident #14 from her chair back in bed using the mechanical lift. The DON stated Resident #14 has always used a mechanical lift, but this was the first time an incident had happened during her transfer. The NHA stated after they were notified about the incident, they conducted inspections on their mechanical lift and slings. They all checked out to be working properly and in good condition. The NHA stated they concluded two experienced CNAs transferred Resident #14 on the day of the incident and the resident experienced pain. The DON and doctor were notified, and the resident was sent out to the hospital. During an interview conducted on 06/11/2025 at 9:13 a.m. with Staff Q, CNA, she said, On 5/12/2025 it was a regular day and routine with assisting Resident #14. She stated she gets the resident up after breakfast on Mondays, Wednesdays and Fridays. She stated she changed the resident, got her dressed, then put the sling underneath the resident to get her ready to transfer her using the mechanical lift. She stated she got Staff F, CNA to assist her with the transfer. She said after they placed Resident #14 in her chair, Staff F, CNA checked to make sure the resident was positioned in her chair properly and placed her footrest onto her chair. Then she placed Resident #14 outside of her room door. She said later the resident was taken to the television room by an unidentified staff member. She stated when they got Resident #14 up she did not see anything unusual, and the resident did not show any signs of pain. She said when she and Staff F, CNA put Resident #14 back to bed using the mechanical lift, they lifted the resident's dress to remove the sling, Staff F, CNA noticed swelling on the resident's right hip. She stated when she saw Resident #14's hip, she knew it was popped out of place. She stated she knows the resident was a mechanical lift transfer, but there was no documentation in the computer showing the type of lift the resident requires. She said she knew how to use a mechanical lift because she was a veteran nurse's aide but had not received a visual demonstration on how to properly lift a resident. She said she has not gotten Resident #14 out of bed since she returned back to the facility on 5/20/2025. An interview was conducted on 06/11/2025 at 10:12 a.m. with the Director of Rehabilitation (DOR). He stated nursing sets the resident's transfer status based on the information from the Agency for Health Care Administration (AHCA) form 3008. He stated, Per therapy standards, if the resident was max-dependent, they are automatically a mechanical lift with two-person assistance. The DOR stated they do not give formal training to staff regarding safe use of a mechanical lift, and they do not perform demonstration with the mechanical lifts. He stated he talks to staff about positioning, having a second person when using the lifts, and staff needing to talk to their residents during the transfer. The DOR confirmed since he had been at the facility he had not provided any training for mechanical lifts with staff. The DOR stated Resident #14 was picked up for therapy on 05/21/2025 for Occupational Therapy and on 05/24/2025 for Physical Therapy. He stated prior to the incident, the resident had not been seen by therapy. He confirmed the resident required a mechanical lift and a two-person transfer. The DOR stated he did not have an assessment for the use of the mechanical lift for Resident #14. He stated he was not involved with sizing residents for sling use. The DOR looked through therapy evaluations for Resident #14 and stated he did not see any evaluation done for the use of the mechanical lift. An interview conducted with the Medical Director on 06/12/2025 at 11:32 a.m. revealed he was involved in the QA (Quality Analysis) process. He stated the facility follows up on his recommendations. He stated the NHA calls him regarding incidents in the facility, but he is not involved in everything. They call him for incidents like medication errors and an injury of an unknown source. He stated he was notified about a patient that ended up with a hip fracture but there was no fall involved. He stated he told them to continue education with the staff on how to care for elderly patients. He stated there were many things that could have happened to contribute to the resident's fracture. 2. On 06/09/2025 at 9:30 a.m. Staff Q, CNA was observed coming out of Resident #4's room with a mechanical lift, by herself. In an interview, Staff Q, CNA confirmed she had just transferred Resident #4 by herself using the mechanical lift. She stated there should have been two staff. A review of an admission Record dated 06/11/2025 showed Resident #4 was admitted to the facility on [DATE] with diagnoses to include but not limited to chronic obstructive pulmonary disease (COPD), unspecified, Communication deficit, need for assistance with personal care, and restless leg syndrome. During an interview with Resident #4 conducted on 06/09/2025 at 10:00 a.m., she stated there was always one CNA in the room when she is transferred to her wheelchair or bed using the Mechanical lift. Resident #4 stated this made her nervous. A review of the Minimum Data Set (MDS), dated [DATE], revealed Resident #4 had a Brief Interview of Mental Status score of 13 out of 15, indicating the resident was cognitively intact. Review of Resident #4's Kardex section (GG) - Bed-to-Chair Transfer showed, Sit-to Stand (a type of mechanical lift), is totally dependent on staff for transferring. The Kardex did not specify the number of staff required for the transfer. During an interview conducted on 06/09/2025 at 3:00 p.m., with the ADON, he stated she told Staff Q, CNA she cannot transfer residents with a mechanical lift by herself. She stated she must have another person with her for safety when transferring a resident using a mechanical lift. An interview was conducted on 06/10/2025 at 1:00 p.m. with the DON. She confirmed mechanical lifts always require two people when used to transfer a resident. She stated this would be the best practice, to ensure the safety of the resident. Review of a facility policy titled Lifting Machine, Using a Mechanical, dated 6/12/25, showed, the purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. It is not a substitute for manufacturer's training or instructions. General Guidelines: 1. At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift. 2. Mechanical lifts may be used for tasks that require: a. Lifting a resident from the floor. b. Transferring a resident from bed to chair. c. Lateral transfers. d. Lifting limbs. e. Toileting or bathing; or f. Repositioning. 3. Types of lifts that may be available in the facility are: a. Floor-based full body sling lifts b. Overhead full body sling lifts; and c. Sit-to-stand lifts. 4. Lift design and operation vary across manufacturers. Staff must be trained and demonstrate competency using the specific machines or devices utilized in the facility. Steps in the Procedure 1. Before using a lifting device, assess the resident's current condition, including: a. Physical: 1. Can the resident assist with transfer? 2. Is the resident's weight and medical condition appropriate for the use of a lift? b. Cognitive/Emotional: 1. Can the resident understand and follow instructions? 2. Does the resident express fear or appear anxious about the use of a lift? 3. Is the resident agitated, resistant, or combative? 2. Measure the resident for proper sling size and purpose, according to manufacturer's instructions. 3. Select a sling bar that is appropriate for the resident's size and the task. 4. Prepare the environment: a. Clear an unobstructed path for the lift machine. b. Ensure there is enough room to pivot. c. Position the lift near the receiving surface; and d. Place the lift at the correct height. 5. Make sure the battery is charged. 6. Test the lift controls. Ensure the emergency release feature works. 7. Make sure the lift is stable and lock Review of a facility policy titled Abuse, Neglect and Misappropriation of Property, revised 5/8/19, showed: It is the organization's intention to prevent the occurrence of abuse, neglect, exploitation, injuries of unknown origin, and misappropriation of resident property, and to assure that all alleged violations of federal or State laws which involve abuse, neglect, exploitation, injuries of unknown origin and misappropriation of resident property are investigated, and reported immediately to the Facility Administrator, the State Survey Agency, and other appropriate State and local agencies in accordance with Federal and State law. Definitions: Injury of Unknown Source: Means an injury that meets both of the following conditions: (1) the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and (2) the injury is suspicious because of the extent of the injury; or the location of the injury (for instance, the injury is located in an area not generally vulnerable to trauma); or the number of injuries observed at one particular point in time; or the incidence of injuries over time. Such occurrences will be investigated by the Administrator, Director of Nursing, or designee as outlined below in the investigation guidelines. Serious Bodily Injury: The term serious bodily injury is defined as an injury involving extreme physical pain; involving substantial risk of death; involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty; or requiring medical intervention such as surgery, hospitalization, or physical rehabilitation. Procedure: B. Training: 1. During orientation, all new Stakeholders, contractors and volunteers will be trained on reporting allegations of abuse; and notify the stakeholders, contractors, and volunteers of the individual's obligation to comply with the reporting requirements of the: Affordable Care Act section 1150 B (Elder Justice Act). Documentation of such training will be kept in each person's personnel file. Employees of the Contractor may be trained by the contractor, so long as such training meets the following requirements, and the contractor certifies that each of its employees providing services at the facility has completed and passed such training. Prevention: 1. Upon admission and periodically there after each resident will have an evaluation completed which identifies potential vulnerabilities such as cognitive, physical, psychosocial, environn1ent and communication concerns. 2. The plan of care will address identified vulnerabilities. Investigation Guidelines: 1. The Facility Administrator will investigate all allegations, reports, grievances and incidents that potentially could constitute allegations of abuse, injuries of unknown source, exploitation, or suspicions of crime as defined in this document. The Facility Administrator may delegate some or all of the investigation to the Director of Nursing, Medical Director or other subject matter experts as appropriate, but the Facility Administrator retains the ultimate responsibility to oversee and complete the investigation, and to draw conclusions regarding the nature of the incident. Review of a facility policy titled Accidents and Incidents - Investigating and Reporting, dated 6/12/25, showed a policy statement: All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. Policy Interpretation and Implementation (1.) The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. The facility's immediate actions to correct the deficient practice and remove the Immediate Jeopardy, received on 6/13/25, included: 1. On 6/12/25 at 2:00 p.m. the Administrator held an Emergency Information Sharing Ad-Hoc Meeting regarding Mechanical Lift Safety Plan at 3:00 p.m. 2. The Assistant Director of Nursing on 6/12/2025 provided education to nursing staff of 2-person lift and mechanical lift policy. Education of nursing staff reached 100%. Of the nursing staff 85% were educated in-person, while the remaining 15% were sent education material through a direct messaging program. 3. The Director of Nursing and ADON initiated Skills Competencies for Mechanical Lift for nursing staff on 6/12/25. At this time, 100% of nursing staff have the competencies completed. 4. On 6/11/25, the MDS Coordinator began updating Care plans for residents to reflect the transfer status of residents. 6/13/25. At this time, 100% of care plans have been updated. 5. On 6/12/25, a Kardex audit was initiated by the Director of Nursing confirming the lift status of residents. Currently the Kardex audit indicates 100% Kardex's have been updated with mechanical lift status. 6. A daily observational audit conducted by the Director of Nursing (or designee) to validate that staff are transferring residents based on the care plan/Kardex. This audit started on 6/12/25 and will report to the monthly QAPI meeting. 7. Manufacturer guidelines on the slings' size have been posted in the clean utility rooms on 6/12/25. 8. The therapy department assesses the lift and transfer status of residents. This information is shared with the nursing staff in the daily clinical meeting and changes reviewed at the weekly Standards of Care Meeting (SOC). The rehab staff have reassessed Resident #4 on June 13, 2025. Resident #14 cannot currently be assessed for transfer status due to pending medical clearance. Verification of the facility's removal plan was conducted by the survey team on 6/13/2025. All steps contained in the removal plan were reviewed and verified. Interviews were conducted with facility staff, licensed nurses, nursing assistants and therapy staff. Thirty-one (31) nursing staff members and therapy staff confirmed having received in-services on topics to include use of mechanical lifts, care plan, care plan/ Kardex review, Mechanical lift use/2-persons transfer, and sling sizes. 100% of staff completed in-services on 6/12/2025, voicing an understanding of the policies and processes required to provide competent care for residents. The staff interviewed have worked across all shifts. A review of the sign-in sheets was conducted to verify education, and training was completed as outlined in the Immediate Jeopardy removal plans. Based on verification of the facility's Immediate Jeopardy removal plan, the immediate jeopardy was determined to be removed on 6/13/2025 and the non-compliance was reduced to a scope and severity of D.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure licensed nursing staff were knowledgeable and competent to provide care and services to include safe mechanical lift transfers for two residents (#4 and #14) out of twenty-one dependent residents sampled. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Resident #14, with potential to affect all residents who are dependent on mechanical lifts for transfers. This failure resulted in the determination of Immediate Jeopardy on 06/13/2025. The findings of Immediate Jeopardy were determined to be removed on 6/13/2025 and the severity and scope was reduced to a D after verification of removal of immediacy of harm. Findings Included: 1. On 6/10/2025 at 3:20 p.m. an interview was conducted with six Certified Nursing Assistants (CNAs) Staff C, H, I, E, J, K, and two Licensed Practical Nurses (LPN) Staff G and L. They stated in order to find out what residents on their shift assignment require mechanical lift transfers, they will find and identify the information on the care planning section of the Kardex (A document used by staff with instructions specific to the resident's care needs). The nursing staff confirmed while using the mechanical lift to transfer a resident, two staff members must be present to ensure safety. The CNAs stated in order to know what type and size of sling to use with the mechanical lift, they make a general observation and self-assessment of the size of the resident and will pick a color-coded sling that best matches. The staff confirmed there were no directions on what sling goes to each resident who requires mechanical lift transfers. The staff members could not confirm they had received specific education at this facility, regarding the use of mechanical lifts. On 6/11/2026 at 6:40 a.m. an interview was conducted with CNAs Staff M, F, N, and LPNs Staff O, and P. The nursing staff confirmed while using the mechanical lift to transfer a resident, two staff members must be present to ensure safety. The CNAs stated in order to know what type and size of sling to use with the mechanical lift, they make a general observation and self-assessment of the size of the resident and will pick a color-coded sling that best matches. The staff confirmed there were no directions on what sling goes to each resident who requires mechanical lift transfers. The staff members could not confirm they had received specific education at this facility, regarding the use of mechanical lifts. On 06/09/2025 at 9:30 a.m. Staff Q, CNA was observed coming out of Resident #4's room with a mechanical lift, by herself. In an interview, Staff Q, CNA confirmed she had just transferred Resident #4 by herself using the mechanical lift. She stated there should have been two staff. A review of an admission Record dated 06/11/2025 showed Resident #4 was admitted to the facility on [DATE] with diagnoses to include but not limited to chronic obstructive pulmonary disease (COPD), unspecified, Communication deficit, need for assistance with personal care, and restless leg syndrome. During an interview with Resident #4 conducted on 06/09/2025 at 10:00 a.m., she stated there was always one CNA in the room when she is transferred to her wheelchair or bed using the Mechanical lift. Resident #4 stated this made her nervous. A review of the Minimum Data Set (MDS), dated [DATE], revealed Resident #4 had a Brief Interview of Mental Status score of 13 out of 15, indicating the resident was cognitively intact. Review of Resident #4's Kardex section (GG) - Bed-to-Chair Transfer showed, Sit-to Stand (a type of mechanical lift), is totally dependent on staff for transferring. The Kardex did not specify the number of staff required for the transfer. During an interview conducted on 06/09/2025 at 3:00 p.m., with the ADON, he stated she told Staff Q, CNA, she could not transfer residents with a mechanical lift by herself. She stated she must have another person with her for safety when transferring a resident using a mechanical lift. An interview was conducted on 06/10/2025 at 1:00 p.m. with the DON. She confirmed mechanical lifts always require two people when used to transfer a resident. She stated this would be the best practice, to ensure the safety of the resident. An interview was conducted on 6/10/2025 at 3:00 p.m. with the Minimum Data Set (MDS) Coordinator, Staff U, LPN. She stated the CNAs use the resident's Kardex to know what type of assistance the resident required during their transfer. She stated about two years ago the facility changed their electronic medical record system and she did not update any of the resident's transfer care plans/ Kardex section to reflect the specific resident's transfer status. She stated Resident #14's information on her Kardex was not correct because the resident cannot use a Sit-to -Stand lift to transfer. She stated the resident required a mechanical lift with two staff present. Staff U stated Resident #4's Kardex was not correct either. She stated they would be revising and updating the care plans. 2. Review of Resident #14's Information Record, dated 06/11/2025, revealed Resident #14 was originally admitted to the facility on [DATE] with diagnoses of primary osteoarthritis, dementia, need for assistance with personal care, cognitive communication deficit. Review of the admission Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. Section C0100 showed the resident is rarely/never understood. Review of Resident #14's physician orders, dated 05/12/2025, showed the resident had an active order to send resident to the emergency room (ER) for evaluation and treatment of right hip pain, one time, only for one day. Review of Resident #14's Kardex (a document used by staff with specific instructions for a resident's care needs) showed transferring Functional Abilities (GG): Bed-to-Chair Transfer, sit-to stand (mechanical lift). The Kardex was updated during the survey on 6/11/2025 showing the resident was totally dependent on staff for transferring, requiring a mechanical lift with two staff assistance for transfers. A review of the Care Plan for Resident #14 revealed a Focus: [Resident #14] has limited physical mobility related to disease process, senile degeneration of brain Weakness, initiated on 12/25/2025. The goal showed Resident #14 will remain free of complication related to immobility, including contractures, thrombus formation, skin-breakdown, fall related to injury through next review date, initiated 12/25/2025 and revised on 06/09/2025. The interventions showed Resident #14 was non-weight bearing, initiated on 06/10/2025. Review of a Change in Condition form, dated 05/12/2025, showed Resident #14's right hip appeared displaced, she had decreased functional mobility compared to her baseline, and experienced new pain. Her non-verbal signs of pain were described as screaming. Resident #14 was transported to the hospital on [DATE] by emergency transport. Review of a local hospital record, dated 5/12/2025, showed Resident #14 to be a [AGE] year-old female who resides at [Name of Facility] with history of dementia presented to the local hospital emergency room with chief complaint of right lower extremity pain after falling out of bed, X-rays taken in the emergency room revealed a displaced spiral subtrochanteric fracture of the right femur with severe osteopenia, also questionable right inferior pubic rami fracture noted as well. Plan for open reduction and internal fixation of the right femur. Review of a local hospital radiology report, dated 5/12/2025, showed: X-ray of the hip unilateral with pelvis when performed; 2-3 view Comparison: No prior. Findings noted: Spiral comminuted fracture in the subtrochanteric portion of the right femur which spirals into the proximal shaft and is displaced and impacted with the proximal portion of the femur rotated laterally. Questionable fracture of the inferior public ramus on the right. Review of a local hospital operative report, dated 5/12/2025, revealed Resident #14 had an open reduction and internal fixation of right hip subtrochanteric fracture with [Medical Equipment Company] 340 x 10 millimeters (mm) intramedullary (IM) rod with 95 millimeters proximal lag screw and 45 millimeters (mm) distal set screw .Incision was irrigated with antibiotic solution. Closure was performed with #1 [Surgical Suture] for the fascial [connective tissue that surrounds and supports bones, muscles, nerves, blood vessels, and organs throughout the body.] closure, 2-0 [Surgical Suture] subcutaneous, and standard skin staples. Xeroform dry dressing was applied. A review of a local hospital progress note, dated 5/19/2025, showed Resident #14 was hospitalized due to a right hip fracture after a fall from bed at the patient's nursing home. She underwent right hip open reduction and internal fixation (ORIF) on 5/13/2025. Resident #14 had intermittently elevated temperatures since 5/13/2025 with no infectious source identified. Acute intertrochanteric fracture of the right femur with varus angulation and mild displacement. Lesser trochanteric avulsion fragment is mildly displaced. No dislocation. No other fractures are identified. Moderate right and mild left hip arthrosis. Conclusion: Acute fracture of the right hip. A review of the Physician Order Summary Report for Resident #14, dated 06/12/2025, revealed the following: -Weekly Skin Sweeps, every day shift, every Tue (Tuesday) for skin observation. -Acetaminophen Oral Tablet (Acetaminophen) Give 1000 milligram (mg) by mouth every 12 hours related to Abnormal Posture: Pain Disorder with related psychological facture - Assess resident for pain every shift; Non-pharmacological interventions: 1 = relaxations, 2 = light touch, 3 = I (pharmaceutical name), 4 = exercise, 5 = music, 6 = N/A, 7= other see progress note. Document corresponding code and pain level in supplemental documentation every shift for monitor - start on 5/21/2025, -Eliquis Oral Tablet 2.5 milligram (mg) (Apixaban) Give 1 tablet by mouth two times a day for status post (s/p) surgery - started on 5/21/2025 -Tramadol Hydrochloride Oral Tablet 50 mg (Tramadol HCI) Give 1 tablet by mouth every 4 hours as needed for pain - started on 5/20/025 - Right Hip Staples: gently cleanse area, dry, cover with long border dressing every shift for Infection Preventions - Start 05/24/2025 - Non-Weight Bearing for 3 weeks every shift for wound care for 21 days. Review of the Medical Administration Records (MAR) for Resident #14, dated May and June 2025, showed Resident #14's pain levels were assessed after she was admitted back to the facility on every shift. The review showed Tramadol was administered on May 27th with a pain level marked 7 out of 10; on May 28th pain level was marked as 7 out of 10; and on June 3rd the pain level was marked as 6 out of 10, meaning the pain levels were very strong keeping Resident #14 from doing things. Source: https://healthy.kaiserpermanente.org/health-wellness/health-encyclopedia/he.learning-about-the-0-to-10-pain-scale.abs0043 An interview was conducted on 6/10/2025 at 12:08 p.m. with Staff F, Certified Nursing Assistant (CNA) /Restorative Aide. He stated the resident was dependent on transfers with two-person assistance using the mechanical lift. He stated he assisted Staff Q, CNA, with transferring Resident #14 using a mechanical lift to get her in and out of bed in the morning and afternoon on the day she was sent to the hospital (5/12/25). He stated when they got the resident up in the morning, there was nothing wrong with her leg, but when they transferred her back into bed, he noticed something wrong with her leg. He said, her leg looked out of place. He stated he called the Assistant Director of Nursing (ADON) immediately to check the resident out. During an interview conducted on 06/10/2025 at 12:24 p.m. with Staff L, Licensed Practical Nurse (LPN), she stated she was familiar with Resident #14 and was usually the nurse assigned to the resident. She stated when she arrived at work, Resident #14 was being sent out to the hospital for evaluation. She stated she went down to the resident's room to check on her. When she arrived at the room, Staff F, CNA asked her if the resident had any pain the day before. She reported the resident was just fine and there was nothing unusual going on with her yesterday. Staff L, LPN said, When I touched Resident #14's leg, [the resident] yelled out like she was in pain. She stated the resident screamed out in pain and said, Lord, it hurts. Staff L, LPN said the resident returned back to the facility with thirty-nine staples in her right leg. Staff L, LPN said, To be honest, I don't know what happened to her because she was just fine the day before. An interview was conducted on 06/10/2025 at 1:01 p.m. with Resident #14's Primary Care Provider (PCP). He stated he was notified the resident was going to the ER. The PCP said, It's kind of sketchy what happened to her. He stated that the chief complaint note from the hospital showed that she had fallen at the facility, but no one told him that was what happened. He stated these types of fracture happen a lot with very frail elderly people, whenever they have a fall or do a sharp turn and then fall. He said he did not look at the radiology report to see what type of fracture the resident had sustained. During an interview conducted on 06/10/2025 at 1:23 p.m. with the ADON, she stated she remembered coming down the hall when she heard Resident #14 yelling. The ADON said she stopped and was getting ready to knock on the door as Staff Q, CNA, opened the door to tell her she needed to check the resident out. The ADON stated as she entered the room, Staff F, CNA was in the room and the mechanical lift was next to the bed. She stated when she looked over at Resident #14, she noticed her right hip bulging out of place and swollen. She said she immediately went to get the Director of Nurses (DON). The ADON said the DON came to the room, did a visual assessment on Resident #14, and had her send the resident out to the local hospital for further evaluation. She stated she received a call from the resident's family member asking what happened to [Resident #14]. The ADON stated the family member reported having to sign consent because the resident had to have surgery due to a fracture. An interview was conducted on 06/10/2025 at 1:54 p.m. with the DON and the Nursing Home Administrator (NHA). The DON reviewed her statement and said she noted at approximately 1400 (2 p.m.) on 5/12/2025, the ADON came to the administrator's office reporting an emergency. The DON stated she went down to the resident's room, and the assigned 7:00 a.m. to 3:00 p.m. CNA showed her Resident #14's right hip, which appeared to be swollen and appeared to be a different size than the left hip. The NHA stated Resident #14 also appeared to be in pain in the right hip. The DON stated she gave the ADON the directive to send the resident to the hospital ASAP (as soon as possible). The DON made recommendations to notify the provider and the [family member]. The NHA stated they were shocked when the [family member] called the DON and stated the resident needed to have surgery. The NHA stated they contacted the hospital to get an update on her status and to request records to see what type of fracture the resident had suffered. The NHA stated when they got the hospital medical records, it was noted the resident had suffered a fracture due to a fall. The NHA stated they interviewed everyone who worked on the unit that day and also gathered information from the resident roommate. The NHA stated the Emergency Medical Services (EMS) Run Report came back two weeks later, showing nursing had reported the resident had right hip pain related to a fall. The NHA stated there was a discrepancy on the reporting, as he had interviewed his nurses and no one said the resident had fallen. The NHA stated they were under the impression that it was the sling or pressure from the mechanical lift that was the cause of her dislocated hip. The DON stated she did not have a good answer as to who was responsible for assessing residents for use of mechanical lift and sling sizes. The DON said, The aides are familiar with the residents, so they know what size sling to use on a resident. The DON stated typically when the CNA goes through orientation, another aide provides the new CNA with training on using the mechanical lift. She stated she and the ADON interviewed the resident's roommate, who reported not having noticed anything different with Resident #14 and not seeing the resident on the floor. The DON stated she interviewed the CNAs, and they stated they assisted Resident #14 from her chair back in bed using the mechanical lift. The DON stated Resident #14 has always used a mechanical lift, but this was the first time an incident had happened during her transfer. The NHA stated after they were notified about the incident, they conducted inspections on their mechanical lift and slings. They all checked out to be working properly and in good condition. The NHA stated they concluded two experienced CNAs transferred Resident #14 on the day of the incident and the resident experienced pain. The DON and doctor were notified, and the resident was sent out to the hospital. During an interview conducted on 06/11/2025 at 9:13 a.m. with Staff Q, CNA, she said, On 5/12/2025 it was a regular day and routine with assisting Resident #14. She stated she gets the resident up after breakfast on Mondays, Wednesdays and Fridays. She stated she changed the resident, got her dressed, then put the sling underneath the resident to get her ready to transfer her using the mechanical lift. She stated she got Staff F, CNA to assist her with the transfer. She said after they placed Resident #14 in her chair, Staff F, CNA checked to make sure the resident was positioned in her chair properly and placed her footrest onto her chair. Then she placed Resident #14 outside of her room door. She said later the resident was taken to the television room by an unidentified staff member. She stated when they got Resident #14 up she did not see anything unusual, and the resident did not show any signs of pain. She said when she and Staff F, CNA put Resident #14 back to bed using the mechanical lift, they lifted the resident's dress to remove the sling, Staff F, CNA noticed swelling on the resident's right hip. She stated when she saw Resident #14's hip, she knew it was popped out of place. She stated she knows the resident was a mechanical lift transfer, but there was no documentation in the computer showing the type of lift the resident requires. She said she knew how to use a mechanical lift because she was a veteran nurse's aide but had not received a visual demonstration on how to properly lift a resident. She said she has not gotten Resident #14 out of bed since she returned back to the facility on 5/20/2025. An interview was conducted on 06/11/2025 at 10:12 a.m. with the Director of Rehabilitation (DOR). He stated nursing sets the resident's transfer status based on the information from the Agency for Health Care Administration (AHCA) form 3008. He stated, Per therapy standards, if the resident was max-dependent, they are automatically a mechanical lift with two-person assistance. The DOR stated they do not give formal training to staff regarding safe use of a mechanical lift, and they do not perform demonstration with the mechanical lifts. He stated he talks to staff about positioning, having a second person when using the lifts, and staff needing to talk to their residents during the transfer. The DOR confirmed since he had been at the facility he had not provided any training for mechanical lifts with staff. The DOR stated Resident #14 was picked up for therapy on 05/21/2025 for Occupational Therapy and on 05/24/2025 for Physical Therapy. He stated prior to the incident, the resident had not been seen by therapy. He confirmed the resident required a mechanical lift and a two-person transfer. The DOR stated he did not have an assessment for the use of the mechanical lift for Resident #14. He stated he was not involved with sizing residents for sling use. The DOR looked through therapy evaluations for Resident #14 and stated he did not see any evaluation done for the use of the mechanical lift. An interview conducted with the Medical Director on 06/12/2025 at 11:32 a.m. revealed he was involved in the QA (Quality Analysis) process. He stated the facility follows up on his recommendations. He stated the NHA calls him regarding incidents in the facility, but he is not involved in everything. They call him for incidents like medication errors and an injury of an unknown source. He stated he was notified about a patient that ended up with a hip fracture but there was no fall involved. He stated he told them to continue education with the staff on how to care for elderly patients. He stated there were many things that could have happened to contribute to the resident's fracture. An interview was conducted on 6/12/2025 at 2:00 p.m. with the Assistant Director of Nurses (ADON). She stated she had not done any competencies with the nursing staff regarding the use of Mechanical lifts. Review of a facility document titled, Facility Assessment 2025 - Name of Facility showed under purpose, the Facility Assessment is a complete review of internal human and physical resources required by the facility to care for residents competently during day to day and emergency operations. The facility assessment identifies your capabilities as a skilled nursing services provider. The facility Assessment will be the basis for surveyors to ascertain whether you are prepared to competently take care of the population you have identified that you serve. The tool is organized in three parts: 2. Services and care offered based on resident needs (includes types of care your resident population requires; the focus is not to include individual level care plans in the facility assessment). 3. Facility resources needed to provide competent care for residents, including staff, staffing plan, staff training/education and competencies, education and training, physical environment and building needs, and other resources, including agreements with third parties. Under heading: Complete the Facility Assessment 7. The goal is to make decisions about needed resources, including direct care staff needs, as well as their capabilities to provide services to the residents in the facility. Review of a Job Description tiled, Nursing Home Administrator showed under Position Summary: The Administrator oversees the overall operation of the nursing home, ensuring regulatory compliance, financial health, resident satisfaction, and team management. Key Responsibilities: Manage daily operations and ensure quality care delivery. Lead department heads and coordinate administrative activities. Ensure compliance with state and federal regulations (e.g., CMS [Centers for Medicare & Medicaid Services]). Oversee budgeting, billing, and financial planning. Represent the facility in community and regulatory matters. Review of a Job Description tiled, Director of Nursing (DON) showed under Position Summary: The DON is responsible for the overall management of the nursing department, including policy development, staff supervision, and regulatory compliance. Key Responsibilities: Lead and manage the nursing team to deliver high-quality care. Oversee recruitment, training, and scheduling of nursing staff. Ensure documentation meets legal and regulatory requirements. Conduct quality assurance and performance reviews. Facility immediate actions to remove the Immediate Jeopardy received on 6/13/25 included: 1. On 6/12/25 at 2:00 p.m. Administrator held an Emergency Information Sharing Ad-Hoc Meeting regarding Mechanical Lift Safety Plan scheduled at 3 p.m. 2. Assistant Director of Nursing on 6/12/2025 provided education to nursing staff of 2- person lift and mechanical lift policy. Education of nursing staff reached 100%. Of the nursing staff 85% were educated in-person while the remaining 15% were sent education material through a direct messaging program. 3. Director of Nursing and ADON initiated Skills Competencies for Mechanical Lift for nursing staff on 6/12/25. At this time, 100% of nursing staff have competencies completed. 4. On 6/11/25 the MDS Coordinator began updating Care plans for residents to reflect the transfer status of residents. 6/13/25. At this time, 100% of care plans have been updated. 5. On 6/12/25 A Kardex audit has been initiated by the Director of Nursing confirming the lift status of residents. Currently Kardex audit indicates 100% Kardex's have been updated with mechanical lift status. 6. A daily observational audit conducted by the Director of Nursing (or designee) to validate staff are transferring residents based on the care plan/Kardex. This audit started on 6/12/25 and will report to the monthly QAPI meeting. 7. Manufacturer guidelines of the slings size have been posted in the clean utility rooms on 6/12/25. 8. The therapy department assesses the lift and transfer status of residents. This information is shared with the nursing staff in the daily clinical meeting and changes reviewed at weekly Standards of Care Meeting (SOC). The rehab staff have reassessed Resident #4 on June 13, 2025. Resident #14 cannot currently be assessed for transfer status pending medical clearance. Verification of the facility's removal plan was conducted by the survey team on 6/13/2025. All steps contained in the removal plan were reviewed and verified. Interviews were conducted with facility staff, licensed nurses, Nursing assistants and therapy staff. 31 nursing staff members and therapy staff confirmed having received in-services on topics to include use of mechanical lifts, care plan, care plan/ Kardex review, Mechanical lifts use/ 2- persons transfer, and sling sizes. 100% of staff completed in-services on 6/12/2025 voicing an understanding of the policies and processes required to provide competent care for residents. The staff interviewed have worked across all shifts. A review of the sign-in sheets was conducted to verify education, and training was completed as outlined in the IJ removal plans. Based on verification of the facility's Immediate Jeopardy removal plan the immediate jeopardy was determined to be removed on 6/13/2025 and the non-compliance was reduced to a scope and severity of D.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy and procedure review, and interviews with facility staff, agency nursing staff, and the key management staff the facility failed to ensure the nursing staff received adequate orientation and training to ensure competency in completing the admission/readmission process in a timely manner for one resident (#1) out of three residents reviewed for re-admission. The facility failed to ensure nursing staff received adequate orientation and training to ensure competency in completing the medication reconciliation. The facility nursing staff failed to reconcile the medication by not entering the physician orders into the facility's system to ensure nursing staff administered medication according to the physician orders for three residents (#1, #11, and #19) out of three residents reviewed for re-admission to the facility. Resident #1 returned to the facility on 7/28/23 from the hospital. Upon return, the facility did not implement admission procedures. The resident was not entered into the facility census and the physician ordered medication was not entered in the computer. Resident #1 did not receive her medication from 7/28/23 at 2:07 p.m. until she transferred out and arrived at the Emergency Department (ED) on 7/30/23 at 11:55 a.m. Resident #11 was also re-admitted to the facility on [DATE] after being in the hospital for two days for a scheduled procedure. Upon return to the facility at 1:15 p.m. on 7/28/23, the resident did not receive her medication for the rest of the day. Resident #11 was not administered her physician ordered antidepressants, antianxiety medication, other the counter medication, or medication she takes to treat her Parkinson's disease until 7/30/23. Resident #19's August Medication Administration Record (MAR) showed the resident had missed multiple doses of seizure and pain medication on 7/29/23 and 7/30/23 when her orders were not entered correctly upon re-admission to the facility on 7/29/23. Resident #19's primary care physician said missing regularly scheduled medications put the resident at higher risk for increased seizures and lowered the threshold for breakthrough seizures. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Resident #1, #11, and #19 and resulted in the determination of Immediate Jeopardy on 07/28/23. The findings of Immediate Jeopardy were determined to be removed on 8/11/23 and the severity and scope was reduced to a D. Findings included: 1. An interview was conducted on 8/9/23 at 12:52 p.m. with the Director of Nursing (DON). The DON stated they had not done education on charting on a resident if the resident is not in the computer system or if the system is down. She said if she was a floor nurse, she would have probably questioned Resident #1 not being in the system or not having medications. The DON said at the time of the incident (7/28/23 to 7/30/23) paper charting options were not available to staff. Review of the Public Health Information Audit Log for Resident #1 showed Resident #1 was not re-entered into the facility census until 7/29/23 at 10:06 p.m. by Staff G, Licensed Practical Nurse (LPN) [agency staff]. From the time of re-admission on [DATE] at 2:07 p.m. until 7/29/23 at 10:06 p.m., Resident #1 did not show up in the facility computer charting system as being in the building. Review of the Medical Certification for Medicaid Long-term Care Services and Patient Transfer form (Agency for Health Care Administration [AHCA] Form 3008) showed Resident #1 was discharged from the hospital on 7/28/23 at 1:00 p.m. She had a diagnosis of urinary tract infection (UTI) and altered mental status (AMS) and was listed as being on Enhanced Contact Isolation Precautions. The Discharge Medications were listed as the following unchanged scheduled medications: -Apixaban 5 milligram (mg) tablet. Twice a day. Next dose was due on 7/28/23 at 9:00 p.m. -Aspirin 81 mg tablet. Once a day. Next dose was due on 7/29/23 at 9:00 a.m. -Bumetanide (Bumex) 2 mg. Once a day. Next dose was due on 7/29/23 at 9:00 a.m. -Carbidopa-levodopa (Sinemet 25 mg-100 mg oral tablet.) 1 tablet four times a day. Next dose due not listed. -Cranberry (Azo-Cranberry oral tablet.) 450 mg by mouth once a day. Next dose was due on 7/29/23 at 9:00 a.m. - Divalproex Sodium (Depakote) 500 mg delayed release tablet. 1 tablet twice a day. Next dose due not listed. -Docusate (Colace 100 mg oral capsule) 1 capsule every 12 hours. Next does due on 7/28/23 at 9:00 p.m. -Escitalopram (Lexapro 20 mg oral tablet.) 1 tablet once a day. Next dose due on 7/29/23 at 9:00 a.m. -Levothyroxine 125 microgram (mcg) oral tablet. 1 tablet once a day. Next dose due on 7/29/23 at 9:00 a.m. -Magnesium hydroxide (Milk of Magnesia 8% oral suspension.) 30 milliliters (ml) once a day as needed for constipation. Next dose due on 7/28/23 at 9:00 p.m. -Multivitamin with minerals. 1 tablet once a day. Next dose due on 7/29/23 at 9:00 a.m. -Omeprazole 20 mg delayed release capsule. 1 capsule once a day. Next dose due on 7/29/23 9:00 a.m. -Potassium chloride 10 milliequivalents (mEq) extended-release oral tablet. 1 tablet three times a day. Next dose due at 7/28/23 9:00 p.m. -Risperidone (Risperdal 0.5 mg oral tablet.) 1 tablet once a day. Next dose due on 7/28/23 at 9:00 p.m. Review of admission Record showed Resident #1 was originally admitted to the facility on [DATE] and had a re-admission date of 7/28/23 with diagnoses to include anxiety disorder, bipolar disorder, Parkinson's disease, chest pain, schizophrenia, venous insufficiency, acute embolism and thrombosis of deep veins of left lower extremities, and depression. Review of progress notes showed Resident #1 was sent to the hospital for evaluation for increased confusion on 7/25/23. The Emergency Medical Services (EMS) Patient Care Report showed the resident returned to the facility on 7/28/23 at 2:07 p.m. with Staff L, Licensed Practical Nurse (LPN) [agency staff] signing as accepting the resident at 2:16 p.m. Review of the July 2023 MAR showed Resident #1 did not receive any of the ordered medications from the time of her re-admission on [DATE] at 2:07 p.m. until 7/30/23 when the resident was sent to the Emergency Department for acute care at 10:30 a.m. The first documentation following Resident #1's re-admission to the facility was a progress note on 7/30/23 at 2:43 p.m. The progress note written by Staff F, Registered Nurse (RN) showed the following: Seizure activity noted for 15 minutes. Resident sent to ER [Emergency room] to be evaluated and Tx [treated.] Per MD's [medical doctor] orders. POA [Power of attorney] and MD notified. An interview was conducted on 8/8/23 at 11:48 a.m. with the Director of Nursing (DON). The DON said Staff H, Licensed Practical Nurse/Unit Manager (LPN/UM) was assigned to Resident #1 when the resident came back to the facility on 7/28/23, but Staff H, LPN/UM was doing treatments on other residents and didn't do any assessments. The DON said Staff H, LPN/UM gave report to Staff J, LPN telling her she needed to do the admission. The DON said Staff J, LPN said she told Staff H, LPN/UM she didn't know how to use the facility's charting system and would need assistance. The DON said, Long story short, the admission wasn't completed as far as medications being entered into the computer. The DON said she thinks Staff H, LPN/UM had A really busy day. She had a fall that day and I forgot what the other things that were happening. I think it was a COVID testing day; maybe just super busy and she was doing treatments. The DON said Staff H, LPN/UM never actually made it into Resident #1's room. She said the next day, 7/29/23, Resident #1's medications were still not entered into the computer and the resident wasn't even entered into the facility census until Saturday night, 7/29/23, at 10:22 p.m. During a follow-up interview with the DON on 8/8/23 at 2:12 p.m., she stated she would consider it unusual for staff to provide care and not document. An interview was conducted on 8/9/23 at 11:17 a.m. with the DON. The DON was asked how agency nurses were educated on doing a resident admission prior to this incident, she said, It is nursing 101. All nurses know how to do an assessment. When asked if there had been information or training about doing an admission prior to this incident she said, No, not that I know of, no. An interview was conducted on 8/8/23 at 3:05 p.m. with Staff H, LPN/Unit Manager (UM.) Staff H, LPN/UM confirmed she was working on 7/28/23 as the Unit Manager and was assigned to a medication cart including the room Resident #1 was re-admitted too. Staff H, LPN/UM said typically if a resident comes in the facility after 2:30 p.m. the nurse coming on for the 3:00 p.m. to 11:00 p.m. shift would do their admission. She said when Resident #1 came into the facility, she was in another resident's room doing treatments. She said when she came back to the nurses' station around 2:35 p.m. the other nurse on duty (Staff L, LPN/agency staff) informed her Resident #1 had returned. Staff H, LPN/UM said she saw the resident was in her room with her private sitter and the resident looked comfortable and fine. She said she continued with a few more treatments she had to complete for other residents. Staff H, LPN/UM said the evening nurse (Staff J, LPN/agency staff) came on for her 3:00 p.m. to 11:00 p.m. shift and she gave her report and let her know Resident #1 had returned and her admission needed to be done. She said that nurse should have been the one to do the assessment and put physician orders in the computer. Staff H, LPN/UM said she was basing which nurse was responsible for the admission on the time she was told the resident had arrived which was close to 2:40 p.m. She said the nurse that took over from her was an agency nurse (Staff J, LPN) who had been to the facility a few times in the previous month or so. Staff H, LPN/UM said she previously showed Staff J, LPN how to enter orders and do a medication pass in the facility's electronic charting system. Staff H, LPN/UM said on 7/28/23 Staff J, LPN didn't ask her for any help or instructions. She said she told Staff J, LPN that she had to finish some treatments then she would be in her office doing her charting if she needed anything. Staff H, LPN/UM said she was in her office until 8:30 p.m. and if Staff J, LPN would have asked her for help she would have assisted. Staff H, LPN/UM said she had been very busy during her shift. They had a call out (staff member not able to work their shift) and she had to work a floor assignment. She said she had a resident fall and multiple residents test positive for COVID and she was getting orders for all of those residents. Staff H, LPN/UM said she asked the Director of Nursing (DON) and the first floor UM (Staff P, LPN/UM) for help. She said that morning the DON had come up and asked her if she needed help passing medication and I told her that I didn't need help with medications. She said she was also informed she was getting three admissions that day. Staff H, LPN/UM said the first floor UM said that she would help her with orders if Staff H, LPN/UM got three admissions. Staff H, LPN/UM said when the first admission arrived, she messaged the first floor UM and got no response. Staff H, LPN/UM said the DON texted her after 4:00 p.m. Staff H, LPN/UM read a text message from the DON that stated, I am sorry you are having a bad day. I don't know what you expect . If you needed help [Staff P, LPN/UM] or myself would have gladly helped. I thought you would be off the cart by 3:00 . I am sorry if this makes you mad. Staff H, LPN/UM said she told the DON she didn't need help with medications, but the DON and Staff P, LPN/UM knew what all was going on her unit. She said they were both texting her saying she had medications in the red (meaning they are late) and admission audits needed to completed from previous days. Staff H, LPN/UM said she shouldn't have to call and say, Can someone help again. We are supposed to be a team. She said she told the DON she wasn't still on the medication cart at 3:00 p.m. but had several dressing changes to do, still had to enter orders for the COVID positive residents, do the incident report for the fall, and there were two residents sending themselves to the hospital. She let her know the other 7:00 a.m.-3:00 p.m. nurse was an agency nurse and asking for her help and her relieving nurse was agency and she was a little late and not that familiar with the facility's charting system and she wasn't sure what was going to get done with the admission. Staff H, LPN/UM said she told the DON she had to work on these several things and then she had to go because she had been there since 6:45 p.m. Staff H, LPN/UM said she texted the DON, I don't know how I'm being angry if I'm simply saying I have a lot on my plate to complete and can't take on something else right now. That's also a sign to help a friend or a teammate is it not? I put a question mark I said this could go on and on, but I don't want to keep going on about it because I need to get my stuff done to get out of here, so she (DON) responded OK. Staff H, LPN/UM said she knew the agency nurse relieving her wasn't fully aware of the admission process and all the assessments they do to complete a full admission. She said she let the agency nurse know she would be in her office finishing her work if she needed help. Staff H, LPN/UM said she was at work until 8:30 p.m. and she was never asked for help. She said she even called the weekend supervisor (Staff D, LPN) on Saturday morning at 8:15 a.m. She said she asked Staff D, LPN to check and make sure the assessments were completed and look at the admission to make sure it was completed due to the 3:00 p.m. -11:00 p.m. nurse being agency. She said Staff D, LPN told her she would look at it. Staff H, LPN/UM said she would have expected the agency nurse that got report from her to put the orders in and she thought Staff D, LPN would review it. Staff H, LPN/UM said she had worked at the facility about four weeks and had not really gotten an orientation and had no training on the admission process. An interview was conducted on 8/9/23 at 2:30 p.m. with Staff J, LPN/agency staff. Staff J, LPN said 7/28/23 from 3:00 p.m. to 11:00 p.m. was her first time caring for Resident #1. Staff J, LPN said she knew there were orders for the resident, but she was never trained on admissions in the electronic medical record system the facility uses. She stated Staff H, LPN/UM told her she was going to complete the orders later that night. Staff J, LPN said she did take care of the resident and made sure she was repositioned, had dinner, and asked if she was in pain. She said she was seen and taken care of, but she did not give her any medications. Staff J, LPN said she did not inform anyone about the problem because Staff H, LPN/UM, that took care of the resident the previous shift, said she was going to take care of it and there was no one else in the building. She also said she did not do an admission assessment as the resident had arrived on the previous shift. Staff J, LPN said she put in a late entry progress note when she came to the facility on 8/1/23. An interview was conducted on 8/9/23 at 12:43 p.m. with Staff K, Certified Nursing Assistant (CNA)[agency staff]. Staff K, CNA confirmed he cared for Resident #1 on 7/28/23 3:00 p.m. to 11:00 p.m. He said the resident was in the bed when his shift started, she was responsive, good-natured, and communicated. He said he provided incontinence care, and she did get a food tray. He said he is an agency CNA and did not have a password to get into the computer system until later in the day. He said he documented on paper but didn't know where that went. He said it was just a piece of paper he was writing on. He said he did not notify anyone he couldn't document on Resident #1. He said a staff CNA gave him a report on Resident #1, but he could not read it. An interview was conducted on 8/10/23 at 10:50 a.m. with Staff G, LPN (agency staff). Staff G, LPN confirmed she cared for Resident #1 on 7/29/23 from 7:00 a.m. to 11:00 p.m. She said she is an agency nurse, and that was her first time at this facility. She said Resident #1 had just been re-admitted to the facility. Staff G, LPN said Resident #1 was not in the electronic medical record system. She said she notified Staff D, LPN, the Weekend Supervisor, who let her know she would get to putting the resident and orders in. Staff G, LPN said she was a late call in, and she got to the unit around 8:00 a.m. She said she notified Staff D, LPN that Resident #1 was not in the system for the first time around 8:30 a.m. She said she checked with Staff D, LPN about four times throughout the day asking if the resident's admission was completed yet. She said each time she was told by Staff D, LPN, she was working on. Staff G, LPN said she typically doesn't do admissions and she had not be trained to do them. She said she did find it odd doing the admission would take so long. She also said she did not administer any medication because she didn't know what medications Resident #1 was on and the resident didn't request any medications. Staff G, LPN said she did assess the resident and do vitals. She also said the CNA cared for the resident. She said she wrote the notes in her notebook but was not able to chart on the resident since she was not in the system. She said she did not have any paper charting options. Staff G, LPN said the DON called her a couple of days later and asked her to write a statement and write her resident assessment on paper. She said finally around 10:00 p.m. when she went to the Weekend Supervisor (Staff D, LPN) for the last time, Staff D, LPN told her how to enter the resident into the census on the electronic medical record and she did so at that time. An interview was conducted on 8/9/23 at 11:50 a.m. with Staff F, Registered Nurse (RN). Staff F, RN confirmed he cared for Resident #1 on Sunday 7/30/23 and he had also taken care of her previously. He said he got report on his residents and proceeded to start his medication pass and assessments. He said when he got to Resident #1, maybe around 9:00 or 9:15 a.m., he saw her MAR for 7/30/23 was empty and he went to the room to confirm she was really there. He said when he reached her, he knew something was different. He said Resident #1 was slightly unresponsive and couldn't talk. He said the resident's eyes were sort of shaking, closing and opening, closing and opening. Staff F, RN said this was not how the resident was before. He said after about 5 minutes the resident revived and could communicate. He said she was not responding the way she should and when he saw there was no medication, he knew she needed to be assessed in case this was due to missing her medication. Staff F, RN said he called 911 and notified the doctor that Resident #1 was being sent out for seizure activity and there had been no medication orders in the system. An interview was conducted on 8/9/23 at 10:16 a.m. with the DON. She said she would have expected Staff D, LPN, the weekend supervisor, to review the census and make sure the admission was accurate. She said, It is part of her job responsibilities. She said she would have expected her to fix the issues, especially since Staff H, LPN/UM called her to check on it. The DON said Staff D, LPN should be reconciling the census on the weekends. The DON confirmed no documentation was entered for Resident #1 from the time of her readmission on [DATE] until she was being sent to the Emergency Department on 7/30/23. She said the notes in the computer now were late entry notes and the paper documentation was done a few days later when staff came in to give their statements. An interview was conducted on 8/9/23 at 10:40 a.m. with the Assistant Director of Nursing (ADON.) He stated he was called Sunday and the nurse (Staff F, RN) told him nothing was being done on Resident #1 and there were no orders in the system. Staff F, RN told the ADON the resident was being sent to the hospital. The ADON asked him, What do you mean there are no orders, if the resident was in the building they should have been admitted . He said he logged into the system from home and saw there were no progress notes or orders for Resident #1. He said he called Staff D, LPN, the weekend supervisor, and asked if he was seeing it correctly or was his system messed up. He asked her, didn't you review the chart, that is what the weekend manager is supposed to do. The ADON said Staff D, LPN said the resident was in the facility since Friday and the admission should have already been done. The ADON said he called Staff H, LPN/UM and she read him text messages between her and the DON. He said on the texts, Staff H, LPN/UM had asked for help and the DON told her she was sure the first floor UM (Staff P, LPN/UM) was going to help. The ADON said Friday evening (7/28/23) he left the building between 8:00-9:00 p.m., at the same time as Staff H, LPN/UM. He said on Friday (7/28/23) he was in the building, but no one asked him for help. He said he spoke with the agency nurse (Staff J, LPN) before he left that evening. He said she was working on her medication cart at the time, and they talked for about 30 minutes. He said the nurse never told him she didn't know how to use their charting system, she never asked for help, or mentioned the admission not being done. The ADON said the DON, Staff H, LPN/UM and the first floor UM (Staff P, LPN/UM) all knew multiple admissions were coming in. He said no one told him the residents were in the building. He said Staff H, LPN/UM was having to work a cart and could not do the management part. The ADON said there seemed to be a breakdown in communication regarding when the resident arrived and what time the nurse found out the resident was in the facility. He said the weekend supervisor (Staff D, LPN) also did not follow up and ensure the admission was done. He said each agency nurse (Staff J, LPN, Staff O, LPN, and Staff G, LPN) didn't question and follow through with why the resident wasn't in the computer, adding to the problem. He said he did find it odd the UM was having to work the floor. He said he has only seen that one time and that time an agency nurse was called in to take the assignment so the UM could do the managerial duties. He said no one has given him an answer as to why no one was called in on Friday, 7/28/23. The ADON said he had not been trained by the facility on doing an admission. He said being a nurse for so long, he could figure it out if he needed to. He said he has seen an admission check list when they review admissions in the morning meetings. He said he used to work the cart at least once a week but has not done an admission. He said he has asked for training on it and will have to see when that happens. The ADON said the facility has an orientation binder for agency nurses to go through before they work in the facility. He retrieved the binder and confirmed there was no information in the binder on completing a resident admission or re-admission. Multiple attempts were made from 8/8/23 to 8/9/23 to contact Staff D, LPN/Weekend Supervisor via the phone number provided and no contact was made. Attempts were made by the facility staff and the ADON confirmed Staff D would not respond to their attempts as well. An interview was conducted on 8/9/23 at 2:43 p.m. with Resident #1's primary care physician. He stated he does not recall being notified the resident had returned to the facility on Friday, 7/28/23. He also said he was not notified Resident #1 had missed any medications until Monday, 7/31/23. He said the expectation is medication orders should be followed when a resident is admitted . An interview was conducted on 8/10/23 at 12:14 p.m. with the DON. The DON said she felt Resident #1 was taken care of but what happened was wrong, absolutely. She added that is was wrong nursing practice. She said they treated the incident as a medication error. A facility provided document titled Incident Timeline, undated, showed the facility completed audits of the three other re-admission on the weekend of 7/28/23 to 7/30/23; this would include Resident #19 and #11. The facility showed no other admissions were missing medication order and there were no errors noted. 2. Review of admission Record showed Resident #19 was admitted on [DATE] with a readmission date of 7/29/23, diagnoses included epilepsy, anoxic brain damage, acute respiratory disease, history of sudden cardiac arrest, acute embolism and thrombosis or left axillary vein, and conversion disorder with seizures or convulsions. Review of progress notes for Resident #19, dated 7/29/23 at 6:05 p.m., showed the following: Resident arrived to facility via Stretcher, unaccompanied by family. No personal belongings brought with resident. Dischage [sic] medication list given to writer by EMT [Emergency Medical Technician.] Allergies noted to be Penicillin, ASA [aspirin,] Depakote, and CABamazepine [sic.] Resident unable to verbally confirm Allergy. REsidnet [sic] is alert, and can intermittently follow simple commands. RE-oriented to room, call light, bed controls, lights and rooms=ates [sic.] Unable to verbalize understanding. Resident is currently resting in bed. so [sic] S&S [signs and symptoms] of distress or pain noted. The admission Pain Assessment for Resident #19 was reviewed. It showed it was completed on 7/29/23 at 9:24 p.m. by Staff D, LPN, the weekend supervisor. The Pain Assessment noted the resident had Vocal complaints of pain and Facial expression (grimaces, winces, wrinkled forehead, furrowed brow, clenched teeth or jaw). The admission Assessment showed it was completed by Staff G, LPN on 7/29/23 at 10:06 p.m. and noted no seizure activity and the Wong-Baker FACES pain level showed, A little more pain. The Wong-Baker FACES pain scale is a pain scale that uses facial expressions to rate pain for those that have difficulty communicating. Review of the Hospital Discharge Medications showed medications to continue including the following: - Baclofen 20 mg every 6 hours - Clonazepam (Klonopin) 2 mg 3 times a day - Lacosamide (Vimpat) 300 mg 2 times a day - Lamotrigine (Lamictal) 200 mg 2 times a day - Levetiracetam (Keppra) 15 ml every 12 hours - Oxycodone/APAP (Percocet 5-325) 1 tab every 8 hours. Review of Resident 19's July 2023 MAR showed her medication orders were discharged on 7/29/23 and put in to restart on 7/30/23. The medications were not set to begin upon her return to the facility on 7/29/23 at 6:05 p.m. The July 2023 MAR showed the resident was taking Clonazepam (Klonopin) 2 mg 3 times a day for epilepsy. The resident missed one dose of Klonopin on Saturday, 7/29/23, at 10:00 p.m. She received four doses of Klonopin on Sunday, 7/30/23, instead of the ordered three doses. The July 2023 MAR showed the resident was taking Lacosamide (Vimpat) 300 mg 2 times a day for epilepsy. The resident missed three doses, one on 9:00 p.m. on Saturday, 7/29/23, and two on Sunday, 7/30/23, at 9:00 a.m. and 9:00 p.m. The July 2023 MAR showed the resident was taking Lamotrigine (Lamictal) 200 mg 2 times a day for epilepsy. The resident missed one dose of Lamictal on Saturday, 7/29/23, at 9:00 p.m. The July 2023 MAR showed the resident was taking Levetiracetam (Keppra) 15 ml every 12 hours for epilepsy. The resident missed one dose of Keppra on Saturday, 7/29/23, at 9:00 p.m. The July 2023 MAR showed the resident was taking Oxycodone/APAP (Percocet 5-325) 1 tab every 8 hours for pain. The resident missed one dose of Percocet on Saturday, 7/29/23, at 10:00 p.m.and three doses on Sunday, 7/30/23, at 6:00 a.m., 2:00 p.m., and 10:00 p.m. Review of the July and August 2023 MAR showed regular pain monitoring was not in place from 7/30/23 through 8/7/23. Review of Resident #19's SBAR (Situation, Background, Assessment, Recommendation) Communication Form, dated 8/7/23 at 10:10 a.m., showed the resident was found by staff with her g-tube (gastrostomy tube) on the bed next to her, fully intact. The resident was transported to the hospital. Review of Resident #19's August 2023 MAR showed the resident did not miss her seizure medication on 8/7/23 due to her PEG tube being dislodged. The resident missed her seizure medication 8 and 9 days prior when her orders were not entered correctly. The seizure medication included: - Clonazepam (Klonopin) 2 mg 3 times a day - Lacosamide (Vimpat) 300 mg 2 times a day - Lamotrigine (Lamictal) 200 mg 2 times a day - Levetiracetam (Keppra) 15 ml every 12 hours An interview was conducted on 8/11/23 at 11:28 a.m. with Resident #19's primary care physician. He stated the provider should be called when a resident returns to the facility to activate medications and nurses should administer the medications accordingly. The physician said he was not notified Resident #19 missed her anti-seizure and pain medications. He said on the weekends, the provider will make a 3-day emergency dispersal if needed. The physician said his office has doctors available 24 hours a day 7 days a week. He said, There is no reason for missed doses. He said for Resident #19 the specific effects of missing 3 or 4 doses of medication are unknown, but missing regularly scheduled medications puts the resident at higher risk for increased seizures and lowers the threshold for breakthrough seizures. An interview was conducted on 8/10/23 at 5:17 p.m. with the DON and the Regional Clinical Reimbursement Nurse (RCRN). The DON said she didn't know why Resident #19 did not get her medications. She said normally when a resident transfers out of the facility, all of the medications go back to the pharmacy. She said, They may not have had a script [prescriptions]. I don't know if we had the medication in the EDK [Emergency Drug Kit.] I will have to check. The facility's emergency medication stock is in the electronic dispensing machine. During a follow-up interview on 8/11/23 at 10:55 a.m., the DON said if the medications are unavailable, the pharmacy should be called. 3. Review of admission Record showed Resident #11 was admitted to the facility on [DATE] and a re-admission date of 7/29/23 with diagnoses including Alzheimer's disease, adult failure to thrive, Parkinson's disease, depression, unspecified convulsions, anxiety, chronic pain, and schizoaffective disorder. Resident #11 was re-admitted at 1:15 p.m. on 7/29/23 following a planned procedure on 7/27/23 performed at an acute care facility. An email sent to the management staff from the facility's admission Director on 7/29/23 at 10:21 a.m. showed Resident #11 was arriving after lunch. Review of the Observation Detail Report for Resident #11, dated 7/29/23 at 6:31 p.m., showed the resident arrived by ambulance with a family member. The report identified the resident had disorganized thinking, impaired memory, and had a gastric/enteral tube. Review of a progress note for 7/29/23 (at 6:22 p.m.) showed Resident #11 returned from an acute care facility as a readmission, vitals were within normal limits (wnl), skin was intact, had a new gtube and showed the resident was to receive bolus nutrition 6 times a day which had been tolerated. The one progress note for 7/29/23 did not show the physician was notified of the resident's return or that medications had been reconciled with the physician. The Medical Certificati[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, facility documentation, and policy review, the facility failed to prevent one (Resident #1) of three residents reviewed for gastric tube medications administration was free from neglect as evidenced by neglecting to give medications per physician orders, neglecting to notify the provider of an abnormal chest X-ray result, and neglecting to monitor the resident after a medication error. Resident #1 had a gastric tube placed on 5/4/2022 and had a physician order to receive nothing by mouth. All of Resident #1's medication orders indicated the route of administration was through her gastric tube. On 4/14/23 at approximately 8:45 a.m. Staff L, Agency, Registered Nurse (RN) neglected to ensure she received an accurate resident assignment and report, neglected to review physician orders, neglected to clarify missing medications, neglected to inquire about enteral feeding orders, and neglected to review Resident #1's cognition status before asking Resident #1 if she was ready to take her medications. Staff L, Agency RN then proceeded to administer approximately four to five tablets of Resident #1's medications orally causing Resident #1 to sustain respiratory complications that required suctioning. Resident #1 continued to have respiratory complications which required suctioning throughout the day and her lungs sounded congested. The Advanced Registered Nurse Practitioner was notified and ordered a chest X-ray to rule out aspiration/pneumonia. The chest X-ray resulted on 4/14/23 at 7:07 p.m. and revealed Resident #1 had slight right lower lobe and modest right upper lobe infiltrates [When interpreting the x-ray, the radiologist will look for white spots in the lungs (called infiltrates) that identify an infection. This exam will also help determine if you have any complications related to pneumonia such as abscesses or pleural effusions (fluid surrounding the lungs). Pneumonia | Lung inflammation - Diagnosis, Evaluation and Treatment, radiologyinfo.org, https://www.radiologyinfo.org > info > pneumonia]. Review of a nursing note dated 4/15/23 at 6:15 a.m., written by Staff M, Agency, LPN (Licensed Practical Nurse), showed at approximately 5:45 a.m. Resident #1 was found in her room to be without breath, pulse, and blood pressure and the body was being released to the funeral home. There was no documentation showing Resident #1 had vital signs monitored from 4/14/23 at 10:38 a.m. until her death. There was no documentation showing Resident #1's physician was notified of the abnormal X-ray results. There was no documentation that indicated Resident #1 was closely monitored from approximately 1:50 p.m., when the resident received X-ray orders as a result of her change in condition, until her death on 4/15/23 at approximately 5:45 a.m. This failure created a situation that resulted in a worsened condition and death to Resident #1 and resulted in the determination of Immediate Jeopardy beginning on 4/14/23. The findings of Immediate Jeopardy were determined to be removed on 4/27/23 and the scope and severity reduced to a D. Findings included: Review of Resident #1's face sheet revealed she was an [AGE] year-old female admitted on [DATE] with medical diagnoses that included but were not limited to, gastrostomy status (since 5/4/22), dysphagia, oropharyngeal phase, need for assistance with personal care oral phase, vascular dementia with behavioral disturbances. Review of Resident #1's quarterly Minimum Data Set assessment dated [DATE], section C, cognitive patterns, revealed a brief interview for mental status (BIMS) score of 5 out of 15 which indicated severely impaired cognition. Review of Section K, Swallowing/Nutritional status revealed .Feeding tube-nasogastric or abdominal (PEG) [percutaneous endoscopic gastrostomy tube] . A physician's order review revealed a diet order for NPO (nothing by mouth), this order started on 10/6/2022 and was discontinued after her death on 4/17/23. A physician's order which started on 5/19/22 and was discontinued on 4/17/23 revealed May crush medications unless contraindicated. A physician's order which started on 5/19/22 and was discontinued on 4/17/23 revealed Enteral feeding: Flush tube with 30cc [cubic centimeter] water before and after every administering [sic] medications and 5cc between each medication every shift day evening night. Review of the speech therapy discharge summary with a date of service of 5/9/22-5/16/22, revealed on 5/2/22 a MBSS (modified barium swallow study) was completed, and the resident became NPO due to severe pharyngeal stasis and deep penetration to VF (video fluoroscopy) without clearance. A percutaneous endoscopic gastrostomy (PEG) tube was placed on 5/4/22 and the resident was discharged from speech therapy on 5/16/22 with orders for NPO with PEG placement for all nutrition/hydration/medication; severe impairment. Review of the nursing progress note dated 4/14/23 at 9:47 a.m. written by Staff L, Agency, LPN [sic] revealed the following documentation. This RN was given report by night shift stating that this pt [patient] was on assignment and took meds whole. Both nurses attempted to locate report sheets unsuccessfully. Verbal report given with handwritten notes for how pts [patients] take meds [medications]. This RN was not informed that this pt had a PEG tube or was confused. This RN went into pt room and verified pt, spoke to pt stating had her medications and asked pt to verify that she took pill whole. Pt stated yes so RN proceeded. Pt immediately started coughing and RN had pt spit meds out. Pt was speaking and following commands but said she still felt that something was stuck. This RN went and sought out help and informed staff RN of what had taken place and was informed at that time that this pt was not on her assignment. Pt was suctioned to get rest of meds out of mouth. Pt still speaking and not in any apparent distress. NP [Nurse Practitioner] [Resident #1's NP] notified as well as pt [Family Member], Both said thanks for letting them know. No new orders at this time. Event report to follow. A nursing note dated 4/14/23 at 1:50 p.m., written by the Assistant Director of Nursing (ADON), revealed the following documentation. Resident received medication by mouth this am [morning]. Frequent monitoring is ongoing, resident lungs sounds congesting [sic] with moist and productive cough. Resident Continues [sic] to receive suctioning as needed and tolerated well. Start [sic] chest X-ray order received to r/o [rule out] aspiration/pneumonia. Noted as ordered, resident daughter notified of new order via phone states that's a good idea. Claim number for X-ray A nursing note dated 4/15/23 at 6:15 a.m., written by Staff M, Agency, Licensed Practical Nurse (LPN), revealed the following documentation. @ [at] approx. [approximately] 5:45 a.m., the CNA [Certified Nursing Assistant] reported to this nurse that res [resident] was not breathing, this nurse toke [sic] a second nurse and upon entering the room, note res chest was not rising and falling, did not feel no movement and was unable to palpate or auscultate a pulse or a B/p [blood pressure], the second nurse also verified these findings. This nurse notified the daughter, The Dr., and the fugneral [sic] home and are now waiting for them to come have the body released to them. A phone interview was conducted on 4/26/23 at 9:16 a.m. with Staff L, Agency RN. She stated I am a Registered Nurse. This was my first time at the facility, I had not received any education at that facility. When I came on shift on 4/14/23 the night nurse and myself couldn't find a report sheet. The report sheet normally has the doctors name, code status, how the residents take meds and other notes or information about the patient. When we couldn't find a report sheet, the night shift nurse ended up writing on a piece of paper what she knew about the residents. She told me [Resident #1] was alert, oriented, and took her pills whole. Another agency nurse was supposed to be on the other medication cart, but she called off late and the ADON was on the med [medication] cart. After I got report I went to each room that I was told were my patients. Typically, you would know who's on your assignment by the report sheet, but we couldn't find it. I was trying to be as careful as possible because I was not familiar with these patients. I was trying to see what I can see from the MAR [medication administration record] and speaking with the patients. Around 8:45 a.m. to 9:00 a.m. I talked to [Resident #1] and I asked her how she was doing this morning and she said fine, and I said here are your medications, are you ready to take them and she said yes, and she opened her mouth. Mostly what [Resident #1] had was just vitamins, ones that the facility provided, she had one or two medications that were not vitamins but that's not atypical to not have some medications on the cart [medication cart]. So, I didn't question that. They were all pills, no liquid. I saw on the MAR something about a tube feed, and I remember thinking well that's weird she didn't tell me anything about that. My thought was I would look further into that and ask questions after I got my meds done because the tube feeding order wasn't due yet. So, when I put the meds in her mouth she started coughing immediately, I already had the bed positioned sitting up so they have a better way to swallow, and I had my gloves on and I scooped everything out of her mouth that I could get, and she said there's still something there. I administered about five pills. The first time I scooped out of her mouth I scooped three pills. She continued to talk to me throughout the whole process and was able to make her needs known and at that point I asked [ADON] for help. She grabbed the suction. We went into the patient's room, and she [Resident #1] would cough occasionally when we went back into the room. She said there was still something stuck and we told her we were going to suction her, and she said okay, and she opened her mouth. As we were standing there [ADON] was saying this patient is confused, she's not alert and oriented and she doesn't take anything by mouth. At that point I was made aware that this wasn't even my patient for the day. I went into the bathroom and cried because I was not really prepared for that type of situation. One, I felt so bad because this could have been prevented in multiple ways. The shift reports that are supposed to be readily available and they weren't that day. The MAR did not indicate the route of administration and that's what made me so confused because it did not indicate that meds were supposed to be given by g-tube [gastric tube]. And even after the situation I went back to make sure I didn't miss anything on the MAR, and I didn't find anything indicating this patient was NPO. In order to do that you would have to go out of the MAR and go into the medical record and with me not being familiar with this patient I should have done that earlier. After the fact, when I looked, it said she was NPO, and she had the bolus tube feed however I did not find anything about her being confused. When I pulled up the resident's MAR, I did not have to pull up a different unit or change a filter on the MAR to another unit. After she [Resident #1] was suctioned, she was still speaking, we asked if she was okay, she said yes, I took her vital signs everything was within normal limits except her blood pressure was a little bit elevated but everything else was within normal limits. Afterwards I talked to [ADON] and my agency because I didn't feel comfortable for myself, and I felt it wasn't safe for the residents. I told [ADON] the same thing and she said I couldn't leave unless I was replaced because it was only me and her on the carts. That's when she pulled a report sheet for me with my assignment, I honestly don't know where she got the sheet. I did an event report, I called the nurse practitioner, and I called the patient's daughter. They [facility staff] were all just not wanting me to leave. I was just blown away because I have never had that happen. I'm used to a very organized facility, and this was a very unorganized situation. I always thought I was careful and now I have to be more careful and making sure I'm given the right report and making sure things match up. The ARNP [Advanced Registered Nurse Practitioner] did come up and see the patient and she told me no new orders because the patient was stable, she even told me that on the phone when I called. But then later on in the afternoon they did order a chest X-ray to verify the patient had not aspirated and the daughter was notified also of the X-ray. I kept my cart [medication cart] by the patient's room and every time I would come out of a room I would go into her room and a couple times I took her vital signs. I think I charted my vitals and the monitoring. She had coughed a little bit and at one point I did suction her again. I did not listen to her lungs. I was not able to be replaced so I told them I was not going to do my second shift and I let them know this more than 2 hours in advance. When it was time to go, they did not have anyone to cover for me. I stayed late till about 3:45 p.m. and [ADON] ended up counting my narcotics with me and taking my report and I left. [ADON] was the only one on the floor when I left because I hung around waiting for relief and eventually, she told me okay I'll take report because relief is on the way. [ADON] stated to me these things happen all the time we called the doctor, we called the family, and we did what we were supposed to do but that did not make me feel better. A phone interview was conducted on 4/24/23 at 4:51 p.m. with Resident #1's Advanced Registered Nurse Practitioner (ARNP). She stated, I am familiar with [Resident #1]. I am aware of the nurse giving the resident oral medications when she was supposed to receive her medications through her g-tube. I was in the building when the nurse called me and told me she gave the resident oral medications when they were supposed to go through her g-tube. I told her I would be right up that I was in the building. I assessed the patient, and she was not in any respiratory distress. I listened to her lungs, and they were clear, she was not gasping or choking or coughing. I went and spoke with the nurse and the ADON, who was on a cart but on a different unit or assignment. Then, it was the weekend, and the ADON requested a chest X-ray, and I okayed it. I'm not typically on call on the weekends but I do answer my phone for the residents. The chest X-ray did get done. I took a picture of it because I knew this was going to be an issue and come up again. It says date of service 4/14/23 at 7:00 p.m. conclusion, slight right lower lobe and modest right upper lobe infiltrate . The patient isn't alert and oriented at baseline, so she didn't complain about any pain or distress or discomfort. At this time, the nurse was on the phone with her agency trying to get released because she was upset by what happened. The ADON was on the same unit and when I talked to her, she told me, 'I don't even know why she even gave the patient the medications because that wasn't her patient' .They didn't call me to tell me the patient had passed away and when I got there on Tuesday [4/18/23] for my rounds around 9:30 a.m. that's when I heard she died, I'm shocked. I had to call and get the X-ray results. I had the nurse, Staff J, LPN, call the X-ray company to request them and they then faxed them over and I waited at the fax to get it. I reviewed it [the imaging] and that's when I found out she died, right before I went into the room. This was definitely a medical error on the nurse's part I would expect the nurse would have stopped everything when she realized there was no medications in her cart and investigated why. The first thing I noticed when I went into the room was suction at the bedside and what made me question it was if someone is NPO there is no need to have suction at the bedside. The nurses did not set up the suction at the bedside that day it was already available. Since February, I have not had any concerns with this patient. The resident was stable, there was no indication that she would be dying anytime soon, the resident does not have a respiratory history to my knowledge, and she was ordered to receive her medications through her g-tube. She should not have had anything by mouth. An interview was conducted on 4/25/23 at 1:52 p.m. with the ADON, she stated, On Friday [4/14/23] the nurse that was supposed to work a cart [medication cart] called off late so I ended up working the cart upstairs on the second floor, I was assigned the front hall. I was on the low side and the other agency nurse was on the high side. I started from room [ROOM NUMBER] to 217 plus I had room [ROOM NUMBER] bed A and B. The ADON indicated she was assigned to be Resident #1's nurse. The ADON also stated, As I was giving medication on my side the agency nurse came to me and she said 'I need your help, I need your help, I gave [Resident #1] her medications and she started to choke I did not realize that she was a peg tube. I was told in report that she took her medication whole.' She [Resident #1] confirmed to me that she took her medication whole and then she started choking and then I realized she was a peg tube patient .' I want to say about 9:00 a.m. she [Staff L, Agency, RN] came to me and told me about the medication error. Because she told me it was about [Resident #1] I know she is a PEG tube patient. So, I stopped at the emergency code cart and grabbed the suction. Then we got to the room and [Resident #1] was talking and I noticed some pills because the nurse did tell me she tried to get the pills out by having her cough and stuff. I saw two pills on the floor. [Resident #1] was acting herself, confused, combative, resistive to care, but she was talking not making sense, but she was talking and coughing, I plugged in the suction machine, and she did sound kind of congested, so I did suction her I asked the other nurse to check the pulse ox [oximeter] because she had it in her hand at that time. I don't remember what her pulse ox reading was but myself and the other nurse were in the resident's room for a good 15-20 minutes suctioning her and making sure she was okay. Then I asked the nurse to call the nurse practitioner, to call the residents daughter, and to document, and to do the event report. The nurse practitioner came in and I told her about what happened, and she told me 'I know the nurse called me,' and she told me she was going to see the patient. The fluid that I suctioned out was not really clear it was milk-like or cloudy color so I was assuming that because of the color of the suctioned fluid that I got more pills out so I told the nurse practitioner that and I asked her if I could still give her, her medications through her peg tube and she said yes. That was about an hour after the incident. Once the resident was safe, I asked the nurse where did you get her medications to give it to her. Because that residents' medications was on my medication cart. I'm not going to lie I did not hear what she said but she did not have one card of [Resident #1's] medications on her medication cart .I don't remember ever leaving my cart unlocked. And I said to her [Staff L, Agency RN] if you did not have one card of her medications wouldn't that be a trigger for you to stop and ask a question. She said, 'well I asked the resident if she took the medications whole and she said yes.' [Resident #1's] bedside table was next to her bed, and it had the flush cup with the syringe [g-tube supplies] and I asked, that didn't trigger you to think she doesn't take her meds whole? And she said, 'well I got in report she takes her meds whole.' The ADON continued to say I have no idea whose medications she administered to [Resident #1]. The night nurse that was on shift before the agency nurse [Staff L, Agency, RN] did not have the right report sheet we use, it was a handwritten report sheet. When the agency nurse [Staff L, Agency, RN] showed me her report sheet she got from the nurse on shift before her, I looked at it but I did not look at it closely to see what was written on it but I told her [Staff L, Agency RN] that this is a teaching moment for you because then I took her to the nurses' station and showed her in the blue folder is where she can find the report sheets. I didn't document this, but I went back almost every 30 minutes to 40 minutes to check on [Resident #1]. When I didn't go back, the other nurse went back. I suctioned the resident two or three more times throughout the shift and the other nurse went back to check on her, I don't know if she suctioned her too. Then maybe it was around 1:00 p.m. I asked the CNA's [Certified Nursing Assistants] to get [Resident #1] up and put her at the nurse's station because that's where she normally sits, and she sounded fine. Then I asked the CNAs to put her back to bed. And around 1:50 p.m. she [Resident #1] sounded congested and that's when I asked the Nurse Practitioner to order a chest X-ray for her. I ordered the chest X-ray, and they came around 6:00 or 7:00 p.m Around 5:30/6:00 p.m. is when a nurse came and relieved me from my shift. I told the nurse what happened earlier that day and I told her that we have been monitoring her and I told her to pay attention and listen to her lungs and suction her as needed and I had gotten an order for the suction, and I told her that the X-ray needs to be taken then I told her to follow up. I don't know if the nurse did follow up on the results of the X-ray because I don't recall seeing any documentation . I received a text from the same nurse that relieved me because she ended up working 11:00 p.m.-7:00 a.m. and she said she went around 1:00 a.m., at the scheduled time, to bolus feed the patient [Resident #1] then the CNA's told her the patient wasn't breathing around 5:45 a.m. We don't do clinical meetings on weekends. On 4/17/23 we went over the patient had expired, they notified the daughter, and the morgue, stuff like that. There was no discussion about the medication error because I was involved so I know what we did, and we did everything. There was nothing to follow up on. When I asked the nurse to do the event [event report], she didn't do it. I ended up doing the event [event report] myself. We did end up discussing the event and what happened. I don't remember what day it was, but I did check for the X-ray, and I asked the nurse, [Staff J, LPN], did you get the X-ray? Can you call for the X-ray? We got the X-ray. It said there was infiltration of her lungs. Sometimes they [radiology company] will fax the results to us and sometimes we will call to ask if they can fax it to us. Receiving the reports, it's getting a tiny bit better now . I have been here for less than two years, but I cannot recall her [Resident #1] having respiratory issues. As long as I have been here the resident has always been NPO. On 04/25/23 at 3:46 p.m., an interview was conducted with Staff N, CNA. He stated he knew Resident #1 quite well. She was normally talkative and lively. She would carry a conversation though not always coherent. She was herself up until the last minute. This CNA stated he worked a double shift the day the resident was given the wrong medication. He stated he worked 7:00 a.m. - 3:00 p.m. and then 3:00p.m. - 11:00 p.m. He stated on that day, the resident was not herself after ingesting the medication. He said, she was groggy and was regurgitating all day. She acted like she was trying to throw up or like she had something in her throat. He stated this was not the resident's normal behavior. I had never seen her like that. She did not speak much after the medication incident. This staff member stated he learned the resident had passed away when he returned to work on Monday 4/17/23. Review of Resident #1's April medication administration record revealed on 4/14/23 between the hours of 7:00 a.m. to 11:00 a.m. Staff L, Agency RN documented the administration of 1 tablet of Cholecalciferol 25mcg(micrograms), 1 tablet of docusate sodium 100mg (milligrams), 2 tablets of acetaminophen 650mg. Staff L, Agency RN also signed off on the administration of Resident #1's order for ferrous sulfate tablet, 325mg (65mg iron) amount to administer: 7.5ml [milliliters]. Staff L, Agency RN documented Resident #1 did not receive her ordered Seroquel 300mg because Drug/Item Unavailable. The documentation revealed Resident #1 received approximately four to five tablets of medication. Each one of Resident #1's medication orders indicated her medication should be administered through her gastric tube. Review of a physician's order with a start date od 4/14/23 and an end date of 4/17/23 revealed PA Chest: LAT [lateral] Chest: Special instructions: Start [sic] chest X-ray to r/o aspiration/pneumonia once a day 07:00-23:00 [7:00 a.m.-11:00 p.m.]. Review of Resident #1's chest X-ray 2 view, with a date of service of 4/14/2023 and a report date and time of 4/14/23 at 7:07 p.m. revealed the following documentation. Conclusion: Slight right lower lobe and modest right upper lobe infiltrates (substances denser than air). This was electronically signed by the interpreting Physician on 4/14/23 at 7:07 p.m. Review of the medical record did not show a note documenting that Resident #1's physician was informed of the abnormal chest X-ray results. Review of the Facility Event Summary Report dated 4/14/23 at 10:14 a.m. revealed. Resident Name: [Resident #1] Event Type: Medication Error Creator: [Staff L, Agency, LPN] [sic] STAT [without delay]: no Status: in progress Open/Closed: Closed Closed Date/by: 4/14/23 [Staff L, Agency, LPN] [sic] Description: RN given report by night shift stating this pt was on assignment and took meds whole. Night shift nurse and this RN attempted to locate assignment sheets unsuccessfully. This RN went into pt room, verified pt, and asked pt if she was able to take meds [medications]. Pt stated yes and opened her mouth. RN administered meds and pt immediately began to cough. RN grabbed napkin and asked pt to spit them out. Pt spit pills out into napkin and told RN that she still felt something was stuck. Pt still able to speak and cough through event. RN verified on report paper that was given with writing that had right pt and then went to seek out staff RN who stated that this pt is confused, NPO, and not on this RN assignment. PT suctioned to remove rest of meds. [Resident #1's Nurse Practitioner] notified as well as [Family Member]. No new orders at this time and [Family Member] thankful for information. Attending faxed: No Physician notified: Yes, date and time 4/14/23 10:30 a.m. Note: no new orders Family notified: Yes, date and time 4/14/23 10:30 a.m. Note: blank Care plan reviewed: Yes, date and time 4/14/23 10:30 a.m. Note: blank Evaluation: pt being monitored Further review of the Facility Event Summary Report dated 4/14/23 at 5:56 p.m. revealed Resident Name: [Resident #1] Event Type: Medication Error Creator: [ADON] STAT: No Status: completed Open/Closed: Open Closed Date/BY: blank e-signed: blank Description: Medication error Review of Resident #1's vital signs revealed on 4/14/23 at 10:38 a.m. the resident's oxygen saturation reading was 91% on room air, her pulse was high at 122 beats per minute. Her respiratory rate was 16 breaths per minute, and her blood pressure was 178/87 mm HG (millimeters of mercury). According to the Cleveland Clinic, normal adult vital signs ranges include blood pressure, 90/60 to 120/80, Pulse 60 to 100 beats per minute, respiratory rate 12 to 18 breaths per minute. https://my.clevelandclinic.org/health/articles/10881-vital-signs. Also, according to the Cleveland Clinic, a healthy oxygen saturation is typically above 90%. https://health.clevelandclinic.org/should-you-get-a-pulse-oximeter-to-measure-blood-oxygen-levels/. There were no other vitals documented in the medical record after 4/14/23 at 10:38 a.m. Further review of Resident #1's vital signs obtained in the month of April revealed her oxygen saturations were 96% and 99%. Her documented pulse readings for the month of April were between 74 beats per minute and 96 beats per minute and her blood pressures were between 116/57 mm Hg and 146/62 mm Hg. On 4/24/23 at 3:30 p.m., an interview was conducted with Staff J, LPN. She stated she had worked at the facility since 2019 and worked with Resident #1 every time she worked. She indicated she was very close with Resident #1, and it broke her heart when she found out she died. She said she could not understand how the nurse could have given the medications orally because all her orders said to administer her medications by g-tube and her diet order said she's NPO. Staff J, LPN said Resident #1 was alert, very confused, but a sweetheart and could be feisty at times. Staff J, LPN indicated Resident #1 had pneumonia before but that was a very long time ago and even then, her oxygen saturations were always good. Staff J, LPN indicated that other than having the pneumonia a long time ago Resident #1 did not have a history of any respiratory distress. On 04/25/23 at 3:50 p.m., an interview was conducted with Staff O, CNA, who had worked at the facility for two years. She stated she worked with the resident often, but not during the time of the incident. She stated she knew the resident well, she was out-going, vocal and could hold a conversation. She stated she worked weekends and had last seen the resident the weekend before. She stated the resident was herself as far as her behaviors were concerned. She was not sick, at least not the last time I saw her . On 04/25/23 at 3:53 p.m., an interview was conducted with Staff P, CNA. She stated she worked with the resident sometimes and was working the night she passed but was not assigned to the resident. She stated she was in her assigned area throughout the night. She stated she did not observe any unusual behavior or incident. There was no commotion at any given time. She stated, everyone was doing their usual thing, and she mostly stayed at her assigned area. She stated from the nurse's unit she could see the resident's room. She said, I did not notice unusual activity throughout the night. She stated the CNA who was assigned to the resident had notified her that the Resident had passed away . On 04/25/23 at 3:57 p.m., an interview was conducted with Staff Q, CNA. She stated she knew the resident very well. She stated as far as she was concerned the resident was her herself. There was nothing unusual when I last saw her, probably two days prior to the incident. She stated the resident had her personality and would scream at you every once in a while . On 4/24/23 at 4:06 p.m. an interview was conducted with the Director of Rehab. She stated . She [Resident #1] is not able to respond to a question appropriately. She is verbal but clearly expressing wants and needs, she's not able to do that, she's not nonverbal but she was nonsensical. Her vascular dementia, psych diagnoses, confusion, and she's a silent aspirator and that is what lead her to staying NPO because she did have the g-tube replaced. Speech [Speech Therapy] had tried to put her on a pleasure diet but due to her confusion, she did not have the compensatory strategies for safe swallowing. She wasn't able to comprehend and follow through with swallowing. When she first came in, she did not have a peg tube, then she was starting to cough and choke more. Then later during her stay she got the peg tube. There has been a decline as she has been here [at the facility]. There was no confusion, she was NPO. If I went in with food she would say yes because she doesn't understand she can't have that. She has no awareness of her deficit. The Director of Rehabilitations indicated she was not here [at the facility] [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews with the Nursing Home Administrator, the Director of Nursing, Assistant Director of Nursing, nursing staff, certified nursing staff, the resident's family member, attending Physician, Nurse Practitioner and Medical Director, review of the of the facilities policies and the resident's medical record, the facility failed to prevent and report neglect for one (Resident #1) of three residents reviewed for gastric tube medications administration. The facility failed to prevent and report neglect for Resident #1 who had a known cognitive deficit, a gastric tube in place, who had an order to receive nothing by mouth and orders to receive her medications through her gastric tube. On [DATE] Staff L, Agency, Registered Nurse (RN) neglected to ensure she received an accurate resident assignment and report, neglected to review physicians orders, neglected to clarify missing medications, neglected to inquire about enteral feeding orders, and neglected to review Resident #1's cognitive status before asking Resident #1 if she was ready to take her medications. Staff L, Agency, RN proceeded to administer approximately 4-5 tablets of medications orally to Resident #1. Resident #1 sustained immediate respiratory complications that required her to be suctioned. Resident #1 was neglected to be closely monitored after a medication error occurred. Approximately five hours after the medication error occurred Resident #1 sustained a change in her respiratory status requiring a STAT (without delay) chest X-ray to rule out aspiration/pneumonia. The X-ray resulted on [DATE] at 7:07 p.m. and the facility neglected to inform a physician of the abnormal X-ray result and on [DATE] at approximately 5:45 a.m., Resident #1 died, and her body was transported to a funeral home. This failure created a situation that resulted in a worsened condition and death to Resident #1 and resulted in the determination of Immediate Jeopardy beginning on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the scope and severity reduced to a D. Findings included: Review of the facility's reportable events log for the month of April revealed no reportable events related to Resident #1. The Nursing Home Administrator (NHA)was interviewed on [DATE] at 11:10 a.m. He said, The nurse documented, from my recollection, to paraphrase, she administered PO [by mouth] meds to a NPO [nothing by mouth] patient then had requested for her to spit them out, resident responded by spitting the meds out, and the ADON [Assistant Director of Nursing] who was present, adjacent on the hallway she was working a cart that day. I had an ice machine issue so I had come in for that and the ADON said can you talk to the nurse, so I did, and she [Staff L, Agency, Registered Nurse [RN] was acting strange, she said her shift report is not great and she said she had a problem with shift report. When I talked to her, she had the computer screen pulled up and it said, clearly highlighted, that the patient was NPO. She said the patient spit the meds out and the patient was suctioned. This is an agency nurse, and I was there to calm her down. I literally just pointed to the screen and on the left-hand side of the screen, I'm assuming it was the MAR [medication administration record], it was blue I believe, maybe green, you'll have to excuse me I'm colored blind, it was rectangular, it was enough for me to look up and it was there that the patient was NPO. So, then I called [employee of the agency company], he is an employee of [Agency Company], the nursing agency, and he is the individual who is the one I call when I have a concern about one of their staff members acting weird and I communicated my concern with [employee of the agency company] and I talked to him and told him she was acting weird, I felt she was acting odd because the nurse kept saying I have to go, I gotta go, and I said wait you can't abandon your shift and [employee of the agency company] said that he got the message that she wanted leave. And at that point I said okay let's put her on the do not return list. She [Staff L, Agency, RN] initially stated her report was good and her report came from another [Agency Company] nurse. I saw her report had typed information and handwritten information on it. and I told her here is your report, here is your computer, and I said you can't leave. You're not walking out right now. Then she seemed to calm down and proceed with her assignment. I don't know when she left. That was one of a thousand, many things, in a day. She was scheduled to work 7-3 [7:00 a.m.- 3:00 p.m.] and 3-11 [3:00 p.m.-11:00 p.m.] on [DATE]. I was made aware of a med [medication] error on [DATE], let's call it early morning, of the wrong route and the patient spit the pills out and needed suction . I know she died. I found out the following day. I don't recollect how I was made aware she died. I don't recall. We have morning meetings five days a week Monday through Friday. There's a clinical meeting from 9:00 a.m.-9:30 a.m. I believe that in the morning meeting on Friday [DATE] the ADON was on the cart. She told me there was two call outs and that's when the ADON says to me can you talk to this nurse because she was holding down the cart and she couldn't be as involved. There was a clinical meeting that day [[DATE]], but it was a bit shortened given the ADON had to go on the cart .An event that occurs over the weekend are reviewed on Monday morning unless it is a reportable event then it would be reported at the time of the event. As part of the census piece of the morning meeting I was made aware the resident passed. At that point I did read the note and as far as her spitting the meds out and being suctioned I did not see how that had anything to do with her passing, also that the family was made aware of both the incident and her passing. I did not see any connectivity .The staff says she follows commands she's a politely delightful lady. I glanced at her when I went up to talk to the agency nurse and she was in a low bed, she was not in distress, she did make eye contact with me. She did not appear to be in any distress from my perspective. We don't typically report med [medication] errors to the abuse hotline. I did not report the med error to the abuse hotline. Sitting here right now, she spit the meds out and she was suctioned. Review of Resident #1's face sheet revealed she was an [AGE] year-old female admitted on [DATE] with medical diagnoses that included but were not limited to, gastrostomy status (since [DATE]), dysphagia, oropharyngeal phase, need for assistance with personal care oral phase, vascular dementia with behavioral disturbances. Review of Resident #1's quarterly Minimum Data Set assessment dated [DATE], section C, cognitive patterns, revealed a brief interview for mental status (BIMS) score of 5 out of 15 which indicated severely impaired cognition. Review of Section K, Swallowing/Nutritional status revealed .Feeding tube-nasogastric or abdominal (PEG) [percutaneous endoscopic gastrostomy tube] . A physician's order review revealed a diet order for NPO, this order started on [DATE] and was discontinued after her death on [DATE]. A physician's order which started on [DATE] and was discontinued on [DATE] revealed May crush medications unless contraindicated. A physician's order which started on [DATE] and was discontinued on [DATE] revealed Enteral feeding: Flush tube with 30cc [cubic centimeter] water before and after every administering medications [sic] and 5cc between each medication every shift day evening night. Review of the speech therapy discharge summary with a date of service of [DATE]-[DATE], revealed on [DATE] a MBSS (modified barium swallow study) was completed, and the resident became NPO due to severe pharyngeal stasis and deep penetration to VF (video fluoroscopy) without clearance. A percutaneous endoscopic gastrostomy (PEG) tube was placed on [DATE] and the resident was discharged from speech therapy on [DATE] with orders for NPO with PEG placement for all nutrition/hydration/medication; severe impairment. Review of the nursing progress note dated [DATE] at 9:47 a.m. written by Staff L, Agency, LPN [sic] RN revealed the following documentation. This RN was given report by night shift stating that this pt [patient] was on assignment and took meds whole. Both nurses attempted to locate report sheets unsuccessfully. Verbal report given with handwritten notes for how pts [patients] take meds [medications]. This RN was not informed that this pt had a PEG tube or was confused. This RN went into pt room and verified pt, spoke to pt stating had her medications and asked pt to verify that she took pill whole. Pt stated yes so RN proceeded. Pt immediately started coughing and RN had pt spit meds out. Pt was speaking and following commands but said she still felt that something was stuck. This RN went and sought out help and informed staff RN of what had taken place and was informed at that time that this pt was not on her assignment. Pt was suctioned to get rest of meds out of mouth. Pt still speaking and not in any apparent distress. NP [Nurse Practitioner] [Resident #1's NP] notified as well as pt daughter [Family member], Both said thanks for letting them know. No new orders at this time. Event report to follow. A nursing note dated [DATE] at 1:50 p.m., written by the ADON, revealed the following documentation. Resident received medication by mouth this am [morning]. Frequent monitoring is ongoing, resident lungs sounds congesting [sic] with moist and productive cough. Resident Continues [sic] to receive suctioning as needed and tolerated well. Start [sic] chest X-ray order received to r/o [rule out] aspiration/pneumonia. Noted as ordered, resident daughter notified of new order via phone states that's a good idea. Claim number for X-ray A nursing note dated [DATE] at 6:15 a.m., written by Staff M, Agency, Licensed Practical Nurse (LPN), revealed the following documentation. @ [at] approx. [approximately] 5:45 a.m., the CNA [Certified Nursing Assistant] reported to this nurse that res [resident] was not breathing, this nurse toke [sic], a second nurse and upon entering the room, note res chest was not rising and falling, did not feel no movement and was unable to palpate or auscultate a pulse or a B/p [blood pressure], the second nurse also verified these findings. This nurse notified the daughter, The Dr. and the fugneral [sic] home and are now waiting for them to come have the body released to them. A phone interview was conducted on [DATE] at 9:16 a.m. with Staff L, Agency, RN. She stated I am a Registered Nurse [RN]. This was my first time at the facility, I had not received any education at that facility. When I came on shift on [DATE] the night nurse and myself couldn't find a report sheet. The report sheet normally has the doctors name, code status, how the residents take meds and other notes or information about the patient. When we couldn't find a report sheet, the night shift nurse ended up writing on a piece of paper what she knew about the residents. She told me [Resident #1] was alert, oriented, and took her pills whole. Another agency nurse was supposed to be on the other medication cart, but she called off late and the ADON was on the med [medication] cart. After I got report I went to each room that I was told were my patients. Typically, you would know who's on your assignment by the report sheet, but we couldn't find it. I was trying to be as careful as possible because I was not familiar with these patients. I was trying to see what I can see from the MAR and speaking with the patients. Around 8:45 a.m. to 9:00 a.m. I talked to [Resident #1] and I asked her how she was doing this morning and she said fine, and I said here are your medications, are you ready to take them and she said yes, and she opened her mouth. Mostly what [Resident #1] had was just vitamins, ones that the facility provided, she had one or two medications that were not vitamins but that's not atypical to not have some medications on the cart [medication cart]. So, I didn't question that. They were all pills, no liquid. I saw on the MAR something about a tube feed, and I remember thinking well that's weird she didn't tell me anything about that. My thought was I would look further into that and ask questions after I got my meds done because the tube feeding order wasn't due yet. So, when I put the meds in her mouth she started coughing immediately, I already had the bed positioned sitting up so they have a better way to swallow, and I had my gloves on and I scooped everything out of her mouth that I could get, and she said there's still something there. I administered about 5 pills. The first time I scooped out of her mouth I scooped 3 pills. She continued to talk to me throughout the whole process and was able to make her needs known and at that point I asked [ADON] for help. She grabbed the suction. We went into the patient's room, and she [Resident #1] would cough occasionally when we went back into the room. She said there was still something stuck and we told her we were going to suction her, and she said okay, and she opened her mouth. As we were standing there [ADON] was saying this patient is confused, she's not alert and oriented and she doesn't take anything by mouth. At that point I was made aware that this wasn't even my patient for the day. I went into the bathroom and cried because I was not really prepared for that type of situation. One, I felt so bad because this could have been prevented in multiple ways. The shift reports that are supposed to be readily available and they weren't that day. The MAR did not indicate the route of administration and that's what made me so confused because it did not indicate that meds were supposed to be given by g-tube [gastric tube]. And even after the situation I went back to make sure I didn't miss anything on the MAR, and I didn't find anything indicating this patient was NPO. In order to do that you would have to go out of the MAR and go into the medical record and with me not being familiar with this patient I should have done that earlier. After the fact, when I looked, it said she was NPO, and she had the bolus tube feed however I did not find anything about her being confused. When I pulled up the resident's MAR, I did not have to pull up a different unit or change a filter on the MAR to another unit. After she [Resident #1] was suctioned, she was still speaking, we asked if she was okay, she said yes, I took her vital signs everything was within normal limits except her blood pressure was a little bit elevated but everything else was within normal limits. Afterwards I talked to [ADON] and my agency because I didn't feel comfortable for myself, and I felt it wasn't safe for the residents. I told [ADON] the same thing and she said I couldn't leave unless I was replaced because it was only me and her on the carts. That's when she pulled a report sheet for me with my assignment, I honestly don't know where she got the sheet. I did an event report, I called the nurse practitioner, and I called the patient's daughter. They [facility staff] were all just not wanting me to leave. I was just blown away because I have never had that happen. I'm used to a very organized facility, and this was a very unorganized situation. I always thought I was careful and now I have to be more careful and making sure I'm given the right report and making sure things match up. The ARNP [Advanced Registered Nurse Practitioner] did come up and see the patient and she told me no new orders because the patient was stable, she even told me that on the phone when I called. But then later on in the afternoon they did order a chest X-ray to verify the patient had not aspirated and the daughter was notified also of the X-ray. I kept my cart [medication cart] by the patient's room and every time I would come out of a room I would go into her room and a couple times I took her vital signs. I think I charted my vitals and the monitoring. She had coughed a little bit and at one point I did suction her again. I did not listen to her lungs. I was not able to be replaced so I told them I was not going to do my second shift and I let them know this more than two hours in advance. When it was time to go, they did not have anyone to cover for me. I stayed late till about 3:45 p.m. and [ADON] ended up counting my narcotics with me and taking my report and I left. [ADON] was the only one on the floor when I left because I hung around waiting for relief and eventually, she told me okay I'll take report because relief is on the way. [ADON] stated to me these things happen all the time we called the doctor, we called the family, and we did what we were supposed to do but that did not make me feel better. An interview was conducted on [DATE] at 1:52 p.m. with the ADON, she stated, On Friday [[DATE]] the nurse that was supposed to work a cart [medication cart] called off late so I ended up working the cart upstairs on the second floor, I was assigned the front hall. I was on the low side and the other agency nurse was on the high side. I started from room [ROOM NUMBER] to 217 plus I had room [ROOM NUMBER] bed A and B. The ADON indicated she was assigned to be Resident #1's nurse. The ADON also stated, As I was giving medication on my side the agency nurse came to me and she said 'I need your help, I need your help, I gave [Resident #1] her medications and she started to choke I did not realize that she was a peg tube. I was told in report that she took her medication whole. She [Resident #1] confirmed to me that she took her medication whole and then she started choking and then I realized she was a peg tube patient' .I want to say about 9:00 a.m. she [Staff L, Agency, RN] came to me and told me about the medication error. Because she told me it was about [Resident #1] I know she is a peg tube patient. So, I stopped at the emergency code cart and grabbed the suction. Then we got to the room and [Resident #1] was talking and I noticed some pills because the nurse did tell me she tried to get the pills out by having her cough and stuff. I saw two pills on the floor. [Resident #1] was acting herself, confused, combative, resistive to care, but she was talking not making sense, but she was talking and coughing, I plugged in the suction machine, and she did sound kind of congested, so I did suction her I asked the other nurse to check the pulse ox [oximeter] because she had it in her hand at that time. I don't remember what her pulse ox reading was but myself and the other nurse were in the resident's room for a good 15-20 minutes suctioning her and making sure she was okay. Then I asked the nurse to call the nurse practitioner, to call the residents daughter, and to document, and to do the event report. The nurse practitioner came in and I told her about what happened, and she told me 'I know the nurse called me,' and she told me she was going to see the patient. The fluid that I suctioned out was not really clear it was milk-like or cloudy color so I was assuming that because of the color of the suctioned fluid that I got more pills out so I told the nurse practitioner that and I asked her if I could still give her, her medications through her peg tube and she said yes. That was about an hour after the incident. Once the resident was safe, I asked the nurse where did you get her medications to give it to her. Because that residents' medications was on my medication cart. I'm not going to lie I did not hear what she said but she did not have one card of [Resident #1's] medications on her medication cart .I don't remember ever leaving my cart unlocked. And I said to her [Staff L, Agency RN] if you did not have one card of her medications wouldn't that be a trigger for you to stop and ask a question. She said, 'well I asked the resident if she took the medications whole and she said yes.' [Resident #1's] bedside table was next to her bed, and it had the flush cup with the syringe [g-tube supplies] and I asked, that didn't trigger you to think she doesn't take her meds whole? And she said, 'well I got in report she takes her meds whole.' The ADON continued to say I have no idea whose medications she administered to [Resident #1]. The night nurse that was on shift before the agency nurse [Staff L, Agency, RN] did not have the right report sheet we use, it was a handwritten report sheet. When the agency nurse [Staff L, Agency, RN] showed me her report sheet she got from the nurse on shift before her, I looked at it but I did not look at it closely to see what was written on it but I told her [Staff L, Agency RN] that this is a teaching moment for you because then I took her to the nurses' station and showed her in the blue folder is where she can find the report sheets. I didn't document this, but I went back almost every 30 minutes to 40 minutes to check on [Resident #1]. When I didn't go back, the other nurse went back. I suctioned the resident two or three more times throughout the shift and the other nurse went back to check on her, I don't know if she suctioned her too. Then maybe it was around 1:00 p.m. I asked the CNAs to get [Resident #1] up and put her at the nurses' station because that's where she normally sits, and she sounded fine. Then I asked the CNAs to put her back to bed. And around 1:50 p.m. she [Resident #1] sounded congested and that's when I asked the Nurse Practitioner to order a chest X-ray for her. I ordered the chest X-ray, and they came around 6:00 or 7:00 p.m . Around 5:30/6:00p.m. is when a nurse came and relieved me from my shift. I told the nurse what happened earlier that day and I told her that we have been monitoring her and I told her to pay attention and listen to her lungs and suction her as needed and I had gotten an order for the suction and I told her that the X-ray needs to be taken then I told her to follow up. I don't know if the nurse did follow up on the results of the X-ray because I don't recall seeing any documentation . I received a text from the same nurse that relieved me because she ended up working 11:00 p.m.-7:00 a.m. and she said she went around 1:00 a.m., at the scheduled time, to bolus feed the patient [Resident #1] then the CNA's told her the patient wasn't breathing around 5:45 a.m. We don't do clinical meetings on weekends. On [DATE] we went over the patient [Resident #1] had expired, they notified the daughter, and the morgue, stuff like that. There was no discussion about the medication error because I was involved so I know what we did, and we did everything. There was nothing to follow up on. When I asked the nurse to do the event [event report] she didn't do it. I ended up doing the event myself . On that Monday [DATE] I attended the morning meeting, the entire team was there, myself, Unit Manager was there, Therapy Director, activities, social services, Administrator, Dietary manger, I'm not sure if laundry director and maintenance was there but the DON was not here, she was on vacation. For the morning meetings, with the Administrator, all the department heads are at that meeting. At this morning meeting the event was not discussed . At morning meeting, I don't recall if the death of the resident was discussed. But there is a census discussion because admission talks about who went to the hospital, who was admitted , and who died. There was not a discussion about it, but it was probably mentioned because we go over the census. I don't remember what day it was, but I did check for the X-ray, and I asked the nurse, [Staff J, LPN], did you get the X-ray? Can you call for the X-ray? We got the X-ray and it said there was infiltration of her lungs. Sometimes they [radiology company] will fax the results to us and sometimes we will call to ask if they can fax it to us. Receiving the reports, it's getting a tiny bit better now . I have been here for less than two years, but I cannot recall her [Resident #1] having respiratory issues. As long as I have been here the resident has always been NPO. A phone interview was conducted on [DATE] at 4:51 p.m. with Resident #1's Advanced Registered Nurse Practitioner (ARNP). She stated I am familiar with [Resident #1]. I am aware of the nurse giving the resident oral medications when she was supposed to receive her medications through her g-tube. I was in the building when the nurse called me and told me she gave the resident oral medications when they were supposed to go through her g-tube. I told her I would be right up that I was in the building. I assessed the patient, and she was not in any respiratory distress. I listened to her lungs, and they were clear, she was not gasping or choking or coughing. I went and spoke with the nurse and the ADON, who was on a cart but on a different unit or assignment. Then, it was the weekend, and the ADON requested a chest X-ray, and I okayed it. I'm not typically on call on the weekends but I do answer my phone for the residents. The chest X-ray did get done. I took a picture of it because I knew this was going to be an issue and come up again. It says date of service [DATE] at 7:00 p.m. conclusion, slight right lower lobe and modest right upper lobe infiltrate [When interpreting the x-ray, the radiologist will look for white spots in the lungs (called infiltrates) that identify an infection. This exam will also help determine if you have any complications related to pneumonia such as abscesses or pleural effusions (fluid surrounding the lungs). Pneumonia | Lung inflammation - Diagnosis, Evaluation and Treatment, radiologyinfo.org, https://www.radiologyinfo.org > info > pneumonia]. The patient isn't alert and oriented at baseline, so she didn't complain about any pain or distress or discomfort. At this time, the nurse was on the phone with her agency trying to get released because she was upset by what happened. The ADON was on the same unit and when I talked to her, she told me, 'I don't even know why she even gave the patient the medications because that wasn't her patient .' They didn't call me to tell me the patient had passed away and when I got there on Tuesday [[DATE]] for my rounds around 9:30 a.m. that's when I heard she died, I'm shocked. I had to call and get the X-ray results. I had the nurse, Staff J, LPN, call the X-ray company to request them and they then faxed them over and I waited at the fax to get it. I reviewed it [the imaging] and that's when I found out she died, right before I went into the room. This was definitely a medical error on the nurse's part I would expect the nurse would have stopped everything when she realized there was no medications in her cart and investigated why. The first thing I noticed when I went into the room was suction at the bedside and what made me question it was if someone is NPO there is no need to have suction at the bedside. The nurses did not set up the suction at the bedside that day it was already available. Since February, I have not had any concerns with this patient. The resident was stable, there was no indication that she would be dying anytime soon, the resident does not have a respiratory history to my knowledge, and she was ordered to receive her medications through her g-tube. She should not have had anything by mouth. On [DATE] at 3:46 p.m., an interview was conducted with Staff N, CNA. He stated he knew Resident #1 quite well. She was normally talkative and lively. She would carry a conversation though not always coherent. She was herself up until the last minute. This CNA stated he worked a double shift the day the resident was given the wrong medication. He stated he worked 7:00 a.m. - 3:00 p.m. and then 3:00 p.m. - 11:00 p.m. He stated on that day, the resident was not herself after ingesting the medication. He said, she was groggy and was regurgitating all day. She acted like she was trying to throw up or like she had something in her throat. He stated this was not the resident's normal behavior. I had never seen her like that. She did not speak much after the medication incident. This staff member stated he learned the resident had passed away when he returned to work on Monday [DATE]. A phone interview was conducted on [DATE] at 10:26 a.m. with Resident #1's family member. She stated, I live away, I am actually getting ready to leave for her [Resident #1] funeral this morning. It's not that her death wasn't unexpected, my mom has had deteriorating heath for years and she had a feeding tube. They [the facility] would get her up and stuff. The last time I saw my mom was June of last year. I feel she has deteriorated over the last few years. And not just at that nursing facility at her ALF [Assisted Living Facility] she was deteriorating, and I don't know, I don't want to press any issues. The only thing I know and I don't know if it has anything to with it or not but, the day before her death a nurse, who must have been unfamiliar with my mom had taken my mom's medications to her and asked my mother if she can take her pills, my mom said yes and I mean, don't ask my mother a question like that she can't answer you. Mom immediately started choking and she spit some of the pills out and they had to suction her, and they told me they think they got it all out. However, that afternoon they called me and told me they were going to do an X-ray to rule out aspiration. I never heard anything back about that. I don't know if the X-ray was done or what it said if it was done. I hate if that's what happened to my mom. I guess they went in, and she was sleeping, and she was breathing, then they went in again and checked on her and she wasn't breathing . An interview was conducted with the Director of Nursing (DON) on [DATE] at 5:50 p.m. She said, I was on vacation for the past seven days, I left on [DATE] and I came back this morning [DATE]. So, I only know what I have read. From the notes that I read I had an agency nurse here and she gave her meds and not through the g-tube because she is NPO. My ADON was here, and she is the one who was covering for me. I'm not sure if my ADON was here at the time of the event. I tried to call her. My expectation was to follow up and it seems like they did that. From reading the notes it seems like they suctioned all the meds out and they ordered a chest X-ray, and my expectation is to follow through and keep the patient safe . The process of change of shift report is to go over the status of each resident. To go over if they are NPO, if they're on IV [intravenous] meds, stuff like that. That happens at change of shift for not just the nurses but the CNA's as well . I see her [Resident #1] BIMS is four. I would not expect the nurse to be asking the resident how they take their pills. That would not be accurate. I would expect the nurse to have read the assignment sheet and when she pulled up all the residents meds it says via g-tube and the diet order was NPO. If you're pulling up the medications to make sure you're giving the medication to the correct resident, the correct dose, the correct route. She would have seen that the patient gets her meds through her g-tube. Agency nurses that are coming here for the first time. We actually have them come 30 minutes earlier to show them how this facility works. We don't teach them how to be a nurse and how to pass meds, but we do teach them how this facility works. I'm not sure if she has worked here before .We have a separate system for our X-ray results. In order to have an X-ray there has to be an order and that looks like it was ordered at 1:50 p.m. on [DATE] and it was ordered STAT [without delay) and usually that's done within four hours. The DON reviewed the medical record and confirmed she did not see any documentation related to the physician being notified of the chest X-ray results .What I know is that she [Resident#1] was given medication in the wrong route, I need to look at the X-ray to see what that showed, then she expired. I cannot say what her cause of death was. I cannot say what I would have done differently because I still have questions about the event, and I have not spoke to the ADON. So, I am still doing my inve[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility policy review, facility document review, and interviews with the Nursing Home Administrator, the Director of Nursing, Assistant Director of Nursing, nursing staff, certified nursing staff, the resident's family member, attending Physician, Nurse Practitioner, and Medical Director, the facility failed to fully investigate the neglectful events surrounding an unexpected death for one (Resident #1) out of three residents reviewed for gastric tube medications administration. Resident #1 was a known cognitively impaired, clinically stable resident who had orders to receive nothing by mouth, and orders to receive her medications through her gastric tube. On [DATE] Staff L, Agency, Registered Nurse (RN) neglected to ensure she received an accurate resident assignment and report, neglected to review physicians orders, neglected to clarify missing medications, neglected to inquire about enteral feeding orders, and neglected to review Resident #1's cognitive status before asking Resident #1 if she was ready to take her medications Staff L, Agency, RN proceeded to administer approximately 4-5 tablets of medications orally to Resident #1. Resident #1 sustained immediate respiratory complications that required her to be suctioned. Resident #1 was neglected to be closely monitored after a medication error occurred. Approximately five hours after the medication error occurred Resident #1 sustained a change in her respiratory status requiring a STAT (without delay) chest X-ray to rule out aspiration/pneumonia. The X-ray resulted on [DATE] at 7:07 p.m. and the facility neglected to inform a physician of the abnormal X-ray result and on [DATE] at approximately 5:45 a.m. Resident #1 died. This failure created a situation that resulted in a worsened condition and death to Resident #1 and resulted in the determination of Immediate Jeopardy beginning on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the scope and severity reduced to a D. Findings included: The Nursing Home Administrator (NHA)was interviewed on [DATE] at 11:10 a.m. He said, The nurse documented, from my recollection, to paraphrase, she administered PO [by mouth] meds to a NPO [nothing by mouth] patient then had requested for her to spit them out, resident responded by spitting the meds out, and the ADON [Assistant Director of Nursing] who was present, adjacent on the hallway she was working a cart that day. I had an ice machine issue so I had come in for that and the ADON said can you talk to the nurse, so I did, and she [Staff L, Agency, RN] was acting strange, she said her shift report is not great and she said she had a problem with shift report. When I talked to her, she had the computer screen pulled up and it said, clearly highlighted, that the patient was NPO. She said the patient spit the meds out and the patient was suctioned. This is an agency nurse, and I was there to calm her down. I literally just pointed to the screen and on the left-hand side of the screen, I'm assuming it was the MAR [medication administration record], it was blue I believe, maybe green, you'll have to excuse me I'm colored blind, it was rectangular, it was enough for me to look up and it was there that the patient was NPO. So, then I called [employee of the agency company], he is an employee of [Agency Company], the nursing agency, and he is the individual who is the one I call when I have a concern about one of their staff members acting weird and I communicated my concern with [employee of the agency company] and I talked to him and told him she was acting weird, I felt she was acting odd because the nurse kept saying I have to go, I gotta go, and I said wait you can't abandon your shift and [employee of the agency company] said that he got the message that she wanted leave. And at that point I said okay let's put her on the do not return list. She [Staff L, Agency, RN] initially stated her report was good and her report came from another [Agency Company] nurse. I saw her report had typed information and handwritten information on it. and I told her here is your report, here is your computer, and I said you can't leave. You're not walking out right now. Then she seemed to calm down and proceed with her assignment. I don't know when she left. That was one of a thousand, many things, in a day. She was scheduled to work 7-3 [7:00 a.m.- 3:00 p.m.] and 3-11 [3:00 p.m.-11:00 p.m.] on [DATE]. I was made aware of a med [medication] error on [DATE], let's call it early morning, of the wrong route and the patient spit the pills out and needed suction . I know she died. I found out the following day. I don't recollect how I was made aware she died. I don't recall. We have morning meetings five days a week Monday through Friday. There's a clinical meeting from 9:00 a.m. - 9:30 a.m. I believe that morning meeting on Friday [DATE] the ADON was on the cart. She told me there was two call outs and that's when the ADON says to me can you talk to this nurse because she was holding down the cart and she couldn't be as involved. There was a clinical meeting that day [[DATE]], but it was a bit shortened given the ADON had to go on the cart .An event that occurs over the weekend are reviewed on Monday morning unless it is a reportable event then it would be reported at the time of the event. As part of the census piece of the morning meeting I was made aware the resident passed. At that point I did read the note and as far as her spitting the meds out and being suctioned I did not see how that had anything to do with her passing, also that the family was made aware of both the incident and her passing. I did not see any connectivity .The staff says she follows commands she's a politely delightful lady. I glanced at her when I went up to talk to the agency nurse and she was in a low bed, she was not in distress, she did make eye contact with me. She did not appear to be in any distress from my perspective. We don't typically report med [medication] errors to the abuse hotline. I did not report the med error to the abuse hotline. Sitting here right now, she spit the meds out and she was suctioned. Review of the facility's reportable events log for the month of April revealed no reportable events related to Resident #1. Review of Resident #1's face sheet revealed she was an [AGE] year-old female resident admitted on [DATE] with medical diagnoses that included but were not limited to, gastrostomy status (since [DATE]), dysphagia, oropharyngeal phase, need for assistance with personal care oral phase, vascular dementia with behavioral disturbances. Review of Resident #1's quarterly Minimum Data Set assessment dated [DATE], section C, cognitive patterns, revealed a brief interview for mental status (BIMS) score of 5 out of 15 which indicated severely impaired cognition. Review of Section K, Swallowing/Nutritional status revealed .Feeding tube-nasogastric or abdominal (PEG) [percutaneous endoscopic gastrostomy tube] . A physician's order review revealed a diet order for NPO, this order started on [DATE] and was discontinued after her death on [DATE]. A physician's order which started on [DATE] and was discontinued on [DATE] revealed May crush medications unless contraindicated. A physician's order which started on [DATE] and was discontinued on [DATE] revealed Enteral feeding: Flush tube with 30cc [cubic centimeter] water before and after every administering medications [sic] and 5cc between each medication every shift day evening night. Review of the speech therapy discharge summary with a date of service of [DATE]-[DATE], revealed on [DATE] a MBSS (modified barium swallow study) was completed, and the resident became NPO due to severe pharyngeal stasis and deep penetration to VF (video fluoroscopy) without clearance. A percutaneous endoscopic gastrostomy [PEG] tube was placed on [DATE] and the resident was discharged from speech therapy on [DATE] with orders for NPO with PEG placement for all nutrition/hydration/medication; severe impairment. Review of the nursing progress note dated [DATE] at 9:47 a.m. written by Staff L, Agency, LPN [sic] revealed the following documentation. This RN was given report by night shift stating that this pt [patient] was on assignment and took meds whole. Both nurses attempted to locate report sheets unsuccessfully. Verbal report given with handwritten notes for how pts [patients] take meds [medications]. This RN was not informed that this pt had a PEG tube or was confused. This RN went into pt room and verified pt, spoke to pt stating had her medications and asked pt to verify that she took pill whole. Pt stated yes so RN proceeded. Pt immediately started coughing and RN had pt spit meds out. Pt was speaking and following commands but said she still felt that something was stuck. This RN went and sought out help and informed staff RN of what had taken place and was informed at that time that this pt was not on her assignment. Pt was suctioned to get rest of meds out of mouth. Pt still speaking and not in any apparent distress. NP [Nurse Practitioner] [Resident #1's NP] notified as well as pt daughter [Family Member], Both said thanks for letting them know. No new orders at this time. Event report to follow. A nursing note dated [DATE] at 1:50 p.m., written by the ADON, revealed the following documentation. Resident received medication by mouth this am [morning]. Frequent monitoring is ongoing, resident lungs sounds congesting [sic] with moist and productive cough. Resident Continues [sic] to receive suctioning as needed and tolerated well. Start [sic] chest X-ray order received to r/o [rule out] aspiration/pneumonia. Noted as ordered, resident daughter notified of new order via phone states that's a good idea. Claim number for X-ray A nursing note dated [DATE] at 6:15 a.m., written by Staff M, Agency, Licensed Practical Nurse (LPN), revealed the following documentation. @ [at] approx. [approximately] 5:45 a.m., the CNA [Certified Nursing Assistant] reported to this nurse that res [resident] was not breathing, this nurse toke [sic], a second nurse and upon entering the room, note res chest was not rising and falling, did not feel no movement and was unable to palpate or auscultate a pulse or a B/p [blood pressure], the second nurse also verified these findings. This nurse notified the daughter, The Dr. and the fugneral [sic] home and are now waiting for them to come have the body released to them. A phone interview was conducted on [DATE] at 9:16 a.m. with Staff L, Agency, RN. She stated I am a Registered Nurse. This was my first time at the facility, I had not received any education at that facility. When I came on shift on [DATE] the night nurse and myself couldn't find a report sheet. The report sheet normally has the doctors name, code status, how the residents take meds and other notes or information about the patient. When we couldn't find a report sheet, the night shift nurse ended up writing on a piece of paper what she knew about the residents. She told me [Resident #1] was alert, oriented, and took her pills whole. Another agency nurse was supposed to be on the other medication cart, but she called off late and the ADON was on the med [medication] cart. After I got report I went to each room that I was told were my patients. Typically, you would know who's on your assignment by the report sheet, but we couldn't find it. I was trying to be as careful as possible because I was not familiar with these patients. I was trying to see what I can see from the MAR and speaking with the patients. Around 8:45 a.m. to 9:00 a.m. I talked to [Resident #1] and I asked her how she was doing this morning and she said fine, and I said here are your medications, are you ready to take them and she said yes, and she opened her mouth. Mostly what [Resident #1] had was just vitamins, ones that the facility provided, she had one or two medications that were not vitamins but that's not atypical to not have some medications on the cart [medication cart]. So, I didn't question that. They were all pills, no liquid. I saw on the MAR something about a tube feed, and I remember thinking well that's weird she didn't tell me anything about that. My thought was I would look further into that and ask questions after I got my meds done because the tube feeding order wasn't due yet. So, when I put the meds in her mouth she started coughing immediately, I already had the bed positioned sitting up so they have a better way to swallow, and I had my gloves on and I scooped everything out of her mouth that I could get, and she said there's still something there. I administered about 5 pills. The first time I scooped out of her mouth I scooped three pills. She continued to talk to me throughout the whole process and was able to make her needs known and at that point I asked [ADON] for help. She grabbed the suction. We went into the patient's room, and she [Resident #1] would cough occasionally when we went back into the room. She said there was still something stuck and we told her we were going to suction her, and she said okay, and she opened her mouth. As we were standing there [ADON] was saying this patient is confused, she's not alert and oriented and she doesn't take anything by mouth. At that point I was made aware that this wasn't even my patient for the day. I went into the bathroom and cried because I was not really prepared for that type of situation. One, I felt so bad because this could have been prevented in multiple ways. The shift reports that are supposed to be readily available and they weren't that day. The MAR did not indicate the route of administration and that's what made me so confused because it did not indicate that meds were supposed to be given by g-tube [gastric tube]. And even after the situation I went back to make sure I didn't miss anything on the MAR, and I didn't find anything indicating this patient was NPO. In order to do that you would have to go out of the MAR and go into the medical record and with me not being familiar with this patient I should have done that earlier. After the fact, when I looked, it said she was NPO, and she had the bolus tube feed however I did not find anything about her being confused. When I pulled up the resident's MAR, I did not have to pull up a different unit or change a filter on the MAR to another unit. After she [Resident #1] was suctioned, she was still speaking, we asked if she was okay, she said yes, I took her vital signs everything was within normal limits except her blood pressure was a little bit elevated but everything else was within normal limits. Afterwards I talked to [ADON] and my agency because I didn't feel comfortable for myself, and I felt it wasn't safe for the residents. I told [ADON] the same thing and she said I couldn't leave unless I was replaced because it was only me and her on the carts. That's when she pulled a report sheet for me with my assignment, I honestly don't know where she got the sheet. I did an event report, I called the nurse practitioner, and I called the patient's daughter. They [facility staff] were all just not wanting me to leave. I was just blown away because I have never had that happen. I'm used to a very organized facility, and this was a very unorganized situation. I always thought I was careful and now I have to be more careful and making sure I'm given the right report and making sure things match up. The ARNP [Advanced Registered Nurse Practitioner] did come up and see the patient and she told me no new orders because the patient was stable, she even told me that on the phone when I called. But then later on in the afternoon they did order a chest X-ray to verify the patient had not aspirated and the daughter was notified also of the X-ray. I kept my cart [medication cart] by the patient's room and every time I would come out of a room I would go into her room and a couple times I took her vital signs. I think I charted my vitals and the monitoring. She had coughed a little bit and at one point I did suction her again. I did not listen to her lungs. I was not able to be replaced so I told them I was not going to do my second shift and I let them know this more than two hours in advance. When it was time to go, they did not have anyone to cover for me. I stayed late till about 3:45 p.m. and [ADON] ended up counting my narcotics with me and taking my report and I left. [ADON] was the only one on the floor when I left because I hung around waiting for relief and eventually, she told me okay I'll take report because relief is on the way. [ADON] stated to me these things happen all the time we called the doctor, we called the family, and we did what we were supposed to do but that did not make me feel better. A phone interview was conducted on [DATE] at 4:51 p.m. with Resident #1's Advanced Registered Nurse Practitioner (ARNP). She stated I am familiar with [Resident #1]. I am aware of the nurse giving the resident oral medications when she was supposed to receive her medications through her g-tube. I was in the building when the nurse called me and told me she gave the resident oral medications when they were supposed to go through her g-tube. I told her I would be right up that I was in the building. I assessed the patient, and she was not in any respiratory distress. I listened to her lungs, and they were clear, she was not gasping or choking or coughing. I went and spoke with the nurse and the ADON, who was on a cart but on a different unit or assignment. Then, it was the weekend, and the ADON requested a chest X-ray, and I okayed it. I'm not typically on call on the weekends but I do answer my phone for the residents. The chest X-ray did get done. I took a picture of it because I knew this was going to be an issue and come up again. It says date of service [DATE] at 7:00 p.m. conclusion, slight right lower lobe and modest right upper lobe infiltrate [When interpreting the x-ray, the radiologist will look for white spots in the lungs (called infiltrates) that identify an infection. This exam will also help determine if you have any complications related to pneumonia such as abscesses or pleural effusions (fluid surrounding the lungs). Pneumonia | Lung inflammation - Diagnosis, Evaluation and Treatment, radiologyinfo.org, https://www.radiologyinfo.org > info > pneumonia]. The patient isn't alert and oriented at baseline, so she didn't complain about any pain or distress or discomfort. At this time, the nurse was on the phone with her agency trying to get released because she was upset by what happened. The ADON was on the same unit and when I talked to her, she told me, 'I don't even know why she even gave the patient the medications because that wasn't her patient .' They didn't call me to tell me the patient had passed away and when I got there on Tuesday [[DATE]] for my rounds around 9:30 a.m. that's when I heard she died, I'm shocked. I had to call and get the X-ray results. I had the nurse, Staff J, LPN, call the X-ray company to request them and they then faxed them over and I waited at the fax to get it. I reviewed it [the imaging] and that's when I found out she died, right before I went into the room. This was definitely a medical error on the nurse's part I would expect the nurse would have stopped everything when she realized there was no medications in her cart and investigated why. The first thing I noticed when I went into the room was suction at the bedside and what made me question it was if someone is NPO there is no need to have suction at the bedside. The nurses did not set up the suction at the bedside that day it was already available. Since February, I have not had any concerns with this patient. The resident was stable, there was no indication that she would be dying anytime soon, the resident does not have a respiratory history to my knowledge, and she was ordered to receive her medications through her g-tube. She should not have had anything by mouth. An interview was conducted on [DATE] at 1:52 p.m. with the ADON, she stated, On Friday [[DATE]] the nurse that was supposed to work a cart [medication cart] called off late so I ended up working the cart upstairs on the second floor, I was assigned the front hall. I was on the low side and the other agency nurse was on the high side. I started from room [ROOM NUMBER] to 217 plus I had room [ROOM NUMBER] bed A and B. The ADON indicated she was assigned to be Resident #1's nurse. The ADON also stated, As I was giving medication on my side the agency nurse came to me and she said 'I need your help, I need your help, I gave [Resident #1] her medications and she started to choke I did not realize that she was a peg tube. I was told in report that she took her medication whole. She [Resident #1] confirmed to me that she took her medication whole and then she started choking and then I realized she was a peg tube patient' .I want to say about 9:00 a.m. she [Staff L, Agency, RN] came to me and told me about the medication error. Because she told me it was about [Resident #1] I know she is a peg tube patient. So, I stopped at the emergency code cart and grabbed the suction. Then we got to the room and [Resident #1] was talking and I noticed some pills because the nurse did tell me she tried to get the pills out by having her cough and stuff. I saw two pills on the floor. [Resident #1] was acting herself, confused, combative, resistive to care, but she was talking not making sense, but she was talking and coughing, I plugged in the suction machine, and she did sound kind of congested, so I did suction her I asked the other nurse to check the pulse ox [oximeter] because she had it in her hand at that time. I don't remember what her pulse ox reading was but myself and the other nurse were in the resident's room for a good 15-20 minutes suctioning her and making sure she was okay. Then I asked the nurse to call the nurse practitioner, to call the residents daughter, and to document, and to do the event report. The nurse practitioner came in and I told her about what happened, and she told me 'I know the nurse called me,' and she told me she was going to see the patient. The fluid that I suctioned out was not really clear it was milk-like or cloudy color so I was assuming that because of the color of the suctioned fluid that I got more pills out so I told the nurse practitioner that and I asked her if I could still give her, her medications through her peg tube and she said yes. That was about an hour after the incident. Once the resident was safe, I asked the nurse where did you get her medications to give it to her. Because that residents' medications was on my medication cart. I'm not going to lie I did not hear what she said but she did not have one card of [Resident #1's] medications on her medication cart .I don't remember ever leaving my cart unlocked. And I said to her [Staff L, Agency RN] if you did not have one card of her medications wouldn't that be a trigger for you to stop and ask a question. She said, 'well I asked the resident if she took the medications whole and she said yes.' [Resident #1's] bedside table was next to her bed, and it had the flush cup with the syringe [g-tube supplies] and I asked, that didn't trigger you to think she doesn't take her meds whole? And she said, 'well I got in report she takes her meds whole.' The ADON continued to say I have no idea whose medications she administered to [Resident #1]. The night nurse that was on shift before the agency nurse [Staff L, Agency, RN] did not have the right report sheet we use, it was a handwritten report sheet. When the agency nurse [Staff L, Agency, RN] showed me her report sheet she got from the nurse on shift before her, I looked at it but I did not look at it closely to see what was written on it but I told her [Staff L, Agency RN] that this is a teaching moment for you because then I took her to the nurses' station and showed her in the blue folder is where she can find the report sheets. I didn't document this, but I went back almost every 30 minutes to 40 minutes to check on [Resident #1]. When I didn't go back, the other nurse went back. I suctioned the resident two or three more times throughout the shift and the other nurse went back to check on her, I don't know if she suctioned her too. Then maybe it was around 1:00 p.m. I asked the CNAs to get [Resident #1] up and put her at the nurses' station because that's where she normally sits, and she sounded fine. Then I asked the CNAs to put her back to bed. And around 1:50 p.m. she [Resident #1] sounded congested and that's when I asked the Nurse Practitioner to order a chest X-ray for her. I ordered the chest X-ray, and they came around 6:00 or 7:00 p.m . Around 5:30/6:00 p.m. is when a nurse came and relieved me from my shift. I told the nurse what happened earlier that day and I told her that we have been monitoring her and I told her to pay attention and listen to her lungs and suction her as needed and I had gotten an order for the suction and I told her that the X-ray needs to be taken then I told her to follow up. I don't know if the nurse did follow up on the results of the X-ray because I don't recall seeing any documentation . I received a text from the same nurse that relieved me because she ended up working 11:00 p.m. - 7:00 a.m. and she said she went around 1:00 a.m., at the scheduled time, to bolus feed the patient [Resident #1] then the CNA's told her the patient wasn't breathing around 5:45 a.m. We don't do clinical meetings on weekends. On [DATE] we went over the patient [Resident #1] had expired, they notified the daughter, and the morgue, stuff like that. There was no discussion about the medication error because I was involved so I know what we did, and we did everything. There was nothing to follow up on. When I asked the nurse to do the event [event report] she didn't do it. I ended up doing the event myself . On that Monday [DATE] I attended the morning meeting, the entire team was there, myself, Unit Manager was there, Therapy Director, activities, social services, Administrator, Dietary manger, I'm not sure if laundry director and maintence was there but the DON [Director of Nursing] was not here she was on vacation. For the morning meetings, with the Administrator, all the department heads are at that meeting. At this morning meeting the event was not discussed . At morning meeting, I don't recall if the death of the resident was discussed. But there is a census discussion because admission talks about who went to the hospital, who was admitted , and who died. There was not a discussion about it, but it was probably mentioned because we go over the census. I don't remember what day it was, but I did check for the X-ray, and I asked the nurse, [Staff J, LPN], did you get the X-ray? Can you call for the X-ray? We got the X-ray it said there was infiltration of her lungs. Sometimes they [radiology company] will fax the results to us and sometimes we will call to ask if they can fax it to us. Receiving the reports, it's getting a tiny bit better now . I have been here for less than two years, but I cannot recall her [Resident #1] having respiratory issues. As long as I have been here the resident has always been NPO. An interview was conducted with the DON on [DATE] at 5:50 p.m. she said, I was on vacation for the past seven days, I left on [DATE] and I came back this morning [DATE]. So, I only know what I have read. From the notes that I read I had an agency nurse here and she gave her meds and not through the g-tube because she is NPO. My ADON was here, and she is the one who was covering for me. I'm not sure if my ADON was here at the time of the event. I tried to call her. My expectation was to follow up and it seems like they did that. From reading the notes it seems like they suctioned all the meds out and they ordered a chest X-ray and my expectation is to follow through and keep the patient safe . The process of change of shift report is to go over the status of each resident. To go over if they are NPO, if they're on IV [intravenous] meds, stuff like that. That happens at change of shift for not just the nurses but the CNA's as well . I see her [Resident #1] BIMS is four. I would not expect the nurse to be asking the resident how they take their pills. That would not be accurate. I would expect the nurse to have read the assignment sheet and when she pulled up all the residents meds it says via g-tube and the diet order was NPO. If you're pulling up the medications to make sure you're giving the medication to the correct resident, the correct dose, the correct route. She would have seen that the patient gets her meds through her g-tube. Agency nurses that are coming here for the first time. We actually have them come 30 minutes earlier to show them how this facility works. We don't teach them how to be a nurse and how to pass meds but we do teach them how this facility works. I'm not sure if she has worked here before .We have a separate system for our X-ray results. In order to have an X-ray there has to be an order and that looks like it was ordered at 1:50 p.m. on [DATE] and it was ordered STAT [without delay] and usually that's done within four hours. The DON reviewed the medical record and confirmed she did not see any documentation related to the physician being notified of the chest X-ray results .What I know is that she [Resident#1] was given medication in the wrong route, I need to look at the X-ray to see what that showed, then she expired. I cannot say what her cause of death was. I cannot say what I would have done differently because I still have questions about the event, and I have not spoke to the ADON. So, I am still doing my investigation for myself. A phone interview was conducted on [DATE] at 10:26 a.m. with Resident #1's family member. She stated, I live away, I am actually getting ready to leave for her [Resident #1] funeral this morning. It's not that her death wasn't unexpected, my mom has had deteriorating heath for years and she had a feeding tube. They [the facility] would get her up and stuff. The last time I saw my mom was June of last year. I feel she has deteriorated over the last few years. And not just at that nursing facility at her ALF [Assisted Living Facility] she was deteriorating, and I don't know, I don't want to press any issues. The only thing I know and I don't know if it has anything to with it or not but, the day before her death a nurse, who must have been unfamiliar with my mom had taken my mom's medications to her and asked my mother if she can take her pills, my mom said yes and I mean, don't ask my mother a question like that she can't answer you. I guess mom immediately started choking and she spit some of the pills out and they had to suction her, and they told me they think they got it all out. However, that afternoon they called me and told me they were going to do an X-ray to rule out aspiration. I never heard anything back about that. I don't know if the X-ray was done or what it said if it was done. I hate if that's what happened to my mom. I guess they went in, and she was sleeping and she was breathing, then they went in again and checked on her and she wasn't breathing . On [DATE] at 3:46 p.m., an interview was conducted with Staff N, CNA. He stated he knew Resident #1 quite well. She was normally talkative and lively. She would carry a conversation though not always coherent. She was herself up until the last minute. This CNA stated he worked a double shift the day the resident was given the wrong medication. He stated he worked 7:00 a.m. - 3:00 p.m. and then 3:00 p.m. - 11:00 p.m. He stated on that day, the resident was not herself after ingesting the medication. He said, she was groggy and was regurgitating all day. She acted like she was trying to throw up or like she had something in her throat. He stated this was not the resident's normal behavior. I had never seen her like that. She did not speak much after the medication incident. This staff member stated he learned the resident had passed away when he returned to work on Monday [DATE]. Review of Resident #1's April medication administration

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interviews, facility documentation review, and policy review, the facility failed to provide adequate supervision to ensure safety for one Resident (Resident #2) out of twelve Residents identified as a high elopement risk. Resident #2 was a newly admitted resident to the facility, who was confused and disoriented. On 05/12/2023 Resident # 2 was found wandering outside of the facility, in the middle of the night, with her bags and looking for her car. This failure resulted in the determination of Immediate Jeopardy on 05/12/23 at a scope and severity of (J) due to the likelihood for serious injury and/or death to Resident #2, and the likelihood of similar accidents for other residents. The facility Administrator was notified of the Immediate Jeopardy on 06/07/23 at 5:21pm. It was determined that the Immediate Jeopardy was removed on 06/08/23 and F689 was reduced to a severity and scope of D after verification of removal of immediacy of harm. Findings included: A review of Resident #2's medical record showed, Resident #2 was admitted to the facility on [DATE] to room near the main lobby and front entrance with the diagnoses of Alcohol abuse with intoxication, Alcohol dependence with withdrawal, Alcohol use, unspecified with intoxication delirium, Generalized anxiety disorder, post-traumatic stress disorder, Tremor and Alcohol abuse with withdrawal delirium. An Admissions Observation form showed In Progress with no information completed in the form (photographic evidence obtained) as of 06/06/23. A review of hospital records revealed: -The History and Physical (H&P) dated 05/06/23 showed that Resident #2 remained confused at times. The H&P revealed Resident #2 showed confusion, gait problems and weakness. The diagnosis, assessment and plan within the H&P showed Resident #2 had Delirium, Tremors, and acute alcohol withdrawal syndrome. The plan showed, Resident #2 would be discharged to a skilled nursing facility for rehabilitation. -A progress note dated 05/10/23 at 6:18pm stated, Resident arrived to facility on stretcher by [Ambulance Company] around 1700. Alert with confusion, gate unsteady, skin check performed, scab noted on right ankle and right forearm, pressure dressing on left forearm, x in permanent marker noted on top of both feet, dinner meal offered and refused, will continue to monitor. A review of the facility's physical therapy note dated 05/11/23 showed Resident #2 precautions included fall risk and confusion. Physical therapy evaluated and completed a plan of treatment on 05/11/23. The plan for services were skills inventions to address Gait training focused on correct sequencing and hand foot placement during gait with assistive devices. Skilled interventions to include focused on dynamic activities while standing, gross motor coordination, transfer training to increase functional task performance. An additional physical therapy note dated 05/12/23 showed Resident #2 precautions included fall risk and confusion. Resident #2 required verbal instruction required due to compromised balance, functional activity tolerance, safety awareness, and strength to enhance muscle strength and improve muscle endurance in order to improve ability to ambulate with assistive device. Working on dynamic standing balance to sit to stand. Pt [Resident #2] unsteady with difficulty with sit to stand. Pt [Resident #2] cooperative but requires instruction and manual assist at times to maintain balance. Gait training using a single cane for 30 feet x 2 CGA [Contact Guard Assist] with assist of 1. Balance fair. The response to treatment showed Resident #2, actively participates, complaint with skilled interventions and required extra time to process new information. A progress note written by Staff B Unit Manager, Registered Nurse (RN) dated 05/12/23 at 7:45am showed, Writer was informed by agency nurse on the second floor that while she was coming back into the building from her 15-minute break she observed resident in the parking lot with her belongings and the resident stated, I am looking for my car per the agency nurse. The agency nurse informed the writer that she assisted resident back into the building and notified the nurse who was taking care of the resident. Writer notified Director of Nursing (DON), and Nurse Practitioner (NP) of the situation. Continued review of Resident #2's medical record revealed Behavioral: Resident is at risk for elopement as evidence by increased elopement observations score and or actual attempts to elope secondary to delirium was added to the care plan on 05/12/23. An elopement evaluation dated 05/12/23 at 4:35pm showed, Resident #2 was ambulatory, was a new admission who had made statements questioning the need to be in the facility, was cognitively impaired, had poor decision making skills, and/or pertinent diagnosis of anxiety, depression, had a history of wandering, made statements of wanting to leave and displayed behaviors of elopement which resulted in a score of being a Resident with high risk of Elopement. The elopement evaluation was completed after Resident #2's elopement incident, and with no other elopement evaluations completed between admission and the elopement incident present in the clinical record. There were no nursing skin assessments available in Resident #2's medical record after the elopement incident. The medical record showed only one progress note dated 05/12/23 at 7:45am written by Staff B Unit Manager, Registered Nurse (RN) who notified the Director of Nursing (DON), and Nurse Practitioner (NP). There was no documentation in the medical record that would indicate the resident's family or physician were notified. During an interview on 06/05/23 at 10:30 am, Staff A Staff Development Coordinator (SDC) Registered Nurse (RN) stated he had not conducted any elopement training/in-services for staff in the facility since being employed at the facility as of 02/27/23. Review of the facility's list of Residents with high elopement risk on 06/05/23 showed Resident #2's name was on the list. During an interview on 06/05/23 at 11:20 am, the Administrator stated, Resident #2 was considered a high elopement risk while in the facility, however Resident #2 was not in the facility now and was discharged home. During an interview on 06/05/23 at 12:45pm, Staff J Certified Nursing Assistant (CNA) stated he had been employed at the facility for a few years now and he had not participated in any elopement drills that he could recall. During an interview on 06/05/23 at 12:48pm, Staff F Certified Nursing Assistant (CNA) stated she had been employed at the facility for a few years now and usually the maintenance department conducts the elopement drills, but the facility had not had one in a long time. During an interview on 06/05/23 at 1:07pm, Staff B Unit Manager, Registered Nurse (RN) stated, the Agency Nurse [Staff C] approached her the morning of 05/12/23 and informed her that Resident #2 had eloped and was found outside looking for her car around 5:00am. Staff B RN stated since Resident #2 was already safely back in the facility and accounted for, she made a note in the Resident #2's chart and informed supervisors of the elopement that occurred on nightshift. Staff B RN stated the facility did not have any elopement drills while she worked in the facility. During a phone interview on 06/05/23 at 3:04 pm, Staff C Agency Nurse, Registered Nurse (RN) stated, the Administrator just called me a few minutes ago and told me the state would be calling soon and advised me to not answer the phone. Staff C RN stated the night of the elopement on 05/12/23 she was outside on her 15-minute break, and she found Resident #2 outside at the front of the building alone. Staff C RN stated Resident #2 was confused and was looking for her car. Staff C RN stated she escorted Resident #2 back into the facility and reported the elopement incident to Staff D Licensed Practical Nurse (LPN), Night Supervisor, who was sleeping at the time. Staff C RN stated Staff D LPN woke up, responded yeah ok and went back to sleep. Staff C RN stated she was not comfortable with the response of the night shift supervisor, so she also reported the elopement incident to Staff B Day shift Unit Manager, RN when she arrived for work. Staff C RN stated the reason she did not document the elopement incident was because Resident #2 was not her assigned resident. During an additional phone interview on 06/07/23 at 10:47am, Staff C Agency Nurse, RN stated she was parked on the left side of the facility in the parking lot when facing the facility. Staff C RN stated when she walked back to the front door entrance there was a lady identified as Resident #2 standing adjacent to the front door near the exit driveway, and close to the road. Staff C RN remembered there were cars passing by on the road and stated that [name of street] is always a busy road. Staff C RN stated, She is lucky it was nighttime or there would be a lot more cars on that road. Resident #2 was closer to the road than the front door. Staff C RN stated when she approached, Resident #2 was very disoriented and confused. Staff C RN stated Resident #2 kept asking where her car was. Staff C RN stated Resident #2's gait was unsteady, but she was able to ambulate. During an interview on 6/5/2023 at 3:59 pm, Staff D Night Shift Supervisor Licensed Practical Nurse (LPN) stated, I worked with Resident #2 on 100 hall the night of 5/11/23. Staff D LPN confirmed she was the assigned nurse to Resident #2 the night of 05/11/23 to the morning of 05/12/23, the shift that Resident #2 eloped. Staff D LPN recalled Resident #2 was alert with confusion. Staff D LPN stated Resident #2 was very disoriented and did not know much of her physical surroundings. Staff D LPN stated Resident #2 was able to complete most of her Activities of Daily Living (ADLs) herself, so I didn't have much care to provide to her, continuing [Resident #2] was just very confused. Staff D LPN stated she last recalled seeing Resident #2 around 5am when she provided Resident #2's roommate some medication. During an interview on 06/05/23 at 3:44pm, Staff E Rehabilitation Director (RD) stated she remembered Resident #2 very well. Staff E RD stated Resident #2 was admitted to the facility with her cane and could ambulate anywhere, although she was not safe. Staff E RD elaborated and stated Resident #2 was not safe because Resident #2 had poor safety awareness. Staff E RD stated that Resident #2 could hold a conversation but had poor cognition and confusion of the surroundings and physical environment. Staff E RD confirmed Resident #2 had an elopement incident, remembered the incident was talked about in the morning care plan meeting, and that was why Resident #2 was moved upstairs. Staff E RD stated the therapy department evaluated Resident #2 on 05/11/23. Staff E RD stated she remembered Resident #2 was ambulatory, had poor cognition with poor safety awareness and had a lot of confusion. Staff E RD stated usually when a Resident was that confused and could ambulate, the resident would get immediately assigned to a room upstairs to alleviate the possibility of elopement. The RD stated, the morning of 05/12/23 after Resident #2 eloped, during the care plan meeting was when the team chose to add elopement to the care plan and move Resident #2 upstairs to the secure unit. During an interview on 06/05/2023 at 4:00pm with an employee who wished to remain anonymous, the employee confirmed a care plan meeting for Resident #2 occurred the morning of 05/12/23 where Resident #2's elopement incident was discussed. The employee stated the Administrator informed the care plan staff he was not defining the incident as an elopement even though the clinical staff disagreed. The employee stated the incident was never thoroughly investigated or reported. During an interview on 06/05/23 at 4:07 pm, Staff F Certified Nursing Assistant (CNA) stated she worked with Resident #2 on 100-hall the night of 05/11/23 into the morning of 05/12/23. Staff F CNA stated Resident #2 was very confused and combative from day one. During an interview on 06/06/23 at 11:00am, the Administrator stated he defined elopement as an unobserved danger to a Resident where a lot of time had passed and places a Resident in harm's way. The Administrator stated he was familiar with the 05/12/23 incident regarding Resident #2. The Administrator stated Resident #2 had followed Staff C Agency Nurse, RN outside on break. The Administrator stated the facility Maintenance Department tested all the doors and they all passed inspection so the only way Resident #2 could have gotten out of the facility had to be by drafting, which he defined as following Staff C Agency Staff RN outside on break that night. The Administrator stated he was notified the morning of the incident but could not recall who informed him. The Administrator stated the care plan team decided to move Resident #2 up to the second floor because she was confused and looking for her car. The Administrator stated he did not feel Resident #2 was in any danger based on the statement the Director of Nursing (DON) got from Staff C Agency Nurse RN. The Administrator stated the witness statement showed the resident followed Staff C Agency Nurse RN out the door and Staff C Agency Staff RN turned around and brought Resident #2 back in. The Administrator stated the administrative team went back and forth as to what time the incident occurred and concluded it must have been around 5:30 am. The Administrator stated that Resident #2 was found in the parking lot not really near the road, so I do not think she was in danger. The Administrator stated Staff A Staff Development Coordinator (SCD), RN could provide documentation on elopement training provided to staff after Resident #2's incident. A review of a witness statement dated 05/12/23, provided by the Administrator for review, on 06/06/23 showed, Nurse [Agency Nurse Initials] RN went on 15-minute break exiting front door in lobby. Resident [Resident #2's initials] followed out through and was noticed by [Agency Nurse initials] RN and returned inside facility. [Agency Nurse initials] RN notified [Night shift Supervisor initials] Nurse Supervisor as she was returned to room. The witness statement was signed by the Director of Nursing and showed, interview with agency nurse. During a phone interview on 06/06/23 at 11:48am, Staff C Agency Nurse, Registered Nurse (RN) stated, I did not speak to the DON, and I have never made a witness statement about the incident. Staff C RN stated no one followed her out the front door and it was not until the end of the 15-minute break that she found Resident #2 wandering in the front of the facility near the road. Staff C RN stated again, I reported the incident to the night shift supervisor who was sleeping and said, yeah, ok and laid her head back down to sleep. Staff C RN stated, that was why I stayed to inform the day shift unit manager about the incident. During an interview on 06/06/23 at 12:36pm, the Director of Nursing (DON) stated yes, the initial on the bottom of the Agency Nurse witness statement dated 05/12/23 was hers, saying That is my signature. During an interview on 06/06/23 at 2:10 pm, Staff G admission Liaison stated she was the one who made the decisions on who got admitted to the facility or not. Staff G Admissions Liaison stated the facility did not accept anyone who was in active delirium tremens (DTs) [defined as severe alcohol withdrawal symptoms such as shaking, confusion, and hallucinations] and the Resident must be out of DTs to be admitted . The Admissions Liaison said the facility also did not accept elopement risk residents unless the person, who was classified as an elopement risk, was wheelchair bound and could not physically wander or elope. Staff G admission Liaison stated someone who was confused and able to ambulate would be classified as a higher elopement risk. Staff G admission Liaison stated if that was the case, I will meet with the family to ensure they are comfortable with the Resident being on the more secure 2nd floor and if they are we will admit them to the second floor. The admission Liaison stated the facility would not admit anyone with a higher elopement risk to the first floor because of the front door and the busy street. Staff G admission Liaison stated, if a Resident was questionable for elopement, the protocol would be to admit to a room close to the nurse station and furthest away from an exit door. Staff G Admissions Liaison could not recall Resident #2 to discuss specific details. An observation on 06/06/23 at 2:30 pm showed Resident #2's first floor Room as located down the 100- hallway near the front entrance of the facility and lobby area. Resident #2's first floor room was the first room on the left side of the hallway when an individual entered the facility's front door and walked through the lobby. Resident #2's first floor room was the closest room to the front door exit in the 100-hallway. Photographic evidence was obtained. A review of the Maintenance Department door audits, provided by the Administrator for review, for the dates of 05/06/23 to 05/12/23 showed documentation that all doors passed. During an interview on 06/06/23 at 3:08pm, the Maintenance Director stated exit doors are always locked, and the front door was always locked and under keypad. The Maintenance Director stated the facility's exit doors were audited daily and put in the logbook. The maintenance logbook was reviewed with pass by each exit door audited that included 1st floor east exit door, 1st floor west exit door, 1st floor at Resident #2's room, 2nd floor by room [ROOM NUMBER],2nd floor by room [ROOM NUMBER], 2nd floor by room [ROOM NUMBER], 2nd floor by room [ROOM NUMBER], Employee entrance door, front door, Kitchen door, physical therapy department door, and patio door for the dates of 04/29/23 to 05/26/23. The Maintenance Director stated facility's exit doors were routinely audited daily and not based solely on elopements or incidents that have occurred at the facility. A review of an additional second witness statement dated 06/05/23, provided by the Administrator for review, showed a statement from Staff D LPN. The witness statement was dated 06/05/23 regarding the elopement incident that occurred with Resident #2 on 05/12/23. During an interview on 06/06/23 at 5:00 pm, the Director of Nursing (DON) explained how the elopement decision was made based on Resident #2's elopement evaluation form dated 05/12/23. The DON stated using this elopement evaluation form Resident #2 would have been considered as a high elopement risk and proceed to behavioral elopement care plan. The DON stated based on Resident #2's active DTs, behaviors, behavioral medications, and history, I would still indicate her as an elopement risk on 05/11/23 prior to the elopement. The DON stated she did not know why the admissions observation evaluation form was not completed by the nurse as it was her expectation it be completed on admission. During an interview on 06/06/23 at 9:00pm, Staff D Nighttime Nursing Supervisor, Licensed Practical Nurse (LPN) stated that she did complete a witness statement for the 05/12/23 elopement incident on 06/05/23. Staff D LPN stated she talked with the DON on the phone at approximately 8:00am on 05/12/23; the DON asked her to confirm if the elopement occurred and if it was reported to her. Staff D LPN stated she informed the DON the Agency Nurse reported the incident to her, and the DON informed her that she would need a witness statement as the elopement was a reportable event. Staff D LPN stated she was approached on 06/05/23 and was asked for her witness statement in writing regarding the 05/12/23 incident so she wrote it up on 06/05/23 as requested. During an interview on 06/07/23 at 9:45am, the Administrator confirmed there were no working security cameras in the facility and no video to review of the incident on 05/12/23. During an interview on 06/07/23 at 10:38 am, the Director of Nursing stated when she assessed Resident #2 on the elopement evaluation dated 05/12/23 she observed Resident #2 having tremors. The DON stated Resident #2 continued to show a lot of confusion and appeared to be having some hallucinations. The DON confirmed Resident #2 was prescribed both Lithium and Valium (sedative medications) and said those medications would have also made Resident #2 a risk for elopement. An observation of [name of road] in front of the facility revealed a six (6) lane highway. Observation showed the road consisted of two Northbound lanes with a third outside lane designated for bus/turn lane and two Southbound lanes with a third outside lane designated for bus/turn lane. There was a median separating the 3 northbound lanes from the southbound lanes. [name of road] had a total of six (6) lanes. Photographic evidence was obtained. The facility's policy review titled, Elopement not dated showed, Elopement includes when a resident leaves the premise or a safe area without authorization and/or necessary supervision placing the resident at risk for harm or injury. The policy showed the steps for when a Resident who was missing was found that included: a. Examine the resident for possible injuries; b. Notify the Attending Physician for consultation; c. Notify the facility Administrator or designee: d. Notify the resident's designated representative; e. Discuss with the Administrator, DONS, or designee if it is prudent to provide the resident with 1:1 or other level of supervision; f. Complete the facility appropriate report to document the event; and g. Complete appropriate documentation to include in the resident's medical record. Facility immediate actions to remove the Immediate Jeopardy included: 1. Identification of Residents Affected or Likely to be Affected: Include actions that were performed to address the citation for recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the facility's noncompliance and the date the corrective actions were completed. (Alleged Completion Date: 06/08/23) o Affected Resident discharged from facility on 5/26/23. o Contract Nurse involved in 5/12/23 resident elopement classified as Do Not Return. o Remaining residents reassessed via the Nurse Management team for elopement risk and added to elopement book/ binder where indicated. 2. Actions to Prevent Occurrence/Recurrence: Include actions the facility will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, by whom and when those actions were completed. (Completion Date: 06/07/23) o SDC reeducation of staff related to elopement with focus on preventing drafting of residents near exit doors. o The Maintenance Director inspected and tested facility magnetic locking exit doors and associated alarm systems, verifying door systems to be working as designed. o SDC conducted an elopement drill to test and reinforce staff response to a potentially missing patient/ resident. o Frequency of facility elopement drills increased to two times monthly. o Frequency of elopement Inservice / re-education increased to once per month for 6 months. o DON or designee to conduct five times weekly review of newly admitted / readmitted residents elopement assessment. Verification of the facility's removal plan was conducted by the survey team on 06/08/23. During an interview on 06/08/23 at 1:59pm, the Administrator stated he had received training, which defined an elopement was a Resident who leaves without permission or a Resident who leaves an area they are assigned. Verification of staff training on Elopement policy and procedures was conducted on 06/08/23. The survey team reviewed records of provided in-service trainings, as well as staff sign-in/roster sheets for training. Verification of an elopement drill conducted on 06/07/23 was reviewed. On 06/08/2023, interviews were conducted with 41 out of 82 staff, which included nine (9) licensed nurses, 13 CNAs and 19 administrative/other disciplinary staff. The staff members were able to state they had been trained and were knowledgeable about the new policies. Based on verification of the facility's Immediate Jeopardy removal plan, the Immediate Jeopardy was determined to be removed on 06/08/23 and the non-compliance was reduced to a scope and severity of D.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, facility documentation, and policy review, the facility failed to provide competent staff, to ensure residents who required gastric tube medication administration received medications as ordered and to ensure follow-up monitoring occurred after a medication error for one (Resident #1) of three residents reviewed for gastric tube medication administration. The facility failed to have competent staff due to the lack of orientation provision to Agency staff, lack of timely communication to the Advanced Registered Nurse Practitioner (ARNP) and physician of X-Ray results, and lack of physician knowledge of who his patients were in the facility. Resident #1 had a gastric tube placed on 5/4/2022 and had a physician order to receive nothing by mouth. All of Resident #1's medication orders indicated the route of administration was through her gastric tube. On 4/14/23 at approximately 8:45 a.m. Staff L, Agency, Registered Nurse (RN) failed to ensure she received an accurate resident assignment and report, failed to review physician orders, failed to clarify missing medications, failed to inquire about enteral feeding orders, and failed to review Resident #1's cognition status before asking Resident #1 if she was ready to take her medications. Staff L, Agency RN then proceeded to administer approximately four to five tablets of Resident #1's medications orally causing Resident #1 to sustain respiratory complications that required suctioning. Resident #1 continued to have respiratory complications which required suctioning throughout the day and her lungs sounded congested. The Advanced Registered Nurse Practitioner was notified and ordered a chest X-ray to rule out aspiration/pneumonia. The chest X-ray resulted on 4/14/23 at 7:07 p.m. and revealed Resident #1 had slight right lower lobe and modest right upper lobe infiltrates [When interpreting the x-ray, the radiologist will look for white spots in the lungs (called infiltrates) that identify an infection. This exam will also help determine if you have any complications related to pneumonia such as abscesses or pleural effusions (fluid surrounding the lungs). Pneumonia | Lung inflammation - Diagnosis, Evaluation and Treatment, radiologyinfo.org, https://www.radiologyinfo.org > info > pneumonia]. Review of a nursing note dated 4/15/23 at 6:15 a.m., written by Staff M, Agency, LPN (Licensed Practical Nurse), showed at approximately 5:45 a.m. Resident #1 was found in her room to be without breath, pulse, and blood pressure and the body was being released to the funeral home. There was no documentation showing Resident #1 had vital signs monitored from 4/14/23 at 10:38 a.m. until her death. There was no documentation showing Resident #1's physician was notified of the abnormal X-ray results. There was no documentation that indicated Resident #1 was closely monitored from approximately 1:50 p.m., when the resident received X-ray orders as a result of her change in condition, until her death on 4/15/23 at approximately 5:45 a.m. These failures created a situation that resulted in a worsened condition and death to Resident #1 and resulted in the determination of Immediate Jeopardy beginning on 4/14/23. The findings of Immediate Jeopardy were determined to be removed on 4/27/23 and the scope and severity reduced to a D. Findings included: Review of Resident #1's face sheet revealed she was an [AGE] year-old female admitted on [DATE] with medical diagnoses that included but were not limited to, gastrostomy status (since 5/4/22), dysphagia, oropharyngeal phase, need for assistance with personal care oral phase, vascular dementia with behavioral disturbances. Review of Resident #1's quarterly Minimum Data Set assessment dated [DATE], section C, cognitive patterns, revealed a brief interview for mental status (BIMS) score of 5 out of 15 which indicated severely impaired cognition. Review of Section K, Swallowing/Nutritional status revealed .Feeding tube-nasogastric or abdominal (PEG) [percutaneous endoscopic gastrostomy tube] . A Physician's order review revealed a diet order for NPO (nothing by mouth), this order started on 10/6/2022 and was discontinued after her death on 4/17/23. A Physician's order which started on 5/19/22 and was discontinued on 4/17/23 revealed May crush medications unless contraindicated. A Physician's order which started on 5/19/22 and was discontinued on 4/17/23 revealed Enteral feeding: Flush tube with 30cc [cubic centimeter] water before and after every administering medications [sic] and 5cc between each medication every shift day evening night. Review of the speech therapy discharge summary with a date of service of 5/9/22-5/16/22, revealed on 5/2/22 a MBSS (modified barium swallow study) was completed, and the resident became NPO due to severe pharyngeal stasis and deep penetration to VF (video fluoroscopy) without clearance. A percutaneous endoscopic gastrostomy (PEG) tube was placed on 5/4/22 and the resident was discharged from speech therapy on 5/16/22 with orders for NPO with PEG placement for all nutrition/hydration/medication; severe impairment. A nursing progress note dated 4/14/23 at 9:47 a.m. written by Staff L, Agency, LPN [sic] revealed the following documentation. This RN [Registered Nurse] was given report by night shift stating that this pt [patient] was on assignment and took meds whole. Both nurses attempted to locate report sheets unsuccessfully. Verbal report given with handwritten notes for how pts [patients] take meds [medications]. This RN was not informed that this pt had a PEG tube or was confused. This RN went into pt room and verified pt, spoke to pt stating had her medications and asked pt to verify that she took pill whole. Pt stated yes so RN proceeded. Pt immediately started coughing and RN had pt spit meds out. Pt was speaking and following commands but said she still felt that something was stuck. This RN went and sought out help and informed staff RN of what had taken place and was informed at that time that this pt was not on her assignment. Pt was suctioned to get rest of meds out of mouth. Pt still speaking and not in any apparent distress. NP [Nurse Practitioner] [Resident #1's NP] notified as well as pt daughter [Family member], Both said thanks for letting them know. No new orders at this time. Event report to follow. A nursing note dated 4/14/23 at 1:50 p.m., written by the Assistant Director of Nursing (ADON), revealed the following documentation. Resident received medication by mouth this am [morning]. Frequent monitoring is ongoing, resident lungs sounds congesting [sic] with moist and productive cough. Resident Continues [sic] to receive suctioning as needed and tolerated well. Start [sic] chest X-ray order received to r/o [rule out] aspiration/pneumonia. Noted as ordered, resident daughter notified of new order via phone states that's a good idea. Claim number for X-ray A nursing note dated 4/15/23 at 6:15 a.m., written by Staff M, Agency, Licensed Practical Nurse (LPN), revealed the following documentation. @ [at] approx. [approximately] 5:45 a.m., the CNA [Certified Nursing Assistant] reported to this nurse that res [resident] was not breathing, this nurse toke [sic], a second nurse and upon entering the room, note res chest was not rising and falling, did not feel no movement and was unable to palpate or auscultate a pulse or a B/p [blood pressure], the second nurse also verified these findings. This nurse notified the daughter, The Dr. and the fugneral [sic] home and are now waiting for them to come have the body released to them. A phone interview was conducted on 4/26/23 at 9:16 a.m. with Staff L, Agency, RN. She stated I am a Registered Nurse. This was my first time at the facility, I had not received any education at that facility. When I came on shift on 4/14/23 the night nurse and myself couldn't find a report sheet. The report sheet normally has the doctors name, code status, how the residents take meds and other notes or information about the patient. When we couldn't find a report sheet, the night shift nurse ended up writing on a piece of paper what she knew about the residents. She told me [Resident #1] was alert, oriented, and took her pills whole. Another agency nurse was supposed to be on the other medication cart, but she called off late and the ADON was on the med cart. After I got report I went to each room that I was told were my patients. Typically, you would know who's on your assignment by the report sheet, but we couldn't find it. I was trying to be as careful as possible because I was not familiar with these patients. I was trying to see what I can see from the MAR [medication administration record] and speaking with the patients. Around 8:45 a.m. to 9:00 a.m. I talked to [Resident #1] and I asked her how she was doing this morning and she said fine, and I said here are your medications, are you ready to take them and she said yes, and she opened her mouth. Mostly what [Resident #1] had was just vitamins, ones that the facility provided, she had one or two medications that were not vitamins but that's not atypical to not have some medications on the cart. So, I didn't question that. They were all pills, no liquid. I saw on the MAR something about a tube feed, and I remember thinking well that's weird she didn't tell me anything about that. My thought was I would look further into that and ask questions after I got my meds done because the tube feeding order wasn't due yet. So, when I put the meds in her mouth she started coughing immediately, I already had the bed positioned sitting up so they have a better way to swallow, and I had my gloves on and I scooped everything out of her mouth that I could get, and she said there's still something there. I administered about five pills. The first time I scooped out of her mouth I scooped 3 pills. She continued to talk to me throughout the whole process and was able to make her needs known and at that point I asked [ADON] for help. She grabbed the suction. We went into the patient's room, and she [Resident #1] would cough occasionally when we went back into the room. She said there was still something stuck and we told her we were going to suction her, and she said okay, and she opened her mouth. As we were standing there [ADON] was saying this patient is confused, she's not alert and oriented and she doesn't take anything by mouth. At that point I was made aware that this wasn't even my patient for the day. I went into the bathroom and cried because I was not really prepared for that type of situation. One, I felt so bad because this could have been prevented in multiple ways. The shift reports that are supposed to be readily available and they weren't that day. The MAR did not indicate the route of administration and that's what made me so confused because it did not indicate that meds were supposed to be given by g-tube [gastric tube]. And even after the situation I went back to make sure I didn't miss anything on the MAR, and I didn't find anything indicating this patient was NPO. In order to do that you would have to go out of the MAR and go into the medical record and with me not being familiar with this patient I should have done that earlier. After the fact, when I looked, it said she was NPO, and she had the bolus tube feed however I did not find anything about her being confused. When I pulled up the resident's MAR, I did not have to pull up a different unit or change a filter on the MAR to another unit. After she [Resident #1] was suctioned, she was still speaking, we asked if she was okay, she said yes, I took her vital signs everything was within normal limits except her blood pressure was a little bit elevated but everything else was within normal limits. Afterwards I talked to [ADON] and my agency because I didn't feel comfortable for myself, and I felt it wasn't safe for the residents. I told [ADON] the same thing and she said I couldn't leave unless I was replaced because it was only me and her on the carts. That's when she pulled a report sheet for me with my assignment, I honestly don't know where she got the sheet. I did an event report, I called the nurse practitioner, and I called the patient's daughter. They [facility staff] were all just not wanting me to leave. I was just blown away because I have never had that happen. I'm used to a very organized facility, and this was a very unorganized situation. I always thought I was careful and now I have to be more careful and making sure I'm given the right report and making sure things match up. The ARNP [Advanced Registered Nurse Practitioner] did come up and see the patient and she told me no new orders because the patient was stable, she even told me that on the phone when I called. But then later on in the afternoon they did order a chest X-ray to verify the patient had not aspirated and the daughter was notified also of the X-ray. I kept my cart [medication cart] by the patient's room and every time I would come out of a room I would go into her room and a couple times I took her vital signs. I think I charted my vitals and the monitoring. She had coughed a little bit and at one point I did suction her again. I did not listen to her lungs. I was not able to be replaced so I told them I was not going to do my second shift and I let them know this more than two hours in advance. When it was time to go, they did not have anyone to cover for me. I stayed late till about 3:45 p.m. and [ADON] ended up counting my narcotics with me and taking my report and I left. [ADON] was the only one on the floor when I left because I hung around waiting for relief and eventually, she told me okay I'll take report because relief is on the way. [ADON] stated to me these things happen all the time we called the doctor, we called the family, and we did what we were supposed to do but that did not make me feel better. A phone interview was conducted on 4/24/23 at 4:51 p.m. with Resident #1's Advanced Registered Nurse Practitioner (ARNP). She stated, I am familiar with [Resident #1]. I am aware of the nurse giving the resident oral medications when she was supposed to receive her medications through her g-tube. I was in the building when the nurse called me and told me she gave the resident oral medications when they were supposed to go through her g-tube. I told her I would be right up that I was in the building. I assessed the patient, and she was not in any respiratory distress. I listened to her lungs, and they were clear, she was not gasping or choking or coughing. I went and spoke with the nurse and the ADON, who was on a cart but on a different unit or assignment. Then, it was the weekend, and the ADON requested a chest X-ray, and I okayed it. I'm not typically on call on the weekends but I do answer my phone for the residents. The chest X-ray did get done. I took a picture of it because I knew this was going to be an issue and come up again. It says date of service 4/14/23 at 7:00 p.m. conclusion, slight right lower lobe and modest right upper lobe infiltrate . The patient isn't alert and oriented at baseline, so she didn't complain about any pain or distress or discomfort. At this time, the nurse was on the phone with her agency trying to get released because she was upset by what happened. The ADON was on the same unit and when I talked to her, she told me, 'I don't even know why she even gave the patient the medications because that wasn't her patient .' They didn't call me to tell me the patient had passed away and when I got there on Tuesday [4/18/23] for my rounds around 9:30 a.m. that's when I heard she died, I'm shocked. I had to call and get the X-ray results. I had the nurse, Staff J, LPN, call the X-ray company to request them and they then faxed them over and I waited at the fax to get it. I reviewed it [the imaging] and that's when I found out she died, right before I went into the room. This was definitely a medical error on the nurse's part I would expect the nurse would have stopped everything when she realized there was no medications in her cart and investigated why. The first thing I noticed when I went into the room was suction at the bedside and what made me question it was if someone is NPO there is no need to have suction at the bedside. The nurses did not set up the suction at the bedside that day it was already available. Since February, I have not had any concerns with this patient. The resident was stable, there was no indication that she would be dying anytime soon, the resident does not have a respiratory history to my knowledge, and she was ordered to receive her medications through her g-tube. She should not have had anything by mouth. An interview was conducted on 4/25/23 at 1:52 p.m. with the ADON, she stated, On Friday [4/14/23] the nurse that was supposed to work a cart [medication cart] called off late so I ended up working the cart upstairs on the second floor, I was assigned the front hall. I was on the low side and the other agency nurse was on the high side. I started from room [ROOM NUMBER] to 217 plus I had room [ROOM NUMBER] bed A and B. The ADON indicated she was assigned to be Resident #1's nurse. The ADON also stated, As I was giving medication on my side the agency nurse came to me and she said 'I need your help, I need your help, I gave [Resident #1] her medications and she started to choke I did not realize that she was a peg tube. I was told in report that she took her medication whole. She [Resident #1] confirmed to me that she took her medication whole and then she started choking and then I realized she was a peg tube patient .' I want to say about 9:00 a.m. she [Staff L, Agency, RN] came to me and told me about the medication error. Because she told me it was about [Resident #1] I know she is a PEG tube patient. So, I stopped at the emergency code cart and grabbed the suction. Then we got to the room and [Resident #1] was talking and I noticed some pills because the nurse did tell me she tried to get the pills out by having her cough and stuff. I saw two pills on the floor. [Resident #1] was acting herself, confused, combative, resistive to care, but she was talking not making sense, but she was talking and coughing, I plugged in the suction machine, and she did sound kind of congested, so I did suction her I asked the other nurse to check the pulse ox [oximeter] because she had it in her hand at that time. I don't remember what her pulse ox reading was but myself and the other nurse were in the resident's room for a good 15-20 minutes suctioning her and making sure she was okay. Then I asked the nurse to call the nurse practitioner, to call the residents daughter, and to document, and to do the event report. The nurse practitioner came in and I told her about what happened, and she told me 'I know the nurse called me,' and she told me she was going to see the patient. The fluid that I suctioned out was not really clear it was milk-like or cloudy color so I was assuming that because of the color of the suctioned fluid that I got more pills out so I told the nurse practitioner that and I asked her if I could still give her, her medications through her peg tube and she said yes. That was about an hour after the incident. Once the resident was safe, I asked the nurse where did you get her medications to give it to her. Because that residents' medications was on my medication cart. I'm not going to lie I did not hear what she said but she did not have one card of [Resident #1's] medications on her medication cart .I don't remember ever leaving my cart unlocked. And I said to her [Staff L, Agency, RN] if you did not have one card of her medications wouldn't that be a trigger for you to stop and ask a question. She said, 'well I asked the resident if she took the medications whole and she said yes.' [Resident #1's] bedside table was next to her bed and it had the flush cup with the syringe [g-tube supplies] and I asked, that didn't trigger you to think she doesn't take her meds whole? And she said, 'well I got in report she takes her meds whole.' The ADON continued to say I have no idea whose medications she administered to [Resident #1]. The night nurse that was on shift before the agency nurse [Staff L, Agency, RN] did not have the right report sheet we use, it was a handwritten report sheet. When the agency nurse [Staff L, Agency, RN] showed me her report sheet she got from the nurse on shift before her, I looked at it but I did not look at it closely to see what was written on it but I told her [Staff L, Agency RN] that this is a teaching moment for you because then I took her to the nurses' station and showed her in the blue folder is where she can find the report sheets. I didn't document this, but I went back almost every 30 minutes to 40 minutes to check on [Resident #1]. When I didn't go back, the other nurse went back. I suctioned the resident two or three more times throughout the shift and the other nurse went back to check on her, I don't know if she suctioned her too. Then maybe it was around 1:00 p.m. I asked the CNAs [Certified Nursing Assistants] to get [Resident #1] up and put her at the nurse's station because that's where she normally sits and she sounded fine. Then I asked the CNAs to put her back to bed. And around 1:50 p.m. she [Resident #1] sounded congested and that's when I asked the Nurse Practitioner to order a chest X-ray for her. I ordered the chest X-ray, and they came around 6:00 or 7:00 p.m Around 5:30/6:00 p.m. is when a nurse came and relieved me from my shift. I told the nurse what happened earlier that day and I told her that we have been monitoring her and I told her to pay attention and listen to her lungs and suction her as needed and I had gotten an order for the suction, and I told her that the X-ray needs to be taken then I told her to follow up. I don't know if the nurse did follow up on the results of the X-ray because I don't recall seeing any documentation . I received a text from the same nurse that relieved me because she ended up working 11:00 p.m.-7:00 a.m. and she said she went around 1:00 a.m., at the scheduled time, to bolus feed the patient [Resident #1] then the CNA's told her the patient wasn't breathing around 5:45 a.m. We don't do clinical meetings on weekends. On 4/17/23 we went over the patient had expired, they notified the daughter, and the morgue, stuff like that. There was no discussion about the medication error because I was involved so I know what we did, and we did everything. There was nothing to follow up on. When I asked the nurse to do the event [event report], she didn't do it. I ended up doing the event [event report] myself. We did end up discussing the event and what happened. I don't remember what day it was, but I did check for the X-ray, and I asked the nurse, [Staff J, LPN], did you get the X-ray? Can you call for the X-ray? We got the X-ray. It said there was infiltration of her lungs. Sometimes they [radiology company] will fax the results to us and sometimes we will call to ask if they can fax it to us. Receiving the reports, it's getting a tiny bit better now . I have been here for less than two years, but I cannot recall her [Resident #1] having respiratory issues. As long as I have been here the resident has always been NPO. Review of Resident #1's April medication administration record (MAR) revealed on 4/14/23 between the hours of 7:00 a.m. to 11:00 a.m. Staff L documented the administration of 1 tablet of Cholecalciferol 25mcg(micrograms), 1 tablet of docusate sodium 100mg (milligrams), 2 tablets of acetaminophen 650mg. Staff L also signed off on the administration of Resident #1's order for ferrous sulfate tablet, 325mg (65mg iron) amount to administer: 7.5ml. Staff L documented Resident #1 did not receive her ordered Seroquel 300mg because Drug/Item Unavailable. The documentation revealed Resident #1 received approximately four to five tablets of medication. Each one of Resident #1's medication orders indicated her medication should be administered through her gastric tube. On 04/25/23 at 3:46 p.m., an interview was conducted with Staff N, CNA. He stated he knew Resident #1 quite well. She was normally talkative and lively. She would carry a conversation though not always coherent. She was herself up until the last minute. This CNA stated he worked a double shift the day the resident was given the wrong medication. He stated he worked 7:00 a.m. - 3:00 p.m. and then 3:00 p.m. - 11:00 p.m. He stated on that day, the resident was not herself after ingesting the medication. He said, she was groggy and was regurgitating all day. She acted like she was trying to throw up or like she had something in her throat. He stated this was not the resident's normal behavior. I had never seen her like that. She did not speak much after the medication incident. This staff member stated he learned the resident had passed away when he returned to work on Monday 4/17/23. On 4/24/23 at 4:06 p.m. an interview was conducted with the Director of Rehab. She stated . She [Resident #1] is not able to respond to a question appropriately. She is verbal but clearly expressing wants and needs, she's not able to do that, she's not nonverbal but she was nonsensical. Her vascular dementia, psych diagnoses, confusion, and she's a silent aspirator and that is what lead her to staying NPO because she did have the g-tube replaced. Speech [Speech Therapy] had tried to put her on a pleasure diet but due to her confusion, she did not have the compensatory strategies for safe swallowing. She wasn't able to comprehend and follow through with swallowing. When she first came in, she did not have a peg tube, then she was starting to cough and choke more. Then later during her stay she got the peg tube. There has been a decline as she has been here [at the facility]. There was no confusion, she was NPO. If I went in with food she would say yes because she doesn't understand she can't have that. She has no awareness of her deficit. The Director of Rehabilitations indicated she was not here [at the facility] at the time of the event. She also indicated the Director of Nursing, and the Staff Development Coordinator were out of town all last week and not here at the time of the event either. But she confirmed there was a meeting which included the ADON, the Nursing Home Administrator (NHA) and other managers. She indicated at the time of the meeting she read the notes and it was clear the resident died from taking oral medications and she verbalized during the meeting that this was not right. The Director of Rehab indicated she had just ordered Resident #1 a custom wheelchair and the resident had been making progress and was able to tolerate sitting up in the wheelchair for four hours. On 4/24/23 at 3:30 p.m., an interview was conducted with Staff J, LPN. She stated she had worked at the facility since 2019 and worked with Resident #1 every time she worked. She indicated she was very close with Resident #1, and it broke her heart when she found out she died. She said she could not understand how the nurse could have given the medications orally because all her orders said to administer her medications by g-tube and her diet order said she's NPO. Staff J, LPN said Resident #1 was alert, very confused, but a sweetheart and could be feisty at times. Staff J, LPN indicated Resident #1 had pneumonia before but that was a very long time ago and even then, her oxygen saturations were always good. Staff J, LPN indicated that other than having the pneumonia a long time ago Resident #1 did not have a history of any respiratory distress. On 04/25/23 at 3:50 p.m., an interview was conducted with Staff O, CNA, who had worked at the facility for two years. She stated she worked with the resident often, but not during the time of the incident. She stated she knew the resident well, she was out-going, vocal and could hold a conversation. She stated she worked weekends and had last seen the resident the weekend before. She stated the resident was herself as far as her behaviors were concerned. She was not sick, at least not the last time I saw her . On 04/25/23 at 3:53 p.m., an interview was conducted with Staff P, CNA. She stated she worked with the resident sometimes and was working the night she passed but was not assigned to the resident. She stated she was in her assigned area throughout the night. She stated she did not observe any unusual behavior or incident. There was no commotion at any given time. She stated, everyone was doing their usual thing, and she mostly stayed at her assigned area. She stated from the nurse's unit she could see the resident's room. She said, I did not notice unusual activity throughout the night. She stated the CNA who was assigned to the resident had notified her that the Resident had passed away . A phone interview was conducted on 4/27/23 at 10:26 a.m. with Resident #1's family member. She stated, I live away, I am actually getting ready to leave for her [Resident #1] funeral this morning. It's not that her death wasn't unexpected, my mom has had deteriorating heath for years and she had a feeding tube. They [the facility] would get her up and stuff. The last time I saw my mom was June of last year. I feel she has deteriorated over the last few years. And not just at that nursing facility at her ALF [Assisted Living Facility] she was deteriorating, and I don't know, I don't want to press any issues. The only thing I know and I don't know if it has anything to with it or not but, the day before her death a nurse, who must have been unfamiliar with my mom had taken my mom's medications to her and asked my mother if she can take her pills, my mom said yes and I mean, don't ask my mother a question like that she can't answer you. I guess mom immediately started choking and she spit some of the pills out and they had to suction her, and they told me they think they got it all out. However, that afternoon they called me and told me they were going to do an X-ray to rule out aspiration. I never heard anything back about that. I don't know if the X-ray was done or what it said if it was done. I hate if that's what happened to my mom. I guess they went in, and she was sleeping and she was breathing, then they went in again and checked on her and she wasn't breathing . Review of a physician's order with a start date of 4/14/23 and an end date of 4/17/23 revealed PA Chest: LAT [lateral] Chest: Special instructions: Start [sic] chest X-ray to r/o aspiration/pneumonia once a day 07:00-23:00 [7:00 a.m. - 11:00p.m.]. Review of Resident #1's chest X-ray 2 view, with a date of service of 4/14/2023 and a report date and time of 4/14/23 at 7:07 p.m. revealed the following documentation. Conclusion: Slight right lower lobe and modest right upper lobe infiltrates [substances denser than air]. This was electronically signed by the interpreting physician on 4/14/23 at 7:07 p.m. Review of the medical record did not show a note documenting that Resident #1's physician was informed of the abnormal chest X-ray results. Review of Resident #1's vital signs revealed on 4/14/23 at 10:38 a.m. the resident's oxygen saturation reading was 91% on room air, her pulse was high at 122 beats per minute. Her respiratory rate was 16 breaths per minute, and her blood pressure was 178/87 mm HG (millimeters of mercury). According to the Cleveland Clinic, normal adult vital signs ranges include blood pressure, 90/60 to 120/80, Pulse 60 to 100 beats per minute, respiratory rate 12 to 18 breaths per minute. https://my.clevelandclinic.org/health/articles/10881-vital-signs. Also, according to the Cleveland Clinic, a healthy oxygen saturation is typically above 90%. https://health.clevelandclinic.org/should-you-get-a-pulse-oximeter-to-measure-blood-oxygen-levels/. There were no other vitals documented in the medical record after 4/14/23 at 10:38 a.m. Further review of Resident #1's vitals obtained in the month of April revealed her oxygen saturations were 96% and 99%. Her documented pulse readings for the month of April were bet[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, facility documentation and policy review the facility failed to ensure one (Resident #1) of three residents reviewed for medication administration was free from a significant medication error as evidenced by the administration of medications orally for Resident #1 who was ordered to receive nothing by mouth. Resident #1 had a gastric tube placed on 5/4/2022 and had a physician order to receive nothing by mouth. All of Resident #1's medication orders indicated the route of administration was through her gastric tube. On 4/14/23 at approximately 8:45 a.m. Staff L, Agency, Registered Nurse (RN) administered approximately four to five tablets of Resident #1's medications orally causing Resident #1 to sustain respiratory complications that required suctioning. Resident #1 continued to have respiratory complications which required suctioning throughout the day and her lungs sounded congested. The Advanced Registered Nurse Practitioner was notified and ordered a chest X-ray to rule out aspiration/pneumonia. The chest X-ray resulted on 4/14/23 at 7:07 p.m. and revealed Resident #1 had slight right lower lobe and modest right upper lobe infiltrates [When interpreting the x-ray, the radiologist will look for white spots in the lungs (called infiltrates) that identify an infection. This exam will also help determine if you have any complications related to pneumonia such as abscesses or pleural effusions (fluid surrounding the lungs). Pneumonia | Lung inflammation - Diagnosis, Evaluation and Treatment, radiologyinfo.org, https://www.radiologyinfo.org > info > pneumonia]. The resident's providers were not informed of the abnormal X ray results. Review of a nursing note dated 4/15/23 at 6:15 a.m., written by Staff M, Agency, LPN (Licensed Practical Nurse), showed at approximately 5:45 a.m. Resident #1 was found in her room to be without breath, pulse, and blood pressure and the body was being released to the funeral home. This failure created a situation that resulted in a worsened condition and death to Resident #1 and resulted in the determination of Immediate Jeopardy beginning on 4/14/23. The findings of Immediate Jeopardy were determined to be removed on 4/27/23 and the scope and severity reduced to a D. Findings included: Review of Resident #1's face sheet revealed she was an [AGE] year-old female admitted on [DATE] with medical diagnoses that included but were not limited to, gastrostomy status (since 5/4/2022), dysphagia, oropharyngeal phase, need for assistance with personal care oral phase, vascular dementia with behavioral disturbances. Review of Resident #1's quarterly Minimum Data Set assessment dated [DATE], section C, cognitive patterns, revealed a brief interview for mental status (BIMS) score of 5 out of 15 which indicated severely impaired cognition. Review of Section K, Swallowing/Nutritional status revealed .Feeding tube-nasogastric or abdominal (PEG) [percutaneous endoscopic gastrostomy tube] . Physicians order review revealed a diet order for NPO (nothing by mouth), this order started on 10/6/2022 and was discontinued after her death on 4/17/23. Physician's order which started on 5/19/22 and was discontinued on 4/17/23 revealed May crush medications unless contraindicated. A physician's order which started on 5/19/22 and was discontinued on 4/17/23 revealed Enteral feeding: Flush tube with 30cc [cubic centimeter] water before and after every administering medications [sic] and 5cc between each medication every shift day evening night. Review of the speech therapy discharge summary with dates of service of 5/9/22 to 5/16/22, revealed on 5/2/22 a MBSS (modified barium swallow study) was completed, and the resident became NPO due to severe pharyngeal stasis and deep penetration to VF (video fluoroscopy) without clearance. A percutaneous endoscopic gastrostomy (PEG) tube was placed on 5/4/22 and the resident was discharged from speech therapy on 5/16/22 with orders for NPO with PEG placement for all nutrition/hydration/medication; severe impairment. A phone interview was conducted on 4/26/23 at 9:16 a.m. with Staff L, Registered Nurse (RN), a staffing agency employee. She stated I am a Registered Nurse. This was my first time at the facility, I had not received any education at that facility. When I came on shift on 4/14/23 the night nurse and myself couldn't find a report sheet. The report sheet normally has the doctors name, code status, how the residents take meds [medications] and other notes or information about the patient. When we couldn't find a report sheet, the night shift nurse ended up writing on a piece of paper what she knew about the residents. She told me [Resident #1] was alert, oriented, and took her pills whole. Another agency nurse was supposed to be on the other medication cart, but she called off late and the ADON [Assistant Director of Nursing] was on the med cart. After I got report I went to each room that I was told were my patients. Typically, you would know who's on your assignment by the report sheet, but we couldn't find it. I was trying to be as careful as possible because I was not familiar with these patients. I was trying to see what I can see from the MAR [medication administration record] and speaking with the patients. Around 8:45a.m. to 9:00 a.m. I talked to [Resident #1] and I asked her how she was doing this morning and she said fine, and I said here are your medications, are you ready to take them and she said yes, and she opened her mouth. Mostly what [Resident #1] had was just vitamins, ones that the facility provided, she had one or two medications that were not vitamins but that's not atypical to not have some medications on the cart. So, I didn't question that. They were all pills, no liquid. I saw on the MAR something about a tube feed, and I remember thinking well that's weird she didn't tell me anything about that. My thought was I would look further into that and ask questions after I got my meds done because the tube feeding order wasn't due yet. So, when I put the meds in her mouth she started coughing immediately, I already had the bed positioned sitting up so they have a better way to swallow, and I had my gloves on and I scooped everything out of her mouth that I could get, and she said there's still something there. I administered about 5 pills. The first time I scooped out of her mouth I scooped 3 pills. She continued to talk to me throughout the whole process and was able to make her needs known and at that point I asked [ADON] for help. She grabbed the suction. We went into the patient's room, and she [Resident #1] would cough occasionally when we went back into the room. She said there was still something stuck and we told her we were going to suction her, and she said okay, and she opened her mouth. As we were standing there [ADON] was saying this patient is confused, she's not alert and oriented and she doesn't take anything by mouth. At that point I was made aware that this wasn't even my patient for the day. I went into the bathroom and cried because I was not really prepared for that type of situation. One, I felt so bad because this could have been prevented in multiple ways. The shift reports that are supposed to be readily available and they weren't that day. The MAR did not indicate the route of administration and that's what made me so confused because it did not indicate that meds were supposed to be given by g-tube [gastric tube]. And even after the situation I went back to make sure I didn't miss anything on the MAR, and I didn't find anything indicating this patient was NPO. In order to do that you would have to go out of the MAR and go into the medical record and with me not being familiar with this patient I should have done that earlier. After the fact, when I looked, it said she was NPO, and she had the bolus tube feed however I did not find anything about her being confused. When I pulled up the resident's MAR, I did not have to pull up a different unit or change a filter on the MAR to another unit. After she [Resident #1] was suctioned, she was still speaking, we asked if she was okay, she said yes, I took her vital signs everything was within normal limits except her blood pressure was a little bit elevated but everything else was within normal limits. Afterwards I talked to [ADON] and my agency because I didn't feel comfortable for myself, and I felt it wasn't safe for the residents. I told [ADON] the same thing and she said I couldn't leave unless I was replaced because it was only me and her on the carts. That's when she pulled a report sheet for me with my assignment, I honestly don't know where she got the sheet. I did an event report, I called the nurse practitioner, and I called the patient's daughter. They [facility staff] were all just not wanting me to leave. I was just blown away because I have never had that happen. I'm used to a very organized facility, and this was a very unorganized situation. I always thought I was careful and now I have to be more careful and making sure I'm given the right report and making sure things match up. The ARNP [Advanced Registered Nurse Practitioner] did come up and see the patient and she told me no new orders because the patient was stable, she even told me that on the phone when I called. But then later on in the afternoon they did order a chest X-ray to verify the patient had not aspirated and the daughter was notified also of the X-ray. I kept my cart [medication chart] by the patient's room and every time I would come out of a room I would go into her room and a couple times I took her vital signs. I think I charted my vitals and the monitoring. She had coughed a little bit and at one point I did suction her again. I did not listen to her lungs. I was not able to be replaced so I told them I was not going to do my second shift and I let them know this more than 2 hours in advance. When it was time to go, they did not have anyone to cover for me. I stayed late till about 3:45 p.m. and [ADON] ended up counting my narcotics with me and taking my report and I left. [ADON] was the only one on the floor when I left because I hung around waiting for relief and eventually, she told me okay I'll take report because relief is on the way. [ADON] stated to me these things happen all the time we called the doctor, we called the family, and we did what we were supposed to do but that did not make me feel better. An interview was conducted on 4/25/23 at 1:52 p.m. with the ADON, she stated, On Friday [4/14/23] the nurse that was supposed to work a cart [medication cart] called off late so I ended up working the cart upstairs on the second floor, I was assigned the front hall. I was on the low side and the other agency nurse was on the high side. I started from room [ROOM NUMBER] to 217 plus I had room [ROOM NUMBER] bed A and B. The ADON indicated she was assigned to be Resident #1's nurse. The ADON also stated, As I was giving medication on my side the agency nurse came to me and she said 'I need your help, I need your help, I gave [Resident #1] her medications and she started to choke I did not realize that she was a peg tube. I was told in report that she took her medication whole. She [Resident #1] confirmed to me that she took her medication whole and then she started choking and then I realized she was a PEG tube patient' .I want to say about 9:00 a.m. she [Staff L, Agency, RN] came to me and told me about the medication error. Because she told me it was about [Resident #1] I know she is a peg tube patient. So, I stopped at the emergency code cart and grabbed the suction. Then we got to the room and [Resident #1] was talking and I noticed some pills because the nurse did tell me she tried to get the pills out by having her cough and stuff. I saw two pills on the floor. [Resident #1] was acting herself, confused, combative, resistive to care, but she was talking not making sense, but she was talking and coughing, I plugged in the suction machine, and she did sound kind of congested, so I did suction her I asked the other nurse to check the pulse ox [oximeter] because she had it in her hand at that time. I don't remember what her pulse ox reading was but myself and the other nurse were in the resident's room for a good 15-20 minutes suctioning her and making sure she was okay. Then I asked the nurse to call the nurse practitioner, to call the resident's daughter, and to document, and to do the event report. The nurse practitioner came in and I told her about what happened, and she told me I know the nurse called me, and she told me she was going to see the patient. The fluid that I suctioned out was not really clear it was milk-like or cloudy color so I was assuming that because of the color of the suctioned fluid that I got more pills out so I told the nurse practitioner that and I asked her if I could still give her, her medications through her peg tube and she said yes. That was about an hour after the incident. Once the resident was safe, I asked the nurse where did you get her medications to give it to her. Because that residents' medications was on my medication cart. I'm not going to lie I did not hear what she said but she did not have one card of [Resident #1's] medications on her medication cart .I don't remember ever leaving my cart unlocked. And I said to her [Staff L, Agency RN] if you did not have one card of her medications wouldn't that be a trigger for you to stop and ask a question. She said well I asked the resident if she took the medications whole and she said yes. [Resident #1's] bedside table was next to her bed, and it had the flush cup with the syringe [g-tube supplies] and I asked, that didn't trigger you to think she doesn't take her meds whole? And she said well I got in report she takes her meds whole. The ADON continued to say I have no idea whose medications she administered to [Resident #1]. The night nurse that was on shift before the agency nurse [Staff L, Agency, RN] did not have the right report sheet we use, it was a handwritten report sheet. When the agency nurse [Staff L, Agency, RN] showed me her report sheet she got from the nurse on shift before her, I looked at it but I did not look at it closely to see what was written on it but I told her [Staff L, Agency RN] that this is a teaching moment for you because then I took her to the nurses' station and showed her in the blue folder is where she can find the report sheets. I didn't document this, but I went back almost every 30 minutes to 40 minutes to check on [Resident #1]. When I didn't go back, the other nurse went back. I suctioned the resident two or three more times throughout the shift and the other nurses went back to check on her, I don't know if she suctioned her too. Then maybe it was around 1:00 p.m. I asked the CNA's [Certified Nursing Assistants] to get [Resident #1] up and put her at the nurses' station because that's where she normally sits, and she sounded fine. Then I asked the CNAs to put her back to bed. And around 1:50 p.m. she [Resident #1] sounded congested and that's when I asked the Nurse Practitioner to order a chest X-ray for her. I ordered the chest X-ray, and they came around 6:00 or 7:00 p.m Around 5:30/6:00 p.m. is when a nurse came and relieved me from my shift. I told the nurse what happened earlier that day and I told her that we have been monitoring her and I told her to pay attention and listen to her lungs and suction her as needed and I had gotten an order for the suction and I told her that the x-ray needs to be taken then I told her to follow up. I don't know if the nurse did follow up on the results of the x-ray because I don't recall seeing any documentation . I received a text from the same nurse that relieved me because she ended up working 11:00 p.m.-7:00 a.m. and she said she went around 1:00 a.m., at the scheduled time, to bolus feed the patient [Resident #1] then the CNAs told her the patient wasn't breathing around 5:45 a.m. I don't remember what day it was, but I did check for the x-ray and I asked the nurse, [Staff J, LPN], did you get the x-ray? Can you call for the x-ray? We got the x-ray it said there was infiltration of her lungs. Sometimes the [radiology company] will fax the results to us and sometimes we will call to ask if they can fax it to us. Receiving the reports, it's getting a tiny bit better now . I have been here for less than two years, but I cannot recall her [Resident #1] having respiratory issues. As long as I have been here the resident has always been NPO. A phone interview was conducted on 4/24/23 at 4:51 p.m. with Resident #1's Advanced Registered Nurse Practitioner (ARNP). She stated I am familiar with [Resident #1]. I am aware of the nurse giving the resident oral medications when she was supposed to receive her medications through her G-tube. I was in the building when the nurse called me and told me she gave the resident oral medications when they were supposed to go through her G-tube. I told her I would be right up that I was in the building. I assessed the patient, and she was not in any respiratory distress. I listened to her lungs, and they were clear, she was not gasping or choking or coughing. I went and spoke with the nurse and the ADON, who was on a cart but on a different unit or assignment. Then, it was the weekend, and the ADON requested a chest X-ray, and I okayed it. I'm not typically on call on the weekends but I do answer my phone for the residents. The chest X-ray did get done. I took a picture of it because I knew this was going to be an issue and come up again. It says date of service 4/14/23 at 7:00 p.m. conclusion, slight right lower lobe and modest right upper lobe infiltrate . The patient isn't alert and oriented at baseline, so she didn't complain about any pain or distress or discomfort. At this time, the nurse was on the phone with her agency trying to get released because she was upset by what happened. The ADON was on the same unit and when I talked to her, she told me, 'I don't even know why she even gave the patient the medications because that wasn't her patient .' They didn't call me to tell me the patient had passed away and when I got there on Tuesday [4/18/23] for my rounds around 9:30 a.m. that's when I heard she died, I'm shocked. I had to call and get the x-ray results. I had the nurse, Staff J, LPN, call the X-ray company to request them and they then faxed them over and I waited at the fax to get it. I reviewed it [the imaging] and that's when I found out she died, right before I went into the room. This was definitely a medical error on the nurse's part I would expect the nurse would have stopped everything when she realized there was no medications in her cart and investigated why. The first thing I noticed when I went into the room was suction at the bedside and what made me question it was if someone is NPO there is no need to have suction at the bedside. The nurses did not set up the suction at the bedside that day it was already available. Since February, I have not had any concerns with this patient. The resident was stable, there was no indication that she would be dying anytime soon, the resident does not have a respiratory history to my knowledge, and she was ordered to receive her medications through her G-tube. She should not have had anything by mouth. On 04/25/23 at 3:46 p.m., an interview was conducted with Staff N, CNA. He stated he knew Resident #1 quite well. She was normally talkative and lively. She would carry a conversation though not always coherent. She was herself up until the last minute. This CNA stated he worked a double shift the day the resident was given the wrong medication. He stated he worked 7:00 a.m. - 3:00 p.m. and then 3:00 p.m. - 11:00 p.m. He stated on that day, the resident was not herself after ingesting the medication. He said, she was groggy and was regurgitating all day. She acted like she was trying to throw up or like she had something in her throat. He stated this was not the resident's normal behavior. I had never seen her like that. She did not speak much after the medication incident. This staff member stated he learned the resident had passed away when he returned to work on Monday 4/17/23. Review of the nursing progress note dated 4/14/23 at 9:47 a.m. written by Staff L, Agency, LPN [sic] the following documentation. This RN was given report by night shift stating that this pt [patient] was on assignment and took meds whole. Both nurses attempted to locate report sheets unsuccessfully. Verbal report given with handwritten notes for how pts take meds. This RN was not informed that this pt had a PEG tube or was confused. This RN went into pt room and verified pt, spoke to pt stating had her medications and asked pt to verify that she took pill whole. Pt stated yes so RN proceeded. Pt immediately started coughing and RN had pt spit meds out. Pt was speaking and following commands but said she still felt that something was stuck. This RN went and sought out help and informed staff RN of what had taken place and was informed at that time that this pt was not on her assignment. Pt was suctioned to get rest of meds out of mouth. Pt still speaking and not in any apparent distress. NP [Nurse Practitioner] [Resident #1's NP] notified as well as pt [Family member], Both said thanks for letting them know. No new orders at this time. Event report to follow. A nursing note dated 4/14/23 at 1:50 p.m., written by the Assistant Director of Nursing (ADON), revealed the following documentation. Resident received medication by mouth this am [morning]. Frequent monitoring is ongoing, resident lungs sounds congesting [sic] with moist and productive cough. Resident Continues [sic] to receive suctioning as needed and tolerated well. Start [sic] chest X-ray order received to r/o [rule out] aspiration/pneumonia. Noted as ordered, resident daughter notified of new order via phone states that's a good idea. Claim number for X-ray A nursing note dated 4/15/23 at 6:15 a.m., written by Staff M, Agency, LPN, revealed the following documentation. @ [at] approx. [approximately] 5:45 a.m., the CNA reported to this nurse that res [resident] was not breathing, this nurse toke [sic], a second nurse and upon entering the room, note res chest was not rising and falling, did not feel no movement and was unable to palpate or auscultate a pulse or a B/p [blood pressure], the second nurse also verified these findings. This nurse notified the daughter, The Dr. and the fugneral [sic] home and are now waiting for them to come have the body released to them. Review of Resident #1's April medication administration record (MAR) revealed on 4/14/23 between the hours of 7:00 a.m. to 11:00 a.m. Staff L, Agency, LPN, documented the administration of 1 tablet of Cholecalciferol 25mcg(micrograms), 1 tablet of docusate sodium 100mg (milligrams), 2 tablets of acetaminophen 650mg. Staff L, Agency LPN, also signed off on the administration of Resident #1's order for ferrous sulfate tablet, 325mg (65mg iron) amount to administer: 7.5ml [milliliters]. Staff L, Agency, LPN, documented Resident #1 did not receive her ordered Seroquel 300mg because Drug/Item Unavailable. The documentation revealed Resident #1 received approximately four to five tablets of medication. Each one of Resident #1's medication orders indicated her medication should be administered through her gastric tube. Review of a physician's order with a start date of 4/14/23 and an end date of 4/17/23 revealed PA Chest: LAT [lateral] Chest: Special instructions: Start [sic] chest X-ray to r/o aspiration/pneumonia once a day 07:00-23:00 [7:00 a.m.-11:00 p.m.]. Review of Resident #1's chest X-ray 2 view, with a date of service of 4/14/2023 and a report date and time of 4/14/23 at 7:07 p.m. revealed the following documentation Conclusion: Slight right lower lobe and modest right upper lobe infiltrates (substances denser than air). This was electronically signed by the interpreting Physician on 4/14/23 at 7:07 p.m. Review of the medical record did not show a note documenting that Resident #1's physician was informed of the abnormal chest X-ray results. Review of the Facility Event Summary Report dated 4/14/23 at 10:14 a.m. revealed, Resident Name: [Resident #1] Event Type: Medication Error Creator: [Staff L, Agency, LPN] [sic] STAT: no Status: in progress Open/Closed: Closed Closed Date/by: 4/14/23 [Staff L, Agency, LPN] [sic] Description: RN given report by night shift stating this pt was on assignment and took meds whole. Night shift nurse and this RN attempted to locate assignment sheets unsuccessfully. This RN went into pt room, verified pt, and asked pt if she was able to take meds [medications]. Pt stated yes and opened her mouth. RN administered meds and pt immediately began to cough. RN grabbed napkin and asked pt to spit them out. Pt spit pills out into napkin and told RN that she still felt something was stuck. Pt still able to speak and cough through event. RN verified on report paper that was given with writing that had right pt and then went to seek out staff RN who stated that this pt is confused, NPO, and not on this RN assignment. PT suctioned to remove rest of meds. [Resident #1's Nurse Practitioner] notified as well as [Family Member]. No new orders at this time and [Family Member] thankful for information. Attending faxed: No Physician notified: Yes, date and time 4/14/23 10:30 a.m. Note: no new orders Family notified: Yes, date and time 4/14/23 10:30 a.m. Note: blank Care plan reviewed: Yes, date and time 4/14/23 10:30 a.m. Note: blank Evaluation: pt being monitored Further review of the Facility Event Summary Report dated 4/14/23 at 5:56 p.m. revealed Resident Name: [Resident #1] Event Type: Medication Error Creator: [ADON] STAT: No Status: completed Open/Closed: Open Closed Date/BY: blank e-signed: blank Description: Medication error Review of Resident #1's vitals revealed on 4/14/23 at 10:38 a.m. the resident's pulse oxygen reading was 91% on room air, her pulse was high at 122 beats per minute. Her respiratory rate was 16 breaths per minute, and her blood pressure was 178/87 mm HG (millimeters of mercury). According to the Cleveland Clinic, normal adult vital signs ranges include blood pressure, 90/60 to 120/80, Pulse 60 to 100 beats per minute, respiratory rate 12 to 18 breaths per minute. https://my.clevelandclinic.org/health/articles/10881-vital-signs. Also, according to the Cleveland Clinic, a healthy oxygen saturation is typically above 90%. https://health.clevelandclinic.org/should-you-get-a-pulse-oximeter-to-measure-blood-oxygen-levels/. There were no other vitals documented in the medical record after 4/14/23 at 10:38 a.m. Further review of Resident #1's vitals obtained in the month of April revealed her oxygen saturations were 96% and 99%. Her documented pulse readings for the month of April were between 74 beats per minute and 96 beats per minute and her blood pressures were between 116/57 mm Hg and 146/62 mm Hg. On 4/24/23 at 4:06 p.m. an interview was conducted with the Director of Rehab. She stated . She [Resident #1] is not able to respond to a question appropriately. She is verbal but clearly expressing wants and needs, she's not able to do that, she's not nonverbal but she was nonsensical. Her vascular dementia, psych diagnoses, confusion, and she's a silent aspirator and that is what lead her to staying NPO because she did have the g-tube replaced. Speech [Speech Therapy] had tried to put her on a pleasure diet but due to her confusion, she did not have the compensatory strategies for safe swallowing. She wasn't able to comprehend and follow through with swallowing. When she first came in, she did not have a peg tube, then she was starting to cough and choke more. Then later during her stay she got the peg tube. There has been a decline as she has been here [at the facility]. There was no confusion, she was NPO. If I went in with food she would say yes because she doesn't understand she can't have that. She has no awareness of her deficit. The Director of Rehab indicated she was not here [at the facility] at the time of the event. She also indicated the Director of Nursing, and the Staff Development Coordinator were out of town all last week and not here at the time of the event either. But she confirmed there was a meeting which included the ADON, the Nursing Home Administrator (NHA) and other managers. She indicated at the time of the meeting she read the notes and it was clear the resident died from taking oral medications and she verbalized during the meeting that this was not right. The Director of Rehab indicated she had just ordered Resident #1 a custom wheelchair and the resident had been making progress and was able to tolerate sitting up in the wheelchair for 4 hours. On 4/24/23 at 3:30 p.m., an interview was conducted with Staff J, LPN. She stated she had worked at the facility since 2019 and worked with Resident #1 every time she worked. She indicated she was very close with Resident #1, and it broke her heart when she found out she died. She said she could not understand how the nurse could have given the medications orally because all her orders said to administer her medications by G-tube and her diet order said she's NPO. Staff J, LPN said Resident #1 was alert, very confused, but a sweetheart and could be feisty at times. Staff J, LPN indicated Resident #1 had pneumonia before but that was a very long time ago and even then, her oxygen saturations were always good. Staff J, LPN indicated that other than having the pneumonia a long time ago Resident #1 did not have a history of any respiratory distress. On 04/25/23 at 3:53 p.m., an interview was conducted with Staff P, CNA. She stated she worked with the resident sometimes and was working the night she passed but was not assigned to the resident. She stated she was in her assigned area throughout the night. She stated she did not observe any unusual behavior or incident. There was no commotion at any given time. She stated, everyone was doing their usual thing, and she mostly stayed at her assigned area. She stated from the nurse's unit she could see the resident's room. She said, I did not notice unusual activity throughout the night. She stated the CNA who was assigned to the resident had notified her that the Resident had passed away . The Nursing Home Administrator (NHA)was interviewed on 4/25/23 at 11:10 a.m. He said The nurse documented, from my recollection, to paraphrase, she administered PO [by mouth] meds to a NPO patient then had requested resident responded by spitting the meds out, and the ADON who was present, adjacent on the hallway she was working a cart that day. I had an ice machine issue so I had come in for that and the ADON said can you talk to the nurse, so I did, and she was acting strange, she said her shift report is not great and she said she had a problem with shift report. When I talked to her, she had the computer screen pulled up and it clearly highlighted that the patient was NPO. She said the patient spit the meds out and the patient was suctioned. This is an agency nurse, and I was there to calm her down. I literally just pointed to the screen and on the left-hand side of the screen, I'm assuming it was the MAR, it was blue I believe, maybe green, you'll have to excuse me I'm colored blind, it was rectangular, it was enough for me to look up and it was there that the patient was NPO. So, then I called [employee of the agency company], he is an employee of [Agency Company], the nursing agency, and he is the individual who is the one I call when I have a concern about one of their staff members acting weird and I communicated my concern with [employee of the agency company] and I talked to him and told him she was acting weird, I felt she was acting odd because the nurse kept saying I have to go, I gotta go, and I said wait you can't abandon your shift and [employee of the agency company] said that he got the message that she wanted leave. [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure medical records contained accurate documentation related to wound care for one (Resident #7) of thirteen sampled residents. Findings included: A review of Resident #7's medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses of need for assistance with personal care, muscle weakness, and hypertension. An observation was conducted on 6/5/2023 at 10:05 AM of Resident #7 inside of the resident's room. Resident #7 was sitting in her room in her wheelchair and was receiving medications from Staff L, Licensed Practical Nurse (LPN). Resident #7 was observed to have bandages to her bilateral upper and lower extremities. A wound was observed to Resident #7's left lateral forearm at the level of the elbow covered with a dried up yellow colored fabric. A soiled gauze wrap was observed wrapped around Resident #7's lower left forearm dated 6/2/23. A wrapped gauze dressing was observed to Resident #7's left shin area dated 6/2/23. A soiled wrapped gauze dressing was observed to Resident #7's right forearm with no date documented on the dressing. Resident #7 stated the dressings were supposed to be changed every day but was not able to state when the dressings were last changed. An interview was conducted following the observation with Staff L, LPN. Staff L, LPN stated they didn't change them when referring to the dressings and addressed the dressings on Resident #7's left forearm and left shin were dated 6/2/23. Staff L, LPN stated she wrote the treatment down on her report sheet and she would change the dressings later. Staff L, LPN did not attempt to perform wound care for Resident #7 during the observation. A review of Resident #7's Minimum Data Set (MDS) assessment dated [DATE] revealed under Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 13, indicating Resident #7 was cognitively intact. A review of Resident #7's physician's orders revealed the following orders: - An order dated 5/9/23 to cleanse wound to the left elbow with normal saline (NS), pat dry, apply xeroform to wound bed, and cover with dry dressing once daily on the 7:00 AM to 3:00 PM (Day) shift. - An order dated 5/2/23 to cleanse wound to the left distal leg with NS, pat dry, apply xeroform to wound bed, cover with gauze, wrap with kerlix, and secure with tape once daily on the Day shift. - An order dated 5/2/23 to cleanse wound to left lower arm with NS, pat dry, apply xeroform to wound bed, cover with gauze, wrap with kerlix, and secure with tape once daily on the Day shift. - An order dated 5/2/23 to cleanse wound to the left proximal leg with NS, pat dry, apply xeroform to wound bed, cover with gauze, wrap with kerlix, and secure with tape once daily on the Day shift. - An order dated 5/9/23 to apply skin prep to the right lower arm every shift. Resident #7's physician's orders did not reveal a dressing order for the right forearm. An interview was conducted on 6/6/2023 at 3:42 with the facility's Director of Nursing (DON). The DON stated the nurse on the floor is responsible for performing everyday wound care treatments. The DON stated she would expect the nurse to notify the administrative nursing team, such as herself or the Assistant Director of Nursing if a wound care treatment was not performed so one of them could perform the treatment if needed. The DON also stated she would expect the nurse to notify the resident's physician and family if wound care was not completed as ordered and she would not expect nursing staff to document wound care as completed if it was not completed. A review of the facility policy titled Physician Services, with no effective date, revealed under the section titled Procedure all physician orders will be followed as prescribed and if not followed the reason shall be recorded on the resident's medical record during that shift. A review of the facility policy titled Documentation, with no effective date, revealed under the section titled Policy the clinical team shall document all relevant data and information pertaining to the provision of care and services to the residents in the medical record. Any and all forms of documentation by a clinician should be recorded according to accepted professional standards of practice. The policy also revealed under the section titled Purpose documentation is relevant as evidence of clinical practice. Documentation demonstrates the clinician's accountability and records his or her care and services. Failure to keep and maintain certain documentation as required by regulatory agencies, falsifying documentation, and incomplete or inaccurate documentation, may be found to constitute unprofessional conduct.