**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #3's Hospital record revealed Resident #3 was hospitalized from [DATE] to 8/15/2024. The History of Present Illness (HPI) section revealed the following: Patient (Resident #3) is a [AGE] year old male with a past medical history of hypertension, alcohol use, tobacco use, and history of open reduction internal fixation, who presents to the ER (Emergency Room) with complaints of worsening right wrist pain. He was recently admitted on [DATE], due to a right wrist abscess, which was MRSA positive osteomyelitis for which he underwent irrigation/debridement. He required 6 weeks of IV Vancomycin as per ID recommendations for which he received a total of 10 days of antibiotics before leaving AMA on July 26th. Today (8/1/2024), the patient arrived at ER due to progressive worsening pain and swelling of the right wrist. Review of Resident #3's admission Record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including primary osteoarthritis right wrist, arthritis due to bacteria, great wrist, alcohol abuse, housing instability, housed, homelessness and past 12 months, other psychoactive substance abuse, tobacco use, and patient's other noncompliance with medication regimen for other reasons. Review of Resident #3's medical record revealed two elopement risk assessments, both completed on 8/16/2024, which did not indicate Resident #3 was an elopement risk. Review of Resident #3's Order Summary Report for December 2024 revealed the following orders: - 8/19/2024: LOA Independent - 8/16/2024: IV: Change Injection cap every 7 days as well as PRN (as needed). Injection cap to be changed after each blood draw. Every day shift every 7 day(s) for iv therapy. - 8/16/2024: IV: Change IV dressing every 7 days as well as PRN for soiling and or dislodgement. Every evening shift every 7 days. - 8/16/2024: IV: Measure external catheter length every 7 days and as needed with dressing change. Every day shift every 7 days for maintain iv access IV. - 8/16/2024: Vancomycin HCI in NaCI intravenous Solution 750-0.9 MG/250 mL-% (Vancomycin HCI-Sodium Chloride) Use 1 dose intravenously every 12 hours for osteomyelitis until 9/12/2024 13:01 (1:01 p.m.). Review of Resident #3's Progress Notes revealed: - A note dated 8/16/2024 at 1:15 p.m. documenting a skin check was completed for Resident #3. Resident has a PICC (peripherally inserted central catheter) line in the left upper arm, for IV therapy post incision 7.5 cm (centimeters) right wrist, all other skin completely intact; will continue to monitor. - An admission note dated 8/16/2024 at 1:50 p.m.: Admitting Diagnosis: Right wrist osteomyelitis, observation of resident speech: clear .The resident stated reason for admission: IV therapy .The resident or resident representative stated discharge goal: other discharge location arrangements (i.e. group home or hotel) .No, the resident does not use alcohol. No, the resident does not use illegal drugs .The resident has NOT had any of the following: current psychotropic medication use, balance issue with sitting, standing or walking, wandering use of restraint .Yes, Is resident currently receiving antibiotics Route: IV .The resident is Independent for Eating. The resident is Independent for setting up supplies and/or brushing their teeth or Dentures. The resident is Independent for toileting. The resident is Independent for bathing . - A note dated 8/16/2024 at 3:02 p.m. documenting Resident #3 was admitted for IV therapy and would like to go LOA to the store. A call was placed to physician for instructions. - A Shift Level Administration note dated 8/17/2024 at 7:35 a.m.: Spoke to the pharmacist regarding the order of Vancomycin HCl IV not be delivered yet. The pharmacist requested new order for serum creatinine level to be drawn. Laboratory order placed and creatinine was drawn. Waiting for results. Day shift made aware. - A Medication Administration note dated 8/17/2024 at 11:38 a.m. documenting Resident #3's Vancomycin HCl IV would be delivered that evening. - A Medication Administration note dated 8/17/2024 at 1:48 p.m. documenting the facility was awaiting lab results for Resident #3. - A Medication Administration note dated 8/17/2024 at 11:20 p.m. documenting Resident #3 was absent from the facility. - A note dated 8/18/2024 at 4:21 p.m.: Resident [#3] is alert and oriented, with independent LOA Order. On 8/17/2024, he left the facility in stable condition to go to [a local] hospital. On 8/18, the admissions department was notified by .Hospital this resident was admitted for Osteomyelitis. Signed by the DON. - A Social Services note dated 8/19/2024 at 6:59 p.m. documenting a wellness check was conducted for Resident #3 while Resident #3 was in the hospital. During an interview on 12/11/2024 at 2:50 PM the NHA stated Resident #3 was alert and oriented and he was able to mobilize independently. She stated on 8/17/2024, she received a call from nursing staff stating Resident #3 was missing from the facility. The NHA started the investigation by asking staff when the last time they saw Resident #3. She stated the nurse assigned to Resident #3 stated she went to administer the IV antibiotics and noticed he was gone. The NHA interviewed the smoking-aide, who stated she had not seen the resident at the last smoking session. At this point, she started a full investigation, called the police, Department of Children and Families (DCF), and reported to the State Agency. She called all of the staff from that day to check on the resident's demeanor. When she contacted the emergency contact for Resident #3, he provided information related to where the resident would normally hang out. The NHA stated she started to call hospitals and found the hospital where Resident #3 was. She was able to speak with Resident #3, who told her he snuck out of a window. He told her he was able to twist the screws from the window and popped the window open. He then used a bench that was in front of the fence and jumped over the fence into the neighbor's yard. The NHA stated they also found a note on Resident #3's bedside table explaining he left the building. During an interview on 12/12/2024 at 11:16 a.m. with Staff C, CNA, she stated Resident #3 kept asking the nurse for his IV antibiotics, and they were scheduled at certain times. Resident #3 kept reminding the nurse throughout the day and the nurse would just brush him off. Staff C, CNA stated around 2 or 2:30 p.m. on 8/17/2024, she reassured Resident #3 he would get his medication. Staff C, CNA also stated before she left her shift around 3:00 p.m., she saw Resident #3 out on the patio smoking. She stated as she was returning to work at 9:45 p.m., she was notified that Resident #3 was missing. She stated she was told he left a note on his bedside table stating he was going to the hospital to get his medication. During an interview on 12/12/2024 at 11:44 a.m., Staff E, Traveling DON stated at admission they assess a resident to determine if they are an elopement risk and they would look at hospital records to check to see if the resident has signed out AMA. She stated that in order for a resident to go out LOA, the resident has to meet some medical points, such as being their own responsible party, has to be able to walk, must have the physical ability, and cannot have a cognitive deficit. Residents who have IV sites do not get an LOA order unless the physician has put in an order to remove the IV first. If residents leave with an IV site for LOA it can cause further risks. During an interview on 12/12/2024 at 1:29 p.m., Staff D, LPN, stated Resident #3 was admitted to the facility due to an infection. She stated when she started her shift on 8/17/2024, she saw the antibiotic order could not be completed because they needed a lab draw first. Staff D, LPN stated she started the order for the lab, and it took some time for the lab to come back. Once the lab was complete, she called the pharmacy about the Vanco prescription. She stated the pharmacy told her it would be there with the next shipment. Staff D, LPN also stated Resident #3 was persistent all day about getting his medications and, the real problem was the ER doctor told the resident he would have a prescription for antibiotics when he got to the facility. Staff D, LPN stated she tried explaining to Resident #3 the process of the facility obtaining medications and he was very adamant about getting his medication. She stated he kept saying he needs his medication and without his medication he would not heal. When she went to pass medications to Resident #3 at 5:00 p.m., she noticed he wasn't in his room and continued doing medication pass thinking he was probably outside smoking. She stated when the antibiotics came in around 9:00 p.m., she went to give him the medication and realized he wasn't in his room. She went and told the charge nurse she could not find the resident and they searched the building and called the administrator. During an interview on 12/12/2024 at 2:59 p.m., the DON stated alert and oriented residents with a Brief Interview Mental Status (BIMS) that does not indicate cognitive impairment and does not have a responsible party, can get independent LOA orders. The nurses do the assessment and contact the doctor, and the nurses inform the doctor of the conditions to obtain an order for independent LOA. If the residents can navigate safely, they can be independent LOA. The DON stated residents with IV sites can leave LOA independently with a doctor order to make sure they are safe. During an interview on 12/12/2024 at 3:09p.m., Staff M, Doctor of Osteopathic Medicine (DO), stated when determining if a resident can leave independently on an LOA, he considers the individual's history regarding alcohol use, drug use, and mental status, and if the person is responsible enough to come back to the facility. Staff M, DO also stated if a resident has a prior history of alcohol or drug abuse, he will think twice about the independent LOA. Staff M, DO stated, If a resident has a PICC line, I will absolutely not allow someone with a PICC line or IV site to go out alone unless the resident is going to a doctor's appointment with transportation. Review of the facility policy titled Elopement-Overview, dated October 2021,revealed in Overview, the facility elopement definition is as follows: Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., in order for discharge or leave of absence) and/or any necessary supervision to do so the elopement prevention and management program is an interdisciplinary process designed to reduce the risk for elopement while maximizing independence. The interdisciplinary team, which includes the resident/patient and family, designs and develops the least restrictive interventions to meet the individualized needs and goals of our residents/patients. The policy also revealed the following under Guidelines: 1. Complete admission data collection as applicable. 2. Review and evaluate data . 4. Provide staffing training and resident/patient and family education. 5. Refer to the resident/patient leave of absence guidelines if the cognitively intact resident/patient leaves independently for an outing (per physician's order) . 7. Initiate the Missing Resident/Patient Action Plan if unable to locate a resident/patient. Review of the facility's policy titled Leave of Absence Policy (LOA), dated October 2021, revealed under Policy, the facility will promote resident leave of absence for temporary and non-emergency leaves through assessment, education, and monitoring. The policy also revealed under Procedure, 1.) The IDT (Interdisciplinary Team) will evaluate the resident as part of the admission process and with any identified change in condition which may impact the level of support needed for LOA. The assessment may include but may not be limited to: Cognition and Physical Abilities. 2.)Based on evaluation, obtain a practitioner's order for the resident LOA. The LOA may be one of the following: a.) LOA independent, b.) LOA with escort for physical assistance, c.) LOA with escort for impaired cognition, or d.)LOA with escort for impaired cognition and physical assistance. 3.) IDT/designee will complete education for resident/representative regarding the LOA process and their specific practitioner's order, following the evaluation and with any change in condition requiring a change in the LOA order. Review of the facility policy titled Abuse Prevention Program, dated August 2022, revealed under Policy, the facility has designated and implemented processes, which strive to reduce the risk of abuse, neglect, exploitation, mistreatment and misappropriation of residence property. These policies guide the identification, management and reporting of suspected or alleged, abuse, neglect, mistreatment and exploitation. It is expected that these policies will assist the facility with reducing the risk of abuse, neglect, exploitation and misappropriation of residence property through education of staff and residents, as well as early identification of staff burnout, or resident behavior which may increase the likelihood of such events. The policy defines Neglect as failure of the facility, its employees or service providers to provide good and services to our resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Based on observations, interviews, and record review, the facility failed to keep residents free from neglect related to 1.) failing to inform the attending physician of critical lab values in a timely manner and infusing three doses of Vancomycin after receiving those critical labs for one resident (Resident #1) of three sampled residents, requiring Resident #1 to be admitted to the Intensive Care Unit and receive renal dialysis and 2.) failing to provide a safe, secure environment, and adequate supervision for one resident (Resident #3) of three sampled residents, who had a history of alcohol abuse, methamphetamine abuse, homelessness, and leaving medical facilities against medical advice (AMA). The facility also failed to properly assess Resident #3 for Leave of Absence, who had an Intravenous site at the time. Findings included: 1. During an observation on 12/11/2024 at 11:10 a.m. Resident #1 was lying in bed on an air mattress. An interview was conducted with Resident #1. He stated he had a big a decubitus ulcer on his bottom from being in another facility. The resident had a urinary catheter and an IV (intravenous) access in his left upper arm. He stated he was getting antibiotics. It was noted on the door he was on contact isolation precautions. He stated the staff mostly used gowns and gloves when they come in the room. Resident #1 was admitted on [DATE] and readmitted on [DATE]. Review of the admission Record showed diagnoses included but not limited to pressure ulcer of sacral region, stage IV, necrotizing fasciitis, chronic kidney disease, neuromuscular dysfunction of bladder, extended spectrum lactamase (ESBL) resistance, diabetes, hypertension, benign prostatic hyperplasia with lower urinary tract symptoms, retention of urine, and adult failure to thrive. Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE] showed the following: - Section C - Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 11 (moderately impaired). - Section I - Active Diagnoses showed wound infection, renal insufficiency or renal failure, and pressure ulcer of sacral region stage IV. - Section M - Skin Conditions showed one stage IV pressure ulcer. - Section N - Medications showed the resident was on antibiotics. - Section O - Special Treatments, Procedures, and Programs showed he was receiving Intravenous (IV) antibiotics. Review of Resident #1's Order Summary Report, for the date range 10/28/2024 to 11/30/2024, showed the following: - Pharmacy to dose Vancomycin (Vanco) as of 11/1/2024. - Transmission Based Precautions, Contact Precautions-ESBL, wound as of 10/30/2024. - Vancomycin HCL (hydrochloride) in NaCL (sodium chloride) Intravenous Solution 750-0.9 mg (milligrams)/250 ml (milliliters) % use 750 ml intravenously two times a day for ESBL in wound as of 10/29/2024. - Vanco trough, one time only for monitoring and fax results to pharmacy, ordered on 11/13/2024 and revised on 11/14/2024. - Vanco trough only, NO VANCO PEAK and fax results to pharmacy ordered on 11/13/2024 and revised on 11/14/2024. - CBC (Complete Blood Count) with differential, CMP (Comprehensive Metabolic Panel) STAT (right now) ordered on 11/13/2024 and revised on 11/14/2024. - Appointment on 11/14/2024 with the Infectious Disease physician at 10:00 a.m. Review of Resident #1's November 2024 Medication Administration Record (MAR) showed the following: - Vancomycin HCL in NaCL Intravenous Solution 750-0.9 mg /250 ml.% use 750 ml intravenously two times a day for ESBL in wound as of 10/29/2024 was administered on 11/13/2024 at 5:20 a.m. by Staff J, Licensed Practical Nurse (LPN), 11/13/2024 at 6:02 p.m. by Staff H, LPN, and 11/14/2024 at 5:52 a.m. by Staff I, Registered Nurse (RN). Review of Resident #1's November 2024 Treatment Administration Record showed the following: - CBC, CMP, sed rate and Vanco trough scheduled for 11/13/2024 - Vanco trough, one time only for monitoring and fax results to pharmacy, performed on 11/13/2024 at 6:32 a.m. - Vanco trough only, NO VANCO PEAK and fax results to pharmacy was performed on 11/14/2024 at 7:38 a.m. - CBC with differential, CMP, STAT performed on 11/14/2024 at 8:25 a.m. Review of Resident #1's lab values showed the following: - On 11/13/2024 Vancomycin Peak was drawn at 7:00 a.m.: Vancomycin Peak was 78.3 (20.0 -40.0). On 11/13/2024 at 9:29 a.m. the critical results were read back and acknowledged. - On 11/13/2024 a CBC, CMP was drawn STAT at 8:30 p.m. with the following results: Sodium 122 (L) (136-145), Potassium critical value 8.1 (HH) (3/5-5.1), Creatinine 4.45 (H) (0.70-1.30), eGFR (estimated glomerular filtration rate) 13 or below, 15 may mean kidney failure. On 11/13/2024 at 10:41 p.m. the following critical results were read back and acknowledged by Staff I, RN: a Potassium level of 8.1, high critical. - On 11/14/2024 a Vancomycin Trough was drawn at 3:45 a.m. The Vancomycin Trough was 74.1 (10.0-20.0). On 11/14/2024 at 6:16 a.m. the critical results were read back and acknowledged by Staff I, RN. A review of Resident #1's Progress Notes showed the following: - On 11/13/2024, 3:37 p.m. a Summary for Providers note, written by Staff F, LPN, revealed Resident #1 had a change in condition, documented under the section titled Situation: Other change in condition. The section titled Primary Care Provider Feedback documented: perform stat labs and urine. - On 11/13/2024 at 3:43 p.m. a CNA (Certified Nursing Assistant) reported Resident #1 had a small amount of urine in the Foley bag, which was reported to the M.D. (Medical Doctor). Received an order to irrigate and change Foley catheter. Blood work on electronic chart and urine sample in the soiled utility room fridge. Passed to the next shift. Written by Staff F, LPN. - On 11/14/2024 at 7:59 a.m., a Post Event Every Shift Nursing Note Assessment Initiated showed MD notified and treatment initiated. Written by Staff G, RN, Unit Manager (UM). - On 11/14/2024 at 8:46 p.m. an eMAR (electronic medication administration record) Note showed Resident #1 was at the hospital. Written by Staff H, LPN. Review of Resident #1's Hospital records showed the following: - A Nephrology consult dated 11/14/2024 showed: (Resident #1) presented due to abnormal labs that were drawn the evening before. Labs at 2030 (8:30 p.m.) yesterday evening showed a potassium of 8.1, sodium 122, chloride 91, CO2 (carbon dioxide) of 20, BUN (Blood Urea Nitrogen) 78, creatinine of 4.45. Patient has been treated for hyperkalemic protocol. He is apparently on Vancomycin and Vancomycin peak was 78.3 and trough of 74.1. Assessment: Acute kidney injury secondary to bladder outlet obstruction in combination with Vanco toxicity hyperkalemia, hyponatremia, metabolic acidosis, Vanco toxicity, large sacral decubitus, BPH [benign prostatic hyperplasia] with urinary retention. Plan: daily dialysis for Vanco toxicity, stat Vanco level 81.9, daily Vanco levels, do not resume Vanco at this time. - An Infectious Disease Service Consult on 11/14/2024 showed Vanco level was found to be 74 and Vanco was discontinued. Assessment: necrotizing fasciitis sacral area, suspected osteomyelitis of sacral area, bilateral pneumonia with possible aspiration with Haemophilus influezae, suspected UTI (urinary tract infection) with E. (Escherichia) coli, vancomycin related nephrotoxicity with hyperkalemia, diabetes, and respiratory failure. Plan: will continue to monitor once Vanco level falls below 15 then will start patient on daptomycin. - An Internal Medicine note dated 11/17/24 showed Acute renal failure, suspected Vanco toxicity, hyperkalemia, hyponatremia, d/c (discontinue) Vanco due to acute renal failure. Review of Resident #1's care plan showed the resident had a sacral/coccyx stage 4 wound, complications related to wound healing related to infection, diabetes, and PVD. Interventions included but not limited to Enhanced Barrier Contact Precautions, obtain and review lab/diagnostic work as ordered, and report results to MD and follow up as indicated, as of 11/21/2024. Resident #1's care plan also revealed the resident is on antibiotic therapy related to having MRSA (Methicillin-resistant Staphylococcus aureus) in sacral/coccyx wound. Interventions included but not limited to administer medication as ordered and report pertinent lab results to MD. During interview on 12/12/2024 at 10:02 a.m. Staff G, RN, UM, stated Resident #1 was a long-term care resident with a wound on his buttocks. The resident was receiving Vanco and another antibiotic IV for his wound. Staff G RN, UM stated the resident required total care, including a mechanical lift, and he rarely got out of bed because he did not want to get out of bed. Staff G RN, UM stated Resident #1 had a Stage III pressure ulcer and got labs drawn one to two times a week, to manage the Vanco levels. Staff G RN, UM also stated they sent the results (lab) to the ID (Infectious Disease) doctor. Staff G RN, UM stated the day Resident #1 was going to the ID doctor, they physically put the lab results in an envelope instead of faxing the labs to the doctor, which was done by the nurse. Staff G RN, UM also stated she printed the labs, but did not look at them and did not review the labs. Staff G RN, UM stated she logged into the lab website, clicked and printed the labs, and the nurse picked the labs up off the printer. The nurse involved was Staff F, LPN on 11/13/2024. Staff G RN, UM stated she does not remember when the labs came in and she was not notified of any abnormal labs when she came in that morning on 11/13/2024. Staff G, RN, UM stated now, she checks the labs herself to see all the labs. Staff G RN, UM also stated the nurses notify her sometimes now, but not all of the nurses notify her. Staff G RN, UM stated she works Monday through Friday, 7 a.m. to 3 p.m. and the weekend supervisor or the nurses working on the weekend should check the labs on evenings and weekends. Staff G RN, UM stated they (the nurses) were all trained and went through the process to make sure they were following up with the labs, calling the doctor and the family. Staff G RN, UM also stated she started at the facility on 11/12/2024 and started that process with the DON (Director of Nursing) to make sure they were following up with the labs, calling the doctor and the family. Staff G, RN, UM stated they all received the log-in documentation to get labs and call the doctor and they are to document in the progress notes that they talked to the doctor. The lab results are kept in the patient's hard/paper chart. Staff G RN, UM stated on Monday she goes to the portal and checks the labs, checks the patient chart and MAR to make sure all labs are completed, and the DON double checks the labs. Staff G RN, UM also stated the nurses are responsible to review the labs, call the doctor and write orders. Staff G RN, UM stated they normally do Vanco troughs here for every patient, the labs are sent to the pharmacy, and based on pharmacy recommendations the dosing and follow-up labs are followed. Staff G RN, UM stated Staff F, LPN was the day nurse on 11/13/2024, and just took the labs off the printer and put them in the envelope for the transport. Staff G RN, UM stated Staff I, RN was the night nurse who had received the call the night before about the lab results. Staff G, RN, UM stated her expectation was for any critical labs to be called to the doctor, no matter what time. During an interview on 12/12/2024 at 10:48 a.m. Staff F, LPN stated she had worked with Resident #1 a couple of times at the facility. Staff F, LPN stated, I was having to log in for labs, but I did not have access at that time [on 11/13/2024]. That day they hired a UM, and she was the one who brings the labs. Staff F, LPN stated, I did not look at the labs. The UM printed everything and put it in an envelope and the face sheet. I was passing meds and asking for help. The laptops do not print, and I asked for help from the UM to print the forms and went back to passing meds. Staff F, LPN also stated, They only told me, I don't remember what was abnormal (labs) but not the Vanco level. Staff F stated, The labs were done the night before. [Staff I, RN] reported to me something was abnormal but not the Vanco. Staff F, LPN also stated, I don't have any way to see [the labs]. Staff F, LPN stated she went to the DON when she started working at the facility and asked her for the lab access, but she was a traveling DON and did not know how to get access. Staff F, LPN also stated she did not ask the UM for labs. Staff F stated, The way [Staff I, RN] reported, [the doctor] had the [lab] report, they did these labs, and [Resident #1's] was okay. Staff F, LPN also stated, [Staff I, RN] said she called the doctor and to keep an eye on when the doctor calls. Staff F, LPN stated she wrote a statement about the incident and, [the facility] knew what was going on over there, the UM started that day. They did not tell me about the appointment. I knew I needed a face sheet, labs, meds. Everything was a rush. So, the UM handed me the face sheet, med list, and labs. I put them into the envelope and rushed off. During an interview on 12/12/2024 at 11:44 a.m. with the Nursing Home Administrator (NHA) and the DON, the NHA stated on 11/14/2024 she was observing on the 100 main nursing station and overheard Staff F, LPN talking to the Infectious Disease clinic and asking questions in reference to the labs sent with Resident #1. The NHA stated Staff F, LPN was speaking with them (ID) and the ID clinic was transferring Resident #1 to the hospital. Staff F, LPN told the NHA, Resident #1 had a critical lab. The NHA stated she started the investigation and spoke with Staff E, Traveling DON and Staff G, RN, UM in the conference room. The NHA stated she told Staff E, Traveling DON and Staff G, RN, UM the ID clinic was sending Resident #1 to the hospital. The NHA stated Staff F, LPN initially told her she was not aware of the lab results when she gave the labs to transportation, she put the results in the envelope and handed them over. The NHA also stated once they started to investigate and looked back, they looked at the orders and lab results. The NHA stated Staff G, RN, UM told her she was not aware of the lab results; she just printed them. The NHA verified Staff I, RN's first statement which showed resident had abnormal blood work results. RN was passing meds. I intended to call MD in a.m. where I thought I would get a response. There was an admission I had to work on my shift. The resident had no [signs and symptoms] of the abnormal labs in my shift. Signed 11/14/24. The NHA verified the second statement by Staff I, RN showed, on 11/20/24, on the night in question, I had many things to tend to. I believe that a Vanco trough level was drawn sometime that evening or early night shift. I believe that if I knew I should have placed a phone call out to the MD. I do know I hung the 0500 Vanco and passed the results of the trough off to the day nurses with another lab result. And explained to her that I hadn't called the MD in the night. Both statements were provided by the NHA. The NHA stated, I called [Staff I, RN] and spoke to her first, she came in and wrote a statement. I explained that there was critical lab/Vanco level. She said she tended to the admission and did not call the doctor. [Staff I, RN] did admit that she knew the Vanco was critical. I asked her why she did not follow the protocol, call the DON and the MD. She instead handled the admission. The NHA stated they brought Staff I, RN back in after doing the investigation. The NHA stated, [Staff I, RN] admitted hanging the Vanco after getting the critical Vanco lab. She acknowledged she should have followed a different protocol, of calling the MD, calling the DON, and not hanging the Vanco. She stated she mentioned to [Staff F, LPN] about the abnormal labs, but it was just word of mouth at this time. The NHA stated Staff F, LPN was getting ready to send Resident #1 out to the appointment around 8 a.m., and she just grabbed the paperwork and sent it off. The NHA verified the statement from Staff F, LPN dated on 11/14/2024 showed, During report nurse-to-nurse today, my co-worker report [to] me only results from Vanco levels. No more labs was reported to pass to me. The NHA verified a second statement from Staff F, LPN on 11/15/2024, showed, that morning night shift only report me Vanco trough levels. I start passing meds, but I stop for print face sheet and med list from the patient. I went to the nurse station and log me in from the print the papers if request to the UM to print the recent labs. She found an envelope and pass the envelope to me. I put the face sheet and med list papers inside and give it to transport. Labs all ready was in the envelope. The NHA stated during the investigation, they got the information about the 11/14/2024 incident and found the 11/13/2024 critical Vanco peak. The NHA stated, I asked [Staff F, LPN] if she called a doctor about the 11/13/2024 [Vanco peak] and she stated to me I called him for several things, and I thought for sure I told him about the labs. She was not confident enough to say she had or not. The NHA stated she called the doctor herself just to ask him (MD) if Staff F, LPN called him about the critical labs. He (the doctor) stated he did not recall, and he had spoken with Staff F, LPN several times and knows his orders would be standard to send the resident out. The NHA stated when she interviewed Staff F, LPN, She stated to me, when she got the envelope, she put the labs in the envelope and gave it to the transportation. The NHA verified two nurses had knowledge of Resident #1's critical labs on two different days, and no one called a doctor or the DON, and the protocol was to call both. The NHA verified the statement from Staff J, LPN which showed, labs were drawn at 2:30 a.m. on 11/13/24 for trough and peak. Peak was drawn by mistake. Call labs back and reordered trough at 8:30 a.m. peak was mistakenly ordered by the nurse. The NHA stated after they obtained the statements, they continued their investigation. During an interview on 12/12/2024 at 1:06 p.m. Staff I, RN stated she was working the night shift on 11/12 through 11/13/2024, and she checked on Resident #1 many times. Staff I, RN also stated, I received the lab results and was going to call the doctor the next morning .The results came in late in the night. It was an elevated abnormal potassium. I make a little mistake once in a while and not call a doctor. All I remember is [the lab] calling about the potass[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to identify and notify the physician of elevated laboratory results for one Resident #207 of the 43 sampled residents. Resident #207's physician ordered repeat labs on 12/13/19 after reviewing elevated lab results on 12/12/19. The 12/13/19 labs were received reflecting a further increase in white blood cell counts; the facility failed to follow through and notify the physician from 12/13/19 to 12/18/19. During chart review on day three of the re-certification survey, the 12/13/19 labs were identified without physician notification or follow up. The facility then obtained stat (immediate) orders for lab testing on 12/18/19. The results of the stat lab tests identified critical values resulting in Resident #207's transfer to the hospital. Findings Included: Review of Resident #207's record reflected the resident admitted on [DATE] with diagnoses of chronic respiratory failure with hypercapnia, tracheostomy status, dysphagia, gastrostomy status, chronic kidney disease, anemia, unspecified focal traumatic brain injury with loss of consciousness, muscle wasting and atrophy, lack of coordination, abnormal posture,need for assistance with personal care, systemic lupus. Review of Resident #207's laboratory results dated [DATE] collected at 5:30 a.m. showed: white blood cell count of 12.4 K/uL (normal 3.8 to 10.8), red blood cell count of 3.09 M/uL (normal 4.40 to 5.80), hemoglobin *verified by repeated analysis 8.5g/dL (normal 13.8 to 17.2), hematocrit 26.1% (normal 41.0 to 50.0). Written at the bottom of the lab results reflected a message for the ARNP (Advanced Registered Nurse Practitioner) left at 2:03 p.m., and also: Please do serum and urine osmolarity, urine sodium, CMP (comprehensive metabolic panel) and CBC (complete blood count) in am and send FOBT (fecal occult blood test) times 3, signed the physician on 12/12/19. Review of Resident #207's laboratory results dated [DATE] collected at 5:20 a.m. showed: white blood cell count of 14.5 K/uL (normal 3.8 to 10.8), red blood cell count of 3.26 M/uL (normal 4.40 to 5.80), hemoglobin 8.8 g/dL (normal 13.8 to 17.2), hematocrit 27.4% normal 41.0 to 50.0) an arrow next to the WBC reflected the lab was higher and out of range without a signature or new orders. Review of Resident #207's laboratory results dated [DATE], 2:00 p.m. completed stat (immediate) showed: white blood cell count of 26.4 K/uL (normal 3.8 to 10.8) Critical High * verified by microscopic examination, red blood cell count of 3.44 M/uL (normal 4.40 to 5.80), hemoglobin 9.3 g/dL (normal 13.8 to 17.2), hematocrit 28.3 % (normal 41.0 to 50.0). During an interview on 12/18/19 at 10:37 a.m., staff member A, LPN confirmed that he wrote a progress note on 12/13/19 at 2:27 p.m. after leaving a message for the nurse practitioner and stated that he would have given the oncoming nurse that report and expected them to follow up. Staff member A, LPN stated he did not work the weekend and was not aware that the labs were not followed up on. During an interview on 12/18/19 at 10:47 a.m. the Director of Nurses (DON) was notified of the abnormal lab result from 12/13/19 and stated, the nurses review the labs and notify the physician of the results. If there are no new orders the labs go in the physician box to sign, then in the resident's chart. If the nurse has new orders or does not get a response, they continue to call back and notify of the results and document in a progress note. During an interview on 12/18/19 at 11:02 a.m. with the resident's nurse practitioner, she stated she was in earlier today and did not see the labs from 12/13/19. She stated that she was told by the nurse that the resident's vitals were stable and gave orders to pull the PICC (peripherally inserted central catheter) intravenous line. The nurse practitioner stated that she saw the resident but was not aware of the 12/13/19 labs as they should have been faxed to the office and placed in the chart. The nurse practitioner stated if the labs were elevated they should have been ordered daily until they were at baseline or under 10 for the white blood cell count and she was unaware that labs were redrawn on 12/13/19. The nurse practitioner stated she saw the resident and that her notes must be at the office still. The nurse practitioner stated that she will have the office send her notes over and will contact the nurse to reorder stat labs. She stated that she was told the labs were lower and ordered the PICC line to be removed due to the information she received from the nurse. Review of the note from a physician or nurse practitioner obtained via fax from the nurse practitioner's office on 12/18/19 at 12:10 p.m. The follow-up note reflected the nurse practitioner did not document lab information received, reviewed or plan of care, documented the resident was alert and oriented times 3 with normal cranial nerves II to XII, normal sensation and strength. Heent/Neck: no neck stiffness or pain, Musculoskeletal: no limitation in motion, no muscle or joint pain, no muscle weakness, no swelling or redness in joints. Neurologic: good coordination, good memory and speech, no numbness and tingling. During an interview with Staff member A, LPN on 12/18/19 at 12:00 p.m. he stated the labs get ordered online and go in the lab book. Staff member A, LPN stated that he does not fax results to the physician's office unless they are completely normal. Staff member A, LPN stated that he never faxed the 12/13/19 results to the physicians office, just called and left a message with the ARNP and let the oncoming nurse know that a message was left. During an interview with the DON on 12/18/19 at 12:13 p.m. she stated the nurse has the ability to go online and check the labs. The DON went online and printed the labs. During an interview with with Resident #207's Physician on 12/19/19 at 2:55 p.m., he confirmed he was in the building on 12/12/19 and saw Resident #207's labs from 12/12/19 and ordered repeat labs to be done on the 13th. The physician stated he did not evaluate or review the resident's information. He confirmed the labs were all that he looked at and the nurse stated Resident #207's vitals were stable. The physician said that when the labs done on 12/13/19 were reviewed the facility should have called the on call person to let them know the results. The physician stated he comes to the facility every Thursday but did not evaluate the new resident or documents other than the labs from 12/12/19. The physician stated he could not see Resident #207 on 12/12/19 due to receiving 7 to 10 new admissions that day and was not able to see them all. The physician restated the nurse told him the vitals were stable and he would normally see all new residents but that day he had about 8 to 10 new admissions. The physician stated he was unsure of how often the ARNP comes. The physician stated he ordered labs for the next day and never heard about the resident after 12/12/19. During observation of Resident #207 on 12/16/19 at 10:30 a.m., the resident was noted in a double room without isolation precautions. Resident #207's name was not posted at the door. Resident #207's bed and feet could be observed from the doorway. After knocking and asking the roommate for permission to enter, Resident #207 was observed on an airmattress with the head of the bed elevated, a tracheostomy tube covered in brown thick mucous with oxygen at 2.5 liters and humidity set at 35%. The urine draining from the catheter was noted a straw yellow. The tube feeding set at 75 ml per hour with 675 ml infused of fibersource HN. During the observation of Resident #207, staff member A, LPN walked in through the adjoining restroom and asked if anything was needed. Staff member A, LPN was asked about the thick brown mucous from the tracheostomy and confirmed the resident needed suctioning and was unsure of the residents orders for oxygen and humidity as the resident was admitted last week. Staff member A, LPN observed hand washing and donning gloves then suctioning the thick brown mucous with a yankauer suction (oral suction tool)to the tracheostomy tube and surrounding area. Staff member A, LPN stated the resident did not need deep suctioning and the inner trach was changed weekly not daily. Staff member A, LPN completed the suctioning with the yankauer then doffed gloves and washed hands. Staff member A, LPN did not listen to the residents lungs and stated that he did not like to perform deep suctioning often as he felt it was not needed. He left the room to verify the orders of the oxygen and humidity and returned stating the orders were for 2 liters of oxygen, humidity at 28% and deep suction or yankauer suction as needed. Staff member A, LPN confirmed the PICC line dressing on Resident #207's left upper arm was dated 12/8/19 and confirmed the dressing was past the date it should have been changed. Staff member A, LPN stated the PICC line was not being used and would be discontinued due to improving or stable white blood cell count although the white cell count still remained elevated. During an interview on 12/16/19 at 11:31 a.m. with staff member A, LPN he confirmed new orders for a chest x-ray related to the dark colored mucous from the tracheostomy and confirmed the PICC line dressing was changed. During an interview on 12/19/19 at 8:15 a.m. with staff member B, LPN she confirmed Resident #207 was sent out to the hospital for critical labs but she had not worked with him. Review of the progress notes dated 12/18/19 at 6:30 p.m. reflected the nurse documented the resident sent out to the hospital by the ARNP for critical labs and the resident's mother was in the building at the time and notified. Review of the 12/18/19 progress note at 1:26 a.m. reflected the resident was admitted to the hospital for sepsis, pneumonia, UTI and abnormal labs. During an interview on 12/19/19 at 11:51 a.m. with the Director of Nursing (DON) she confirmed that the resident was sent to the hospital for elevated labs and confirmed his last labs were completed on 12/13/19. The DON stated that she had begun inservicing on tracheostomy care, IV care and following up on labs. Review of in-service training completed on 7/19/19 reflected lab services/physician included Notification of the physician on any abnormal lab results, Physician should be made aware of all critical labs immediately. If unable to reach physician within two hours of stat labs or critical lab values, contact facility medical director for further orders. Review of the notification of resident/patient change in condition policy from clinical guidelines manual 5.1.1, one page dated 2/19 reflected 1) Notify the physician resident/ resident representative, and case management when indicated, if there is a significant change in condition, regardless of the time of day. a) If the nurse responsible for the care of the resident is remaining with the resident and us unable to place the telephone calls, another nurse will place the calls. 2) Document the Nurse's notes, the time of notification was made and the names of the person(s) to whom you spoke.