**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement appropriate interventions to include provision of adequate supervision to prevent fall with major injury for 1 of 3 residents reviewed for falls, of a total sample of 4 residents, (#1). The facility's failure to increase supervision for a resident with a history of repeated falls resulted in actual harm for resident #1. Findings: Review of the medical record revealed resident #1, an [AGE] year old female was admitted to the facility from an acute care hospital on 7/12/24 with diagnoses including acute respiratory failure, sepsis (blood infection), primary thrombocytopenia (slow blood clotting), dementia with behavioral disturbance, need for assistance with personal care, and difficulty walking. Review of the most recent Minimum Data Set (MDS) admission 5-day assessment with assessment reference date of 7/16/24 revealed during the look-back period, resident #1 scored 4 out of 15 on the Brief Interview for Mental Status which indicated she was severely cognitively impaired. No behavioral symptoms or rejection of care necessary to achieve goals for health and well-being were noted. The Preferences for Customary Routine and Activities interview completed with the resident noted it was somewhat important for her to go outside for fresh air. The Functional Abilities and Goals assessment showed the resident required a wheelchair and walker, substantial/maximum staff assistance to complete Activities of Daily Living (ADL), mobility functions, and to wheel a wheelchair. Walking was not assessed due to her medical condition/safety concerns. The resident was incontinent of bladder and bowel functions, short of breath with exertion or lying flat, did not have a history of falls within the previous 6 months of admission, nor since admission or during the assessment period. The assessment indicated a Care Area was triggered for an identified problem of Falls. Review of the Lifestyle & Activity Preferences Evaluation dated 7/24/24 noted resident #1 had impaired hearing, required glasses, needed reminders for activity participation, and needed assistance to/from activity settings with wheelchair mobility. On 10/13/24 at 12:10 AM, resident #1 was observed sitting in a wheelchair at the end of the nursing unit hallway looking out the windows into the parking lot. Licensed Practical Nurse (LPN) U was nearby and explained the resident had poor cognition; was confused and enjoyed the sun. Review of Unscored Fall Risk Evaluations completed on 9/05/24 and 9/14/24 noted nurses assessed resident #1's Safety Awareness/Behavior with a lack of understanding of cognitive functions and altered awareness of physical environment. The evaluation completed 9/15/24 noted additional risks had developed related to Safety Awareness/Behaviors with lack of understanding of physical limitations, including anxiety and restlessness. On 10/15/24 at 11:05 AM, resident #1 was observed lying awake in bed in her room. The resident's right lower leg was hanging off the side of the bed. Faded, healing bruises were observed under her eyes and a half inch partially healed laceration was visible near the bridge of her nose. Resident #1 was not able to answer basic questions appropriately. Review of the facility's September and October 2024 Fall Logs revealed before resident #1 fell on [DATE], she had 4 previous falls on 9/05/24, twice on 9/13/24, and again on 9/15/24. In an interview on 10/14/24 at 3:26 PM, the Director of Nursing (DON) confirmed none of the falls before the fall incident on 10/05/24 were witnessed by staff. A nurse's Progress Note completed by the Unit Manager (UM) showed that on 9/05/24, a Certified Nursing Assistant (CNA) observed resident #1 on the floor of her room, bleeding from the back of her head. A Physical Medicine And Rehabilitation Progress Note dated 9/05/24 read, . (resident #1) reports falling but does not remember how. She states she does have some pain to her head. Nurse reports patient attempted to transfer herself this morning and subsequently fell in the process. Nurse reports patient is at baseline with confusion and neurochecks and vital signs had been normal. Patient had a head laceration that was bleeding. I asked patient if she would like Tylenol, she initially stated no that she has a high pain tolerance but when asked again she said yes. Psych: Alert oriented to person only.Falls: Risk of complication: HIGH . PT (Physical Therapy)/OT (Occupational Therapy) to assess balance/gait and recommended to improve balance/coordination, and strength. Fall precautions optimized per facility. On 10/15/24 at 10:50 AM, CNA J explained she knew resident #1 well and sometimes had her on assignment. The CNA said resident #1 often attempted to get out the wheelchair to stand up on her own, she enjoyed being near the windows with sunlight, and CNAs monitored the resident in common areas or the television viewing area. She described frequent checks as, whenever I'm done and making sure they're okay. The CNA said she was not ever directed to check on resident #1 within specific timeframes. She described the resident as impulsive and could get up from her wheelchair very quickly and it was difficult to monitor her all the time. She explained they could be attending to another resident for more than 20 minutes at one time and staff needed to watch the resident closely to make sure she was not trying to go outside alone. Review of a SBAR (Situation-Background-Assessment-Recommendation) form completed by LPN A documented resident #1 fell on [DATE] and had a facial laceration with altered level of consciousness that required emergency 911 transport to the hospital. The Hospital Transfer Form noted the resident was combative and confused, and was high fall risk. On 10/14/24 at 11:17 AM, CNA F recalled on 10/05/24 at approximately 1:00 PM, he returned lunch trays to the dining room and as he looked outside, he saw resident #1 alone across the courtyard on the patio getting out of her wheelchair. He explained he ran outside and across the courtyard to help, but by the time he reached her, she was lying on the ground face first. He said resident #1 had blood on her face and swelling on her head. On 10/14/24 at 10:44 AM, CNA G said she frequently had resident #1 on her assignment. The CNA recalled she was working on 10/05/24, the day the resident fell outside. She said staff knew the resident was a high fall risk and they had to keep a very close eye on her because she liked to go outside for sunshine and frequently tried to go out the door unsupervised. She said she intercepted the resident multiple times over the past few months and prevented her from going out alone. The CNA explained resident #1 was not safe to be outside on her own. She described resident #1 used her feet to scoot in the wheelchair and could not go very far but she could open the door. She said on 10/05/24 after lunch, the resident was sitting in her wheelchair in the common area near the courtyard exit door when she told the CNA she wanted to go outside. The CNA said she told the resident she would return to go out with her as soon as she could, after she assisted other residents. The CNA explained, she assisted another resident in a room with lunch and was later alerted by another CNA that resident #1 was outside on the ground. She said CNAs were unable to monitor the resident closely while they assisted other residents with meals and incontinence care because she was very quick. The CNA explained frequent checks were supposed to be every 15 minutes or as often as possible. She said CNAs did not have written documentation for residents who were at high risk for falls and that it was communicated to each other verbally, we all just know. In a telephone interview with LPN A on 10/13/24 at 3:53 PM, she explained resident #1 was frequently included in her assignments and knew her well. She recalled on 10/05/24 at approximately 1:00 PM, she was alerted by CNAs the resident had fallen outside on the patio, face down on the ground. She said she assessed the resident and found her to be more disoriented than normal. She was bleeding from her nose and face with a large bump on her forehead. The LPN said she was very concerned the resident may have a serious head injury and she contacted Advanced Practice Registered Nurse (APRN) L for orders to send her out to the hospital. She said the APRN was hesitant to send the resident out because she wasn't on blood thinner medication and the Health Care Surrogate (HCS) didn't want her to go out to the hospital. The LPN said she was unable to reach the HCS and then successfully reached another Emergency Contact who consented to the transfer. She said the resident was transported to the hospital by emergency personnel. On 10/14/24 at 1:04 PM, Personal Care Assistant (PCA) B said she knew resident #1 well. The PCA said the resident enjoyed being outside and often wandered. The PCA explained the resident previously had someone with her at all times doing one to one supervision but that had stopped a few weeks ago. She said after the one to one supervision stopped, resident #1 had many falls. She recalled on 10/05/24, the day the resident fell, she was assigned to resident #1 during the day shift. She explained that from 11:30 AM to 1:00 PM, she was assigned to be in the dining room to assist with lunch and was unable to monitor the resident. The PCA explained staff were often occupied in a room for extended periods with other residents for meal assistance, incontinence care, and showers and could not always monitor resident #1 closely. She recalled when she returned to the unit after dining room duties, the resident was outside on the concrete, flat on her face. The PCA stated, I don't know what we can do for her if she doesn't have that one on one supervision. On 10/14/24 at 1:15 PM, the long term care UM stated nurses delegated to CNAs and let them know verbally when residents were on frequent checks. She explained, frequent checks normally meant about every 15 minutes. The Unit Manager stated, she (resident #1) likes to sit outside, she is very confused, and she will try to open the door and go out when she's on the unit; she doesn't remember she can't walk; no, she is not safe to sit outside by herself. Review of the Comprehensive Care Plan documented undated Special Instructions that read, Staff to escort resident for safety to the courtyard. A focus initiated on 7/15/24 read, The resident has impaired cognitive function/impaired thought processes r/t [related to] diagnosis of dementia. Interventions initiated on 7/15/24 noted nurses were expected to notify the physician of any changes in the resident's condition, and communicate concerns with family/caregivers about confusion, and the resident's capabilities or needs. A focus initiated 9/19/24 read, The resident has a history of exhibiting the following behaviors: Chronic/frequent refusals of care and/or services, Impulsivity, Resists care, Verbal aggression. In an interview on 10/14/24 at 2:23 PM, the Regional Nurse Consultant checked resident #1's records and acknowledged the care plan Special Instructions for staff to escort the resident to the courtyard were undated. She confirmed the entry was added to the care plan after the resident fell on [DATE], but she could not locate any date/time stamp entry history for it in the Electronic Health Record (EHR). Review of a Care Plan focus initiated 7/17/24 and revised 9/16/24 read, The resident is at risk for falls R/T Unsteady Gait/Poor Balance, Use of antihypertensive medications, Use of psychotropic medications, Hx [history] of falls. The care plan goal was for the resident's potential for sustaining a fall-related injury would be minimized by utilizing fall precautions/interventions through next review date. On 9/06/24, an intervention was initiated to offer the resident assistance with toileting before and after meals. On 9/16/24 interventions initiated included a non-slip mat applied to the wheelchair, floor mats, offer and assist to common areas while awake and as tolerated, and a scoop mattress. There were no interventions in place before resident #1's fall on 10/05/24 that specified increased supervision or the frequency of any supervision by staff. A Progress Note entered by LPN I on 10/05/24 at 10:04 PM, documented after resident #1 was treated at the hospital emergency room (ER), she returned to the facility on a stretcher with two attendants. The nurse noted facial bruising and swelling, and orders for antibiotic medications for a urinary tract infection (UTI). A Progress Note entered by LPN I on 10/06/24 at 8:14 AM, noted the physician was notified the resident had returned from the hospital the previous day with findings of a UTI with antibiotic medication orders. A Progress Note entered by the Assistant DON on 10/07/24 indicated the interdisciplinary Team reviewed resident #1's fall incident that occurred at approximately 4:45 PM the resident was observed lying on the ground with a laceration to the facial area an swelling of the forehead. The note revealed first aid was performed, and the family and physician were notified. Treatment to the skin alterations were in place, neurological checks and the care plan was reviewed and updated. Review of the Electronic Health Record (EHR) revealed no neurological evaluations/assessments were completed by nurses after the resident returned from the hospital on [DATE]. On 10/16/24 at 12:51 PM, the DON checked resident #1's medical record and acknowledged nurses did not complete neurological (neuro) checks after the fall on 10/05/24. The DON stated, there wouldn't be a reason for them not to do neuro checks after the fall; they should do them. Review of the hospital's Emergency physician's discharge note dated 10/05/24 revealed the resident sustained a closed nondisplaced nasal fracture. The CT scan showed possible nasal fracture. On 10/14/24 at 12:09 PM, the DON said the Assistant DON was not available for interview. Review of the Safety Interventions Record reports from July through October 2024 revealed no record of any entries for instructions or interventions for fall prevention. The CNA Kardex with print date 10/14/24 indicated resident #1 required two staff for transfers with a mechanical lift as she was dependent and unable to assist. Under the section for Behavior/Mood it was noted if the resident had behavior issues, CNAs were expected to remove her from the situation and take her to an alternate location. The form read, Special Instructions: Staff to escort resident for safety to the courtyard . SAFETY . Encourage and remind resident to use CALL BELL and to wait for staff assistance with transfers, ambulation, toileting, etc. Encourage resident to only go out with staff family supervision. Offer and assist to common areas while awake as tolerated. The Physical Therapy (PT) Evaluation & Plan of Treatment report dated 7/14/24 indicated the reason for referral was due to new onset of decrease in functional mobility, decrease in strength, reduced dynamic balance and increased need for assistance from others. The Evaluation indicated resident #1 had precautions due to falls and Confusion. The document revealed patient behaviors required consistent supervision, and had worsening of cognitive impairment and changes. On 9/18/24 at 8:49 AM, additional precautions section was changed from one to one supervision required for falls and confusion to only falls and confusion, modified by the Therapy Director. The Occupational Therapy Progress Report dated 9/21/24 read, . Remaining impairments: Patient continues with deficits in standing balance/tolerance, general strength and cognition . The PT Treatment Encounter Note dated 10/04/24 was similar and read, . Precautions: (falls) and Confusion . with no mention of the previous required supervision from 7/14/24. On 10/15/24 at 10:43 AM, the Therapy Director said he participated in daily clinical meetings where fall management and interventions were discussed. He said resident #1 received ongoing PT and OT services since she was admitted [DATE]. He recalled the resident had multiple falls and therapy implemented wheelchair interventions and continued services for fall risk prevention to improve ADL self-care functions, balance, strength, and gait (walking). He did not recall clinical discussions to increase supervision for the resident. He stated therapy services included treatments and adaptive equipment, and did not include or provide increased supervision interventions outside of therapy sessions. On 10/15/24 at 10:39 AM, LPN H said when the resident was admitted to the facility, her family paid for one on one supervision, and she did well. She explained the private aide took her outside as resident #1 enjoyed it and it seemed to make her calmer. She said after the private supervision stopped, facility nurses and CNAs were expected to do frequent checks on resident #1 which meant every 15 minutes. The LPN said nurses were concerned the resident had multiple falls, after the one to one supervision was removed. She said several nurses informed management who responded that nurses' concerns were discussed in clinical meetings, but resident #1's supervision was never increased. The LPN recalled the resident was never safe to go outside to the courtyard patio alone before or after she fell outside. She said it was difficult for nurses to monitor up to 33 residents at a time and also constantly watch resident #1. She said in the past, the facility placed other residents on one to one when needed, but not resident #1. She stated, after she came off the private one to one, we could see why she needed it; she was restless; I would take her outside when I could, but I couldn't even chart. On 10/16/24 at 2:25 PM, LPN E said frequent checks meant every 15 to 30 minutes. She said residents who were not safe to be outside alone needed staff present to make sure they didn't fall. She explained nurses voiced their opinions about residents' needs for increased supervision and/or fall risks to the Unit Managers, and they relayed the concerns to management. She conveyed it was unrealistic for nurses to frequently check and watch residents with dementia, poor safety awareness, and impulsivity who tried to walk or get up on their own as well as being responsible for other multiple residents at the same time. The LPN stated, it's difficult for us to keep them safe and it's hard to get them management) to put them on one to one. On 10/15/24 at 2:36 PM, LPN I explained, resident #1 was a super high fall risk and when the resident was admitted , she needed to be watched constantly and had a 24-hour sitter that helped to keep her calmer. The LPN said she tried to check on resident #1 every 15 minutes, but she was really fast and didn't understand even when staff tried to reorient her. The LPN stated, she tried to self-transfer, get up and walk. The LPN conveyed, that many nurses inquired with management about the resident's high fall risk because they struggled to keep her redirected and busy to avoid falling. The LPN stated, when the sitter went away, we saw why she needed one to one; the CNAs cannot constantly watch her. On 10/15/24 at 2:08 PM, CNA F explained resident #1 was very impulsive, sometimes combative, and tried to move around all the time. The CNA expressed staff often were not able to closely observe resident #1 and take care of other residents at the same time. The CNA stated, it was known not to put her outside by herself; she's pretty quick. On 10/15/24 at 3:16 PM, LPN A said she struggled to keep a close eye on resident #1 because she had poor safety awareness and was impulsive. The LPN explained she tried to be creative and redirect the resident while she passed medications to other residents by keeping her busy and distracted at the medication cart. She recalled on 10/05/24, CNA G took the resident outside before lunch time until the CNA was occupied and assigned to assist other residents in their rooms with meals. The LPN recalled at about 1:00 PM, CNAs alerted her the resident was outside on the ground. She said the resident was at the hospital for the remainder of her shift that ended at 7:00 PM. She said she returned the next day for the day shift and received report from LPN I who said resident #1 had a UTI with prescriptions. The LPN said all the nurses thought the resident should go back on 1:1 and stated, even if you take your eyes off her for 5 minutes it can be a disaster; she is confused and can get up again. Review of Progress Notes documented by the Psychiatric Nurse Practitioner on 9/11/24 read, . Mood is labile. She is agitated. Nursing staff report she's had increased behaviors since her private duty nurse was discontinued by the patient's POA (power of attorney). She had a recent fall due to impulsive behaviors and trying to self-transfer. She is confused and reports not knowing what is going on. She enjoys sitting outside in the sun and eating in the dining room. Appearance/Behaviors: Sitting in the common area restless . Thought process: Somewhat disorganized . Thought association: Somewhat loose . Insight and Judgement: Impaired . Recall/Short-term memory: Impaired . Attention span/Concentration: Impaired . Fund of knowledge: Impaired . The Psychiatry Subsequent Note dated 9/20/24 read, . Mood is, trapped. Nursing staff report the patient remains anxious and restless. She is impulsive and gets up without asking for help . She reports feeling trapped in the facility . As per collected information and interview, it appears that patient is unstable. I feel the symptoms are occurring due to exacerbation of underlying anxiety disorder. They symptoms are occurring almost daily and causing severe distress . In a telephone interview on 10/13/24 at 4:05 PM, resident #1's POA explained she was responsible for the resident's financial affairs. The POA recalled when resident #1 was admitted to the facility in July 2024, she had 24-hour 1:1 supervision paid for by the resident because the Healthcare Surrogate (HCS) was concerned she would fall and be seriously injured, she was very impulsive and had very bad dementia. She stated the resident paid 1:1 service was discontinued after a couple of months because it was very expensive, and the resident could no longer afford it. On 10/16/24 at 10:05 AM in a telephone interview, resident #1's Emergency Contact Representative explained the resident was never safe to be outside in the courtyard alone. She said the resident was placed on private duty supervision at her own expense because the HCS feared she would fall and be seriously hurt. She said the resident was very impulsive and she stood up on her own while in the wheelchair. She said the private supervision stopped for financial reasons and she worried after that because the resident started to have falls and stated, they (facility) don't provide 1:1 service. On 10/16/24 at 10:54 AM in a telephone interview, resident #1's HCS recalled she was worried the resident would fall and get seriously hurt at the facility without 1:1 supervision, so she requested the POA pay for the services on behalf of the resident. She explained she was especially worried and concerned when the resident started having multiple falls in September 2024, after the individual supervision stopped. She said after the resident fell on [DATE], the facility did not provide her with any updates and she found out from the hospital later that the resident had a nasal fracture. She said the facility told her they didn't have staff to provide 1:1 supervision and stated, she started falling when the one on one went away. Review of APRN L's Nursing Home Visit Encounter dated 10/07/24 read, . weakness, had a fall out of her wheelchair over the WE (weekend). Sent to ER, no sutures required and sent back to the facility . bruises to both eyes, forehead and abrasion to her nose and forehead. The note did not mention resident #1 sustained a nondisplaced nasal fracture. On 10/16/24, two unsuccessful attempts were made to contact APRN L by telephone. On 10/15/24 at 2:36 PM in a telephone interview, LPN I said she frequently had resident #1 on her assignment. She recalled on 10/05/24 during the 7:00 PM to 7:00 AM shift, the resident returned to the facility by stretcher from the hospital. She recalled 2 transportation attendants accompanied the resident with the hospital discharge packet. She said the discharge packet included new prescriptions for UTI, and she contacted the on call APRN for orders. The LPN explained the records contained lab results, a chest X-ray, and CT of the head and stated, she had a lot of stuff; I didn't read the scans in-depth; when they dropped her off, they said she had no fractures. On 10/16/24 at 9:20 AM, the Long Term Care Unit Manager explained all resident falls and interventions/revisions of care were discussed in morning clinical meetings where she participated. She said resident #1 was on frequent checks and the 1:1 status was removed by the family for financial reasons. She said on 10/07/24, a Monday, she discussed what happened with APRN L who saw and assessed her. She said CNAs were expected to check on residents with frequent checks in between patient care and stated, we know she's a fall risk so everybody on the unit that works frequently check on her. On 10/16/24 at 2:17 PM, the DON explained the facility had a Falling Leaf Program to alert staff of residents who were high fall risk. She said the program consisted of a green magnet placed on the residents door to alert staff and it was intended to bring increased awareness. The DON said the facility did not have written standards and guidelines for the program and stated, we didn't consider putting her on the 1:1; she's (resident #1) on the Falling Leaf Program; it's to keep eyes on them; we review her in the clinical meetings. On 10/16/24 at 12:51 PM, the DON explained the facility reviewed all resident emergency visits for orders and test results every weekday morning during clinical meetings. She recalled the resident's fall and ER visit was discussed, on 10/07/24, and the Unit Manager reported the resident had a UTI and was prescribed antibiotic medications. She checked the hospital ER discharge records and said she was not aware resident #1 had sustained a nasal fracture. The DON stated, I didn't know we had this; I would say that the hospital didn't send it; she should be monitored for the fracture. On 10/16/24 at 1:00 PM, the DON explained when staff had concerns about any resident's behavior or safety, they reported it to the Unit Manager who communicated the information to the Interdisciplinary Team (IDT) in morning meetings. She said the team was aware resident #1 was a high fall risk and she was placed on the Falling Leaf Program with a magnet on her door after she started falling in September. Review of resident #1's Comprehensive Care Plan, Kardex for CNAs, and Safety Interventions Records revealed no Falling Leaf Program nor Frequent Checks were added to the plan of care since the resident was admitted to the facility on [DATE], for three months. On 10/16/24 at 2:17 PM, the NHA conveyed resident #1 was not considered for facility provided 1:1 supervision and stated, she's on the Falling Leaf Program; it's to keep eyes on them; we review her and any resident in the clinical meetings. On 10/16/24 at 2:30 PM, LPN E referred to the Falling Leaf Program and stated, it's something about guardian angel or something like that. The LPN could not accurately explain what the facility's high risk fall program was. On 10/16/24 at 2:34 PM, CNA P explained the magnet on the door to designate a leaf was to check the room when it's cleared for a fire. PCA Q stated, I think you're right; I've seen them. We check the room then we put it there. The CNA nor the PCA had knowledge of the facility's Falling Leaf Program for residents with high fall risk. In a telephone interview on 10/16/24 at 9:53 AM, MD M said he was aware resident #1 fell on [DATE], he previously reviewed the hospital records, and recalled she had a UTI. The MD explained he expected APRN L to review hospital ER records and test results as part of the assessment. At 1:42 PM, MD M said he was unaware resident #1 had sustained a nasal fracture. He explained he expected nurses to monitor residents for complications of fractures and stated, any head injury we always want to keep an eye on it after they come back from the ER and if they complain of pain we jump on it. A written statement provided by MD M dated 10/15/24 read, . I completed a case study on resident (#1) related to her fall on 10/05/24. After review of chart including but not limited to: hospital records, BIMS assessment, care plan, activity preferences, psych notes, prior falls, etc. The facility followed residents plan of care and resident preferences and resident was adequately supervised based on the investigation review including statements. On 10/16/24 at 12:36 PM in a telephone interview the Medical Director said he expected nurses to notify the physician of ER findings and test results. He said he expected nurses to monitor residents with fractures and stated, they must do neuro checks if it's a head injury. Review of the Facility assessment dated [DATE] read, . Mobility and fall/fall risk with injury prevention Transfers, ambulation, restorative nursing, falling leaf program for high fall risk residents, supporting resident independence in doing as much of these activities by himself/herself. With consistent assignments in person-centered care, staff and management place value on a stable team of individuals committed to knowing the resident and building care on a foundation of relationships. Staff, as well as residents and families benefit, as they get to know and depend on one another to work fluidly and flexibly support the unique strengths of each elder: .Routine tasks are assigned by the appropriate manager based upon demonstrated knowledge, skills and abilities per shift and needs of the facility/resident. When requirements are identified that overlap departments, the manager that identifies a shortfall will address the concern with the interdisciplinary team toward establishing a process. Managers are expected to closely monitor any changes in processes or procedures to maintain a positive culture for our staff and residents. A nasal fracture is a break in the bone or cartilage over the bridge, or in the sidewall or septum (structure that divides the nostrils) of the nose. Serious nose injuries cause problems that need a health care provider's attention right away. For example, damage to the cartilage can cause a collection of blood to form inside the nose. If this blood is not drained right away, it can cause an abscess or a permanent deformity that blocks the nose. It may lead to tissue death and cause the nose to collapse. Sometimes, surgery may be needed to correct a nose or septum that has been bent out of shape by an injury. A doctor may be able to return nasal bones that have moved out of place back to their normal position within the first 2 weeks after the break. (retrieved on 10/17/24 from www.medlineplus.gov). Review of the facility's standards and guidelines dated February 2024 and titled Falls-Managing, Preventing, and Documentation read. Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and caus[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide care and services, according to professional standards of practice, to avoid complications of a known medical condition and prevent rehospitalization for 1 of 2 residents reviewed for hospitalization, out of a total sample of 43 residents, (#574). The facility's failure to promptly identify and treat a change in condition and failure to obtain and implement physician orders in a timely manner resulted in actual harm for resident #574. The resident suffered altered mental status and debilitating symptoms which necessitated transfer to an acute care hospital for evaluation and treatment. Findings: Review of the medical record revealed resident #574, a [AGE] year-old female, was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a brain disorder) and liver cirrhosis. The resident was discharged to the hospital on 6/20/24. Cirrhosis is scarring of the liver that results from injury or long-term disease. The scar tissue impacts the function of the liver and affects its ability to clean the blood (retrieved on 8/05/24 from www.medlineplus.gov/cirrhosis.html). Hepatic encephalopathy develops when toxins or poisons such as ammonia, build up in the brain because the liver cannot break them down. It can cause nausea, vomiting, confusion, loss of consciousness, and coma (retrieved on 8/05/24 from www.medlineplus.gov/lab-tests/ammonia-levels). The General admission Data assessment dated [DATE] revealed resident #574 was alert, easily arousable, cooperative, and oriented to person, place, time, and situation. The document indicated the admission nurse(s) contacted the resident's medical provider to reconcile her medications, and all orders were confirmed and verified. Review of the Order Summary Report revealed resident #574 had physician orders dated 6/09/24 for Lactulose 10 grams/15 milliliter (gm/ml), give 30 ml four times daily for hyperammonia, and Rifaximin 550 milligrams (mg), give one tablet every 12 hours for hyperammonia. Lactulose causes a decrease in blood ammonia concentration and reduces the degree of encephalopathy by drawing ammonia from the blood into the colon where it is excreted in an increased number of bowel movements (retrieved on 8/05/24 from www.liverfoundation.org/liver-diseases/complications-of-liver-disease/hepatic-encephalopathy/treating-hepatic-encephalopathy). Rifaximin 550 mg is an antibiotic medication that is usually administered twice daily. If you are taking Rifaximin to prevent hepatic encephalopathy, do not stop taking it without talking to your doctor as you may experience symptoms of encephalopathy (retrieved on 8/05/24 from www.medlineplus.gov/druginfo/meds/a604027.html). Review of resident #574's medical record revealed she had a care plan for antibiotic therapy related to liver disease, initiated on 6/11/24. The goal was the resident would receive the drug. The interventions instructed nurses to administer antibiotic medication as ordered, obtain pertinent labs and report to the physician. Review of a care plan for risk for alteration in neurological status related to a diagnosis of encephalopathy, initiated on 6/11/24, had a goal that resident #574 would be free from signs and symptoms of complications of neurological deficit and would maintain optimal status and quality of life. The interventions instructed nurses to administer medications as ordered and report signs and symptoms of neurological complications such as constipation, difficulty swallowing, decline in range of motion, decline in cognitive function, change in level of consciousness, and slurred speech. A care plan for liver disease related to cirrhosis, initiated on 6/17/24, had a goal that the resident would be free from signs and symptoms of liver complications including cognitive decline or mental status changes. The interventions included administer medications as ordered by the physician. The document indicated nursing staff would monitor, document, and report malaise, fatigue, constipation, altered level of consciousness, confusion, or disorientation, and notify the physician as indicated. The care plan read, Obtain and monitor lab/diagnostic work as ordered by [physician]. Report results and follow up as indicated. Review of a Psychiatry Evaluation Note dated 6/10/24 revealed resident #574 was newly admitted to the facility and was alert and oriented with appropriate affect and mood. The psychiatrist noted the resident had an organized thought process, intact thought associations, good insight and judgement, and was at her baseline status. A Physician/Practitioner Note dated 6/11/24 revealed Advanced Practice Registered Nurse (APRN) G reviewed resident #574's medical chart which included hospital records. APRN G noted the resident had a past medical history of nonalcoholic cirrhosis. His assessment findings showed the resident was alert, awake, able to follow simple commands, and able to communicate. Review of the Minimum Data Set (MDS) admission assessment with assessment reference date of 6/12/24 revealed resident #574 was admitted from a short-term general hospital. The document indicated she had adequate hearing and vision, clear speech, clear comprehension, and was able to express her ideas and wants. The resident's Brief Interview for Mental Status score was 15/15 which showed she was cognitively intact. The document revealed resident #574 did not exhibit inattention, disorganized thinking, or an altered level of consciousness. The MDS assessment indicated she displayed no behavioral symptoms and did not reject evaluation or care that was necessary to achieve her goals for health and well-being. Resident #574 participated in and provided information for the assessment, and her overall goal was to discharge to the community. Review of the medical record revealed a Late Entry Physician/Practitioner Progress Note dated 6/13/24 at 4:56 PM. The document was created four days later, on 6/17/24 at 4:56 PM, by APRN G who noted resident #574 denied any specific problems and remained alert and able to follow simple commands. The assessment showed the resident was comfortable, alert and oriented, and able to communicate. However, an Occupational Therapy Treatment Encounter Note dated 6/13/24 revealed resident #574 refused to get out of bed for her therapy session and complained of nausea. The therapy note read, Provided patient with bucket and reported to nursing. A Physical Therapy Treatment Encounter Note dated 6/13/24 indicated the resident refused to get out of bed for therapy. There were no associated nursing or provider progress notes regarding the resident's complaint of nausea or refusal to get out of bed on 6/13/24. Review of another Late Entry Physician/Practitioner Progress Note dated 6/15/24 at 2:00 PM, revealed APRN G wrote resident #574 denied any specific problems and remained alert and able to follow simple commands. The assessment showed the resident was comfortable, alert and oriented, and able to communicate. The note read, Nursing reports patient at baseline with no recent acute events.reviewed patient plan of care with assigned nurse, Nurse added no new patient concerns.Nursing to notify provider of any change in mentation or behavior. The document indicated resident #574's ammonia level was being monitored and the resident continued to receive Rifaximin 550 mg and Lactulose 45 ml. The ordered dosage of Lactulose on 6/15/24 was 30 ml and it was not increased to 45 ml until 6/17/24; therefore, the note did not accurately reflect the resident's active plan of care. A Laboratory progress note dated 6/16/24 at 2:52 AM, revealed Licensed Practical Nurse (LPN) B notified APRN G of resident #574's lab result. Review of the lab report showed the resident's ammonia level was elevated to 97 micromoles/Liter (mcmol/L). However, review of the Order Summary Report revealed no physician order for the stat or immediate lab, and review of nursing progress notes and APRN G's progress note on 6/15/24 showed no evidence of identification of a change in status or signs and symptoms of hyperammonia that required an urgent lab test. The medical record did not show a response from APRN G or any new orders to treat the resident's elevated ammonia level. According to the Merck Manual Professional Version (reviewed/revised December 2021), a normal Ammonia level is 23-47 mcmol/L (retrieved on 8/05/24 from www.merckmanuals.com/professional/resources/normal-laboratory-values/blood-tests-normal-values). Review of a Psychiatry Subsequent note dated 6/17/24 revealed the provider assessed resident #574 and noted, Mood is unwell. She reports nausea which is affecting her appetite. A Physical Therapy Treatment Encounter Note dated 6/17/24 revealed resident #574 refused four separate attempts to participate in therapy sessions. An Occupational Therapy Treatment Encounter Note dated 6/17/24 read, .patient reporting not feeling well and too tired to get out of bed. Review of a Progress note dated 6/17/24 at 7:30 PM, revealed resident #574's family members voiced concerns that their mother had a history of high ammonia levels, complained of constipation with no bowel movement for at least two days, and was exhibiting increased confusion. LPN E notified the provider and received orders for an abdominal x-ray and a routine ammonia lab test. The provider increased the resident's Lactulose from 30 ml to 45 ml, almost 18 hours after the facility received and reported the stat ammonia lab result of 97 mcmol/L to APRN G. An Occupational Therapy Treatment Encounter Note dated 6/18/24 revealed resident #574, demonstrated increased fatigue on this day. A Progress Note dated 6/18/24 at 2:33 PM, revealed resident #574's son repeated his concerns about his mother. The document indicated he notified the Casabella UM that she, .did not have a [bowel movement] in 3 days and that his mother's ammonia level was high. Son wanted mother transfer to [Emergency Department]. The note revealed the UM informed the son his mother's needs could be met in the facility. She contacted the provider and obtained orders for another type of laxative drug and a stat ammonia lab test. Review of a Progress Note dated 6/18/24 at 7:01 PM, revealed resident #574 was alert with confusion, complained of continued constipation despite a small, hard bowel movement. The progress note indicated the resident's ammonia level had decreased. Review of the laboratory result dated 6/18/24 revealed the resident's ammonia level was 66 mcmol/L, still above the normal range. A Physical Therapy Treatment Encounter Note dated 6/19/24 revealed resident #574 remained in bed and, .had poor responsiveness to therapist throughout session and nursing was notified. Review of an Occupational Therapy Treatment Encounter Note dated 6/19/24 revealed resident #574 was, .lethargic this date and difficulty with arousal, nursing aware of [patient] status. Review of the medical record revealed the Casabella UM completed a Change in Condition note on 6/20/24 at 2:40 PM. The document indicated resident #574 had altered mental status and the provider recommended sending her to the hospital. There was no associated nursing progress note with details of the resident's status. A Late Entry Physician/Practitioner Progress Note dated 6/20/24 at 3:33 PM was created by APRN G on 6/21/24 at 3:33 PM. The document indicated he assessed resident #574 in her room, and as in all previous notes, described her as alert, awake, able to communicate and follow simple commands. APRN G noted the resident's ammonia level and mentation were improved, but her son was insistent that his mother required hospitalization. A progress note dated 6/20/24 at 3:50 PM, revealed resident #574 was transferred to the hospital by ambulance personnel, accompanied by a family member. In a telephone interview on 8/05/24 at 7:07 PM, resident #574's daughter stated she received a text message from her mother on Monday 6/17/24 at 11:32 AM, that indicated she had abdominal pain, could not eat anything for breakfast, and had not had a bowel movement for a week. The daughter recalled her response to her mother was that the facility needed to check her ammonia level as it was probably increasing. She stated her mother stopped texting and she became worried, so she visited later that evening. The resident's daughter said, Her lunch was untouched, and the dinner tray was there as well. Her eyes were closed, and I touched her to wake her up. She did not seem like her normal self. She was not alert and not talking. Usually, she is excited to see me and asks about my kids. The daughter stated she expressed her concerns to the assigned night shift nurse who contacted APRN G and received orders for an abdominal x-ray and bloodwork. The daughter stated the nurse explained the results would likely not be available until the following morning, so she asked her to contact the physician again regarding sending her mother to the hospital. The resident's daughter stated the nurse returned and informed her she got push-back from the practitioner, who felt there was nothing the hospital could do that could not be done in the facility. The daughter recalled the following morning, on Tuesday 6/18/24, she returned to the facility at about 9:40 AM and her mother's uneaten breakfast was on the tray table. She stated there were two medication cups on the table beside the meal tray, one with pills and the other with 10 ml of liquid medication that appeared to be Lactulose, and no nurse in the room or nearby. The resident's daughter recalled the Casabella Unit Manager (UM) reassured her she would fix the situation, and she returned with an additional 30 ml cup of Lactulose. Resident #574's daughter stated no family members visited the facility on Wednesday 6/19/24, and by Thursday 6/20/24, her mother's condition had declined even more. On 8/01/24 at 2:29 PM, in a telephone interview with resident #574's son, he explained after about a week in the facility, his mother began exhibiting symptoms of high ammonia levels and she was barely responsive during the final three days. He stated the change in his mother's condition was significant as she was usually very alert, oriented, and talkative. The son recalled the facility denied several requests made by him and his sister to send his mother to the hospital as they noticed her symptoms worsening. He explained on Thursday, 6/20/24 at about 2:00 PM, he unexpectedly received a phone call from his mother's phone. He stated he was happy when he saw her number, as a call from her would suggest she felt better and was finally able to converse with him. Resident #574's son said, I was surprised because it was a [Certified Nursing Assistant] on my mom's phone, and she said my mom was not really responding so she thought it would help to hear my voice. I told her to get a nurse immediately. The son stated he waited for 25 minutes but did not hear back from a nurse, so he called the Casabella UM on her direct line and demanded she send his mother to the hospital. The resident's son emphasized that his mother's ammonia levels would not have escalated to that extent if she had been receiving her medication as prescribed. He stated he felt a significant factor was staff did not want to give the Lactulose at times because it caused frequent and/or loose bowel movements which they did not want to clean up. The resident's son explained as his mother became less responsive, it would have been difficult or almost impossible for her to take her medication orally, so he was not sure the medical record accurately reflected medications given. He explained when he arrived at the facility at approximately 3:30 PM, Emergency Medical Services (EMS) personnel were there, and his mother was unresponsive except for occasional slight moans. Review of a written statement by resident #574's son dated 8/05/24 revealed when he arrived at the hospital his mother was unresponsive, and the Emergency Department (ED) nurse informed him the facility reported to EMS that was her baseline status. The son indicated he immediately called the Casabella UM and while on speakerphone, he asked her who informed EMS that his mother's current condition was her baseline. The document revealed the Casabella UM replied, Well she's been like that for a few days. Resident #574's son noted that the facility's delay in care did not make his mother's unresponsive state a new baseline. The statement indicated resident #574 was unable to swallow any medication and she required two courses of rectally administered Lactulose before her mental status improved. Review of resident #574's hospital record revealed an Emergency Department Clinical Report dated 6/20/24. The document indicated on arrival at the ED, EMS personnel gave the history of the resident's illness as decreased responsiveness for about a week. The physician assessment revealed resident #574 responded only to painful stimulus and bloodwork collected in the ED revealed her ammonia level was 141 mcmol/L. The hospital record showed the resident required Lactulose enemas to treat her elevated ammonia level that was, .likely secondary to her not receiving her Lactulose. The ED Primary Assessment Document showed the resident's Glasgow Coma Scale score on arrival was 7 based on best motor response as withdrawal from pain, best verbal response as incomprehensible words, and no eye opening. The Glasgow Coma Scale (GCS) is used to measure a patient's level of consciousness by assessing eye, motor, and verbal responses. A GCS score of 8 or less indicates the possibility of a severe traumatic brain injury (retrieved on 8/07/24 from www.webmd.com/brain/what-is-the-glasgow-coma-scale). On 8/01/24 at 5:37 PM, in a telephone interview with a Pharmacy Customer Service Technician, she validated pharmacy records showed only six tablets Rifaximin 550 mg were dispensed for the resident, which was enough to last for three days. She stated the pharmacy sent an authorization form to the facility, according to the protocol for any high-cost medication, but it was never returned. The Pharmacy Customer Service Technician verified no additional Rifaximin 550 mg tablets were dispensed for resident #574. On 8/01/24 at 2:43 PM, APRN G was informed the facility's pharmacy Packing Slip Details showed the pharmacy dispensed only a 3-day supply of Rifaximin 550 mg for resident #574. After review of the Medication Administration Record (MAR), he was told the resident did not receive three doses of Lactulose between 6/17/24 and 6/19/24, and despite documentation to the contrary, the resident's lethargy and nausea during that period made it highly unlikely that she received all doses of Lactulose as ordered. APRN G stated he was never made aware the resident's Rifaximin was not available, and nurses did not mention the drug required authorization due to the cost. APRN G verified medications should be administered as ordered, and if that was not possible, nurses should have contacted him. He said, My expectation is I will be notified about all refusals or medications not available. I could have made an adjustment, probably increased Lactulose since that was already shown to be effective. When asked about the delayed response to the stat Ammonia lab result of 97 mcmol/L reported on 6/16/24, APRN G acknowledged he received the result from LPN B via text message. He reviewed his communication records and confirmed there was no evidence he responded to the message. When informed the order to increase resident #574's Lactulose from 30 ml to 45 ml to treat her elevated ammonia level was not received until after 7:00 PM on 6/17/24, APRN G said, Eighteen hours is too long to respond to a lab. In a follow up telephone interview with APRN G on 8/02/24 at 1:22 PM, he stated he reviewed his communication records again and discovered he was notified of resident #574's refusal to take her medication only once, on 6/18/24. APRN G added that he had no recollection or documentation of ordering the initial stat ammonia lab on 6/15/24. On 8/01/24 at 3:08 PM, Certified Nursing Assistant (CNA) D joined the interview with APRN G and confirmed she spoke to resident #574's son on the phone on the afternoon of 6/20/24, the resident's last day in the facility. CNA D recalled from the beginning of the day shift, the resident's eyes remained closed, even when she informed her that breakfast was there. She stated it almost seemed as if resident #574 was ignoring her, and she reported to the nurse that the resident seemed different. CNA D explained during change of shift report that morning, the off going night shift CNA told her resident #574 had not responded to her during the night shift either. CNA D said, She was conscious but not responding. Even therapy had that same concern. APRN G confirmed he was not notified of the significant decrease in resident #574's level of consciousness. He validated CNA D's description of resident #574 depicted classic symptoms of a high ammonia level. On 8/01/24 at 1:23 PM and 8/05/24 at 4:52 PM, in telephone interviews, LPN B stated she assumed care of resident #574 on the night shift of 6/15/24, after she received change of shift report from LPN A. She explained LPN A never mentioned any concerns regarding the resident's clinical status, so she was surprised when another night shift nurse approached her with a note from LPN A that indicated resident #574 required a stat ammonia lab test. LPN B explained she called LPN A, who told her that as she left the facility, she ran into APRN G in the parking lot, and he gave her that order. LPN A wrote it on a piece of paper, handed it to another nurse who was on her way into the building, and told her to give it to LPN B. LPN B expressed disbelief and said, Really! We're doing things like this now? She stated she arranged for the stat lab after she texted APRN G and received confirmation he needed the test to be done. LPN B verified she did not receive a response from APRN G after she texted him the lab result and she texted him again on 6/16/24 at 6:37 AM, regarding contacting the day shift nurse if he had any new orders for the resident. LPN B stated LPN A returned the next morning for the day shift and she relayed the lab result to her. When asked about her notes on the electronic MAR dated 6/14/24 and 6/15/24 regarding the resident's Rifaximin that was not available, LPN B stated she wrote the notes after she thoroughly searched the medication room and the medication cart and realized it was not there. LPN B said, When I gave report to [LPN A] the next morning, I mentioned that the medicine was not there, and she was like a deer in the headlights.I told [LPN A] that when [APRN G] calls they need to get an alternative. I told her it's funny that some people are saying they give it, but it isn't here. LPN B expressed frustration that some nurses habitually documented they administered medications that were not given and said, No wonder her numbers are going high. On 8/02/24 at 12:26 PM, the Casabella UM described resident #574's baseline mentation as alert, oriented and chatty. The UM stated she was never made aware the resident's Rifaximin was not dispensed by the pharmacy beyond the initial 3-day supply. She acknowledged the resident's daughter informed her that her mother's ammonia level was high, she was not doing well, and she probably did not receive the correct dose of Lactulose. The UM verified resident #574's stat ammonia lab result on 6/16/24 was not addressed timely, and her expectation was nurses would have contacted her or the Director of Nursing if APRN G did not respond. The UM validated on 6/20/24, resident #574's son called her as he became concerned after his conversation with CNA D. The UM said, I went to check on her and she was drowsy, slurring, not sitting. I was concerned. I called [APRN G] on the phone and he said go ahead and send her out. The UM stated she could not explain why nurses' documentation did not show the decline in the resident's condition reported by CNAs and therapy staff, and she was unsure if medications were given as ordered. In an undated, written Case Study document, the facility's co-Medical Director wrote, It is critical for patients to adhere to their prescribed medication regimen. The Case Study validated the consistent failure to administer essential medications like Lactulose posed a significant risk to patients' health. The co-Medical Director noted the importance of adherence to both Rifaximin and Lactulose as a comprehensive treatment plan for liver disease. Review of the facility's policy and procedure Change in Resident Condition or Status - Resident Rights revised in June 2023, revealed the facility would notify the resident, the attending physician, and his/her representative of changes in the resident's medical or mental condition that included significant changes and the need to alter treatment. The document indicated a significant change of condition included a major decline that would not resolve itself without intervention, impacted more than one area of the resident's health status, and required interdisciplinary review and/or revision of the care plan. The policy read, The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Review of the Facility Assessment, dated 3/22/24, revealed the facility would accept residents with common diseases and conditions that included digestive system disorders such as cirrhosis. The document indicated the facility would offer care and services to manage medical conditions by providing assessment, early identification of problems/deterioration, and management of medical symptoms. The Facility Assessment revealed nurses would administer medications needed by residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review, the facility failed to allow a resident to remain in the facility, failed to provide rationale as to why the resident's care needs could not be met at the facility and failed to document attempts at meeting those needs before transfer for 1 of 3 residents reviewed for transfers of a total sample of 8 residents, (#1). Findings. Resident #1 was admitted to the facility on [DATE] under Hospice care with diagnoses of Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Major Depressive Disorder, Dementia, Nicotine Dependence and Brief Psychotic Disorder. Review of the Nursing admission assessment dated [DATE] indicated the resident was not an elopement risk with a score of 5. A score of 10 or higher indicated risk for elopement. Resident #1's comprehensive Hospice Care plan was initiated on 7/1/22 with plan for the resident to remain at the facility long term hospice care due to chronic diastolic heart failure. The resident's admission Minimum Data Set (MDS) assessment dated [DATE] noted resident #1 had adequate hearing and clear speech. The resident had the ability to express his ideas and understood others. Despite the resident's ability to express himself and understand others neither the Brief Interview for Mental Status (BIMS) nor the Staff Assessment for Mental Status was conducted. Review of monthly nursing summaries from June 2022 to November 2022, all noted resident #1's cognition was clinically stable and he was not an elopement risk. Review of the nurse's progress note dated 12/6/23 indicated the resident was observed smoking a cigarette in his room. The nurse noted the resident was instructed to extinguish the cigarette and was informed the facility was a non-smoking facility. Resident #1 expressed understanding that he was in a non-smoking facility. The nurse informed the Hospice provider and received new orders for nicotine patches. Three days later on 12/9/22, the Director of Nursing, (DON) documented a progress note that indicated the resident had a change in condition for altered mental status. The note read, .Resident is confused more than normal, states he was looking for another resident's room but is seeking the exits. An elopement care plan was initiated on 12/9/22 with interventions for one to one supervision, psychological services as ordered and directed staff to distract resident from exit seeking with pleasant diversion such as activities, food, conversation, television, book, etc. The medical record progress notes from 11/22/22 to 5/17/23 indicated the resident received regular visits from a Psychiatric Mental Health Nurse Practitioner (PMHNP). On 12/23/223 the resident had a follow up visit with the PHMNP. She noted, .Alert and orientated x3. Affectively blunted. Mood is irritable . The PHMNP noted the resident had paranoid delusions that people were out to harm him. He reported someone is trying to kill him. He saw a person standing in the doorway of his room, holding a gun. He reports there was a helicopter landing on the roof of the building. The PHMNP noted the resident was unstable and added the antipsychotic medication Seroquel, 25 mg twice a day for brief psychotic disorder. There was no indication she had diagnosed resident #1 with dementia. On 7/16/23 at 1:04 PM, LPN A said resident #1 eloped from the facility a few months ago. She remembered she was in room [ROOM NUMBER] when resident #3 came and tried to tell her something. She said resident #3 was difficult to understand so she followed him back to his room. She said he pointed out the window and she saw resident #1 was by outside by himself, walking on the sidewalk. LPN A recalled she immediately alerted LPN B and ran out the fire exit door and headed towards the resident. LPN A said when she caught up to the resident, he was appropriately dressed, wearing shoes and had his rolling walker. Resident #1 told her he was going to Walmart to buy cigarettes. She said resident #1 was tired and short of breath as he did not have his oxygen. He agreed to go with her and she and LPN B wheeled him back into the facility on the seat of his walker. On 7/16/23 at 3:45 resident #1's elopement was discussed with the Director of Nursing, DON. She indicated the resident had eloped from the facility on 4/8/23 between 11 AM and 11:15 AM. She said when the resident returned to the facility, on 4/8/23, he was immediately placed on 1:1 supervision which was subsequently decreased to 15-minute checks on 4/10/23. The 15 minute checks were discontinued on 4/18/23. The DON stated resident #1 made no further elopement attempts while he was on the 1:1 supervision or 15-minute checks. She added resident #1 was transferred to a sister facility that had a locked unit. She did not respond when asked why the resident was discharged from the facility when the resident did not make any further attempts to leave. On 4/10/23 the PHMNP had a follow up visit with resident #1. The resident reported people were chasing him around and he had paranoid thoughts that a man is out to harm him. He cut the interview short and said he was too tired to answer any more questions. The PHNP noted, Dementia persisting with behavioral disturbance. She also noted that the resident was unstable but did not require any medication changes. Ongoing medical stabilization and emotional support would be good enough. The PHMNP did not indicate the resident needed be transferred to another facility with a locked unit. A review of the progress note by the Advance Practice Registered Nurse dated 5/11/23 showed the resident was placed on 1:1 supervision for wandering. There was no documentation the resident was exit seeking. On 5/15/23 the PHMNP saw resident #1 and noted in her progress note the resident was managed effectively in the nursing home and all ADLs (Activities of Daily Living) are provided. Her recommendations included, Patient is getting adequate level of care giver support in the facility. No significant changes are needed. At the same time, she noted, The patient requires to go to higher level of care (locked memory care unit). The PHMNP did not provide any evidence of why the resident would benefit from a locked unit, only that he needed one. Review of the medical record noted a transfer form that indicated the resident was transferred to another nursing home on 5/17/23. The form indicated the facility could not meet resident #1's needs. The explanation on the transfer form read, Resident is confused and wanders building IDT (Interdisciplinary Team) felt [name of another nursing home] would be better for him-brother agreed. Further review of the form revealed that neither the physician nor the resident signed the transfer form. There was no documentation of the which resident needs the facility could not meet or why another nursing home would be better for him when he had been at this facility for almost one year. On 7/18/23 at 1:47 PM, resident #'1's discharge was discussed with the DON and ADON. The DON said resident #1 had increased exit seeking behavior which contradicted her previous statement made on 7/16/23 at 3:45 PM where she noted the resident had made no further attempts to exit. She was informed there was no documentation of exit seeking behavior in the clinical record after the resident's elopement on 4/8/23. She explained the facility had wanted to transfer the resident to a facility with a secure unit, but he did not have a diagnosis of dementia. She indicated she had spoken with the PHMNP and diagnosis of dementia was added to resident #1's diagnoses list. The DON stated they had spoken to resident #1's brother and he agreed with the transfer. When asked if resident #1 had been deemed incapacitated to make medical decisions, the DON said he was his own person and was not deemed incapacitated. On 7/18/23 at 2:14 PM, during a telephone interview, the resident's brother explained the resident told people he was the emergency contact. The brother stated he lived in another state and did not make any decisions for resident #1.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pain management services in accordance with the comprehensive care plan, and the resident's goals for care and preferences for 1 of 2 residents reviewed for pain management, of a total sample of 40 residents, (#164). The facility's failure to provide pain medications as requested by the resident, per physician's orders, and consistent with the plan of care and accepted standards of practice, resulted in actual harm from prolonged periods of unmanaged pain. Findings: Clinical record review revealed resident #164 was a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included generalized muscle weakness, dysarthria and anarthria, post laminectomy syndrome, and myelopathy. The resident's History and Physical, dated 6/26/22, revealed diagnoses including chronic back pain syndrome. The document indicated the resident had multiple prior back surgeries and surgical revision with laminectomy on 6/20/22. A laminectomy is a type of back surgery used to relieve compression on the spinal cord . performed when less invasive treatments have failed. (Retrieved on 7/21/22 from www.healthline.com). Anarthria is a severe form of dysarthria. Dysarthria is a motor speech disorder that occurs when someone can't coordinate or control the muscles used for speaking. (Retrieved on 7/28/22 from www.healthline.com). Myelopathy is an injury to the spinal cord due to severe compression. (Retrieved on 7/28/22 from www.hopkinsmedicine.org). The resident's admission readmission Nursing Packet, dated 6/25/22, revealed on admission, resident #164 had pain to her sacrum, a vertical spinal surgical site, and complained of a burning sensation to her right lower leg. The assessment noted the resident described her pain as severe, sharp, radiating at level 10 on a pain scale of 1 to 10. The assessment identified the most likely cause of the resident's pain was her post-operative incision, and pain relief was achieved with pain medications. Review of the physician's orders for resident #164 revealed she was prescribed Fentanyl patch 75 microgram (mcg)/hour every 72 hours for chronic pain, and Percocet 10-325 milligram (mg) every 4 hours as needed for pain levels of 5 to 10. Fentanyl belongs to a class of drugs known as opioid analgesics. It works in the brain to change how your body feels and responds to pain. Percocet is a combination medication used to help relieve moderate to severe pain. (Retrieved on 7/21/22 from www.webmd.com). The resident's admission Minimum Data Set (MDS) assessment with assessment reference date of 7/02/22 revealed the resident's cognition was moderately impaired with a Brief Interview for Mental Status score of 8/15. The assessment indicated the resident received scheduled and as needed pain medications for frequent pain of moderate intensity. A physician's note, dated 7/09/22, read, Pain under control on great amount of narcotics around clock . acute on chronic back pain . [history of Thoracic-Sagittal spine] fusion. On 7/11/22 at 4:38 PM, resident #164 stated she was sutured from T3 to L5-6, the Thoracic to Lumbar spine region, and had issues with her spine that caused both chronic and acute pain. She recalled on the day she was admitted to the facility, transportation from the hospital took over one hour. The resident stated by the time she arrived at the facility, her pain level was 10/10 and she had to wait for one hour to get pain medication. Resident #164 stated nursing staff explained there was a pharmacy problem as a nurse had not entered her prescribed medications into the computer system. She recounted another incident on 7/09/22 when she went without pain medications for eight hours. The resident said, It was not pretty. She described vomiting as she suffered high levels of pain. The resident's husband said, It was really bad! He explained that while his wife was vomiting, she was unable to get any medication. The resident and her husband stated the facility needed to be more consistent with administration of pain medications. Resident #164 stated she had informed a couple of Licensed Practical Nurses (LPNs) of her concerns, and she was told they would get caught up on her pain medication and/or pass her concerns to the next shift. The resident explained she usually tried to get pain medication prior to therapy but these requests were not always honored. Review of the resident's Medication Administration Record (MAR) for 7/09/22 revealed Percocet 10-325 mg was administered at 4:05 AM, 10:01 AM, 2:09 PM, and 6:36 PM. The document revealed a period of approximately 9 hours elapsed before the next dose was administered on 7/10/22 at 3:22 AM, as reported by the resident. On 7/12/22 at 3:42 PM, LPN J stated resident #164 was a post-surgical patient who received pain medication as scheduled and as needed. LPN J explained the resident's care needs included medication administration and pain management. On 7/13/22 at 11:41 AM, the resident stated last night, 7/12/22, was a bad night with pain as there was some problem with narcotic medications. She explained at 10:00 PM, a nurse told her the pharmacy would deliver her Percocet tablets no later than midnight. The resident stated she told her assigned nurse that the nurse on the 7:00 AM to 7:00 PM shift had promised her the Percocet tablets would arrive by 10:00 PM. Resident #164 stated the 7:00 PM to 7:00 AM nurse responded, I am not the pharmacy. The resident reported the nurse, whose name she could not recall, told her to lay off the call light as she had reached her limit for pain medication. The resident stated the nurse informed her she would not call the physician or the pharmacy to obtain the code to access the facility's emergency medication supply. Resident #164 stated at about 5:00 AM this morning, 7/13/22, the night nurse entered her room, placed a cup with a tablet on the tray table, and walked away. On 7/13/22 at 5:58 PM, in a telephone interview, LPN H stated she was regularly assigned to resident #164 on the 7:00 PM to 7:00 AM shift and was aware of the resident's condition. She verbalized the resident normally requested Percocet every 4 hours. She recalled during the change of shift report, the previous nurse, LPN J, informed her she had to retrieve Percocet for the resident from the facility's Emergency Drug Kit (EDK). She stated LPN J told her the pharmacy would deliver narcotics for the resident on the next scheduled pharmacy run. LPN H stated the resident received her last dose of Percocet on 7/12/22 at approximately 5:00 PM. She verbalized the resident asked for pain medication between 9:30 PM to 10:00 PM on 7/12/22 and reported her pain level at that time as 7 on a pain scale of 1 to 10. LPN H stated she told the resident she would get her medication when the pharmacy delivered it. LPN H explained that when a medication was not available, the facility's process included either checking if it could be obtained from the EDK or calling the pharmacy for a stat or rush delivery. LPN H stated she could not obtain a code from the pharmacy to access the EDK because the previous nurse had already used a code, retrieved and administered one tablet to the resident. LPN H further explained if the pharmacy delivery was in transit, she could not obtain a code for emergency medication. She acknowledged she did not notify the physician or request any additional medication to address the resident's report of level 7 pain and lack of access to as needed medications for breakthrough pain. LPN H stated she rounded on the resident at 3:00 AM and she was asleep. However, LPN H verbalized she did not actually enter the resident's room to assess her pain level, but observed the resident from the hallway. She confirmed resident #164 requested pain medication at 9:30 PM but did not receive Percocet for pain until 8 hours later at 5:30 AM on 7/13/22. Review of the facility's job description for Licensed Practical Nurse revealed the LPN was responsible for the optimal quality of care for residents, and his/her responsibilities included administration of medication and treatments according to the physician's orders and assumes responsibility for ordering medications. On 7/14/22 at 9:43 AM, the Montecito Unit Manager (UM) stated the goal of pain management was for pain to be treated and managed appropriately. She stated the facility had an Automated Dispensing System (ADS) and all LPN H had to do was submit another request to the pharmacy to obtain Percocet from the ADS. The UM stated the physician should have been notified that the medication was not available, and an order obtained for breakthrough pain medication. She said, Ultimately, the nurse should have obtained medication from the ADS. The UM stated it was not acceptable for the resident to be in pain and not receive medication as ordered. She validated the resident's pain was not managed adequately. On 7/14/22 at 10:12 AM, the Director of Nursing (DON) stated the facility had an ADS, and the process was for the physician to contact the pharmacy to authorize dispensing of medication. The nurse would then contact the pharmacy to obtain a code to access the ADS, and two nurses would retrieve the medication from the ADS using the code. The DON stated he was not aware the nurses could not obtain a code if a pharmacy delivery was in transit as described by LPN H. He verbalized the physician should have been informed the medication was not available, and LPN H should have then repeated the process used by the previous nurse to obtain the medication from the ADS. The DON stated the expectation was for the nurse to follow the physician's order and utilize the ADS to obtain medications that were not available in the medication carts. The DON stated if a resident requested pain medication, it should be administered within a reasonable timeframe. He confirmed LPN H should have contacted the physician and obtained orders to address resident #164's pain in a timely manner. Review of the resident's Medication Administration Record (MAR) for the period 7/01/22 to 7/12/22 revealed the resident requested and received Percocet 10-325 mg routinely around the clock, approximately every 4 hours. The MAR showed on 7/12/22, Percocet 10-325 mg was administered at 5:24 PM and the next dose was not given until 7/13/22 at 5:32 AM, approximately 12 hours between doses and 8 hours after the medication was requested. During review of the MAR with the DON and the Montecito UM on 7/14/22 at 10:12 AM and 7/14/22 at 9:43 AM respectively, they acknowledged the findings. Review of the Policies and Procedures for Management of the [name of Automated Dispensing Systems] read, Nursing and Pharmacy will use the ADS Station as an inventory, charging and information system for the control and distribution of medications for Emergency, First-Dose use and other situations where medications are not available from the pharmacy . The facility must contact the pharmacy and obtain an authorization code for removal of any controlled substance . If there is no script on file, the pharmacist will page the prescriber for an electronic prescription or an emergency supply . If the medication is not available, call the pharmacy using the after- hours emergency number(s) if necessary. On 7/14/22 at 11:05 AM, resident #164 stated she would be comfortable with a pain level of 3/10. She explained that after her post-operative acute pain was resolved, she would be able to cope better with her chronic pain. Interventions on the resident's care plan At increased risk for alteration in comfort [related to] generalized discomfort and recent laminectomy initiated on 7/11/22 included administer pain medication as ordered, and notify physician of unrelieved or worsening pain. The facility's policy Pain Assessment and Management, revised in March 2020, read, The pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. The policy Administering Pain Medications revised in October 2010 revealed steps in the procedure included, Administer pain medications as ordered. The Facility Assessment, updated/reviewed on 6/29/22, indicated services and care offered by the facility would be based on the residents' needs and included assessment of pain and pharmacologic and non-pharmacological pain management.