**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and resident and staff interview, it was determined the facility failed to ensure the physician was notified of a significant change in a resident's condition. This was true for 1 of 1 resident (Resident #19) reviewed for change of condition. This failed practice resulted in harm to Resident #19 when he experienced a change in condition that resulted in hospitalization due to sepsis (a potentially life-threatening condition caused by the body's response to an infection), community acquired pneumonia, urinary tract infection, and Influenza A. Findings include: The facility's policy for Resident Change of Condition, dated 11/28/17, documented the following: * Upon recognition of a potentially life-threatening condition or significant change in status, the nurse should communicate with other health care providers to meet the needs of the resident. * The physician was informed at the time of the event, as soon as possible. * Notification occurred immediately if any symptom was sudden in onset, a marked change from the usual signs and symptoms, and unrelieved by prescribed measures. * For non-immediate notification, the physician was informed of the event during office hours and generally no later than the next regular business day. If a non-immediate event occurred on a weekend or holiday, good nursing judgment determined if the notification could wait until the next business day or if it should occur during the weekend or holiday. * The facility informed the resident, consulted with the physician, and notified the resident's representative when there was a significant change in the resident's physical, mental, or psychosocial status. This policy was not followed. Resident #19 was admitted to the facility on [DATE] and readmitted to the facility on [DATE], with multiple diagnoses including spina bifida (a birth defect that occurs when the spine and spinal cord don't form properly), hemiplegia and hemiparesis (weakness and paralysis) affecting the right side following a stroke, neuropathic bladder (a bladder that does not empty or store urine properly due to a neurological condition or spinal cord injury), and history of traumatic brain injury. A progress note by the Medical Director, dated 1/2/20, documented he saw Resident #19 due to increased urinary sediment, which necessitated staff changing his catheter every 5 or 6 days. The progress note documented Resident #19's skin was warm and dry. The Medical Director recommended encouraging fluids and changing Resident #19's catheter as needed due to obstruction. A Progress Note by the NP, dated 1/7/20, documented he saw Resident #19 due to pain all over his body that felt like arthritis pain. The NP documented the pain was well controlled with Tylenol, and there was no fever or chills. Resident #19's blood pressure was 152/77, temperature was 97 degrees Fahrenheit (F), and pulse was 63. The note stated his skin was warm and dry, and his lungs were clear. The treatment plan was to continue scheduled Tylenol 325 mg 2 tablets three times a day as well as Tylenol 2 tablets three times daily as needed and follow up with urology as needed. A progress note, dated 1/9/20 at 8:30 PM, documented Resident #19 stated I'm burning up. The note documented his blood pressure was 156/77, a heart rate of 88, and a temperature of 99.0 F. A progress note, dated 1/10/20 at 3:35 AM, documented Resident #19 had a distended (swollen) abdomen with less active bowel sounds. The note documented Resident #19 told the nurse he had not had a bowel movement in two weeks. The note also documented Resident #19's had a blood pressure of 82/54, a heart rate of 91, and a temperature of 99.0 F. The nurse documented Resident #19 was medicated for his temperature and given a Dulcolax suppository (laxative). There was no documentation Resident #19's physician was notified of his low blood pressure and he had a distended abdomen with no bowel movement in two weeks. According to the Mayo Clinic website, accessed 3/4/20, a sudden fall in blood pressure can be dangerous. A change of just 20 mm Hg (millimeters of mercury), such as a drop from 110 systolic (top number) to 90 mm Hg systolic, can cause dizziness and fainting when the brain fails to receive an adequate supply of blood. The Mayo Clinic website stated big plunges, such as those caused by uncontrolled bleeding, severe infections or allergic reactions, can be life-threatening. The Fundamentals of Nursing, eighth edition, by [NAME] and [NAME] (2013) stated hypotension when associated with paleness, skin mottling, clamminess, confusion, increased heart rate, or decreased urine output is considered life threatening and should be reported to a health care provider immediately. Resident #19's systolic blood pressure had dropped 74 mmHg in eight hours. A progress note, dated 1/11/20 at 9:16 AM, documented Resident #19 complained of extreme pain, and he was perspiring profusely. His blood pressure was 88/58, the heart rate was 118, and temperature was 101 F. Resident #19 was sent to the emergency room. A history and physical from the hospital, dated 1/11/20, stated Resident #19 presented to the emergency room with rapid breathing and hypotension. Resident #19 was admitted to the hospital with severe sepsis, community acquired pneumonia, urinary tract infection, and Influenza A. On 2/20/20 at 10:03 AM, the DON said she spoke to the NP, and he said although Resident #19 met the criteria for sepsis, he did not have sepsis because his white blood cell count was normal. The DON said she did not know if the physician was notified when Resident #19 demonstrated signs of fever and becoming ill. On 2/20/20 at 12:01 PM, the Medical Director said Resident #19 was chronically sick and became ill rapidly when he had to go to the hospital in January 2020. The Medical Director said the facility's nurses monitored residents' vital signs and notified him if they were abnormal. The Medical Director said Resident #19 was feeling sick, and the nurses would not necessarily notify him of things like that if the vital signs were okay. The Medical Director said Resident #19 could become ill very quickly, and he would have to read the hospital report to see if he had a urinary tract infection. The Medical Director said if one vital sign was abnormal he would not be concerned. The Medical Director said Resident #19 was at risk for infection due to the bacteria in the environment and the fact he had a catheter, a feeding tube, and immobility. On 2/21/20 at 10:19 AM, the DON said something should have been done related to Resident #19's blood pressure on 1/10/20 at 3:35 AM. Resident #19's physician was not notified when he had a significant change in his blood pressure and health status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and resident and staff interview, it was determined the facility failed to identify a skin abscess on a resident. This was true for 1 of 3 residents (Resident #19) reviewed for infections. This resulted in harm to Resident #19 when he developed the skin abscess and was sent to the hospital and the abscess likely contributed to his diagnosis of severe sepsis (a potentially life-threatening condition caused by the body's response to an infection). Findings include: The facility's policy for Prevention and Treatment of Pressure Ulcers and Other Skin Alterations, revised 7/13/18, documented residents had routine weekly skin checks to confirm there were no unidentified skin concerns. In addition, staff were to address potential new areas of concern. This policy was not followed. Resident #19 was admitted to the facility on [DATE] and readmitted to the facility on [DATE], with multiple diagnoses including spina bifida (a birth defect that occurs when the spine and spinal cord don't form properly), hemiplegia and hemiparesis (weakness and paralysis) affecting the right side following a stroke, neuropathic bladder (a bladder that does not empty or store urine properly due to a neurological condition or spinal cord injury, and history of traumatic brain injury. Resident #19's care plan directed staff to perform daily skin inspection during cares, notify the nurse of impaired skin integrity, the licensed nurse was to perform weekly skin assessments, and staff were to monitor for increased urethral erosion from the indwelling catheter. Resident #19's weekly skin checks, dated 11/14/19 at 10:04 AM through 1/2/20 at 6:26 AM, documented he had a urethral erosion (a wound often caused by the long term use of indwelling catheters) on his penis. The skin checks did not document an abscess on his scrotum. A progress note by the Medical Director, dated 1/2/20, documented he saw Resident #19 due to increased urinary sediment, which necessitated staff changing his catheter every 5 or 6 days. The progress note documented Resident #19's skin was warm and dry. The Medical Director recommended encouraging fluids and changing Resident #19's catheter as needed due to obstruction. A progress note by the NP, dated 1/7/20, documented he saw Resident #19 due to pain all over his body that felt like arthritis pain. The pain was well controlled with Tylenol, and there was no fever or chills. The NP stated Resident #19's skin was warm and dry. A discharge MDS assessment, dated 1/11/20, documented Resident #19 had an unplanned discharge to the hospital. The assessment documented he had an indwelling catheter and there was no documentation he had skin problems. A History and Physical (H&P) from the hospitalist, dated 1/11/20 at 1:59 PM, documented Resident #19 had an abscess (a painful collection of pus, usually caused by a bacterial infection, just under the skin) in the scrotum/perineal area. The H&P documented an abscess was noted in the scrotum when his catheter was changed, and a urologist opened the abscess and placed packing (a type of dressing) into the open wound. A Urology progress note, dated 1/13/20 at 4:43 PM, documented Resident #19 had a left scrotal abscess, chronic urinary retention, a urethral erosion, and sepsis (a potentially life-threatening condition caused by the body's response to an infection) due to pneumonia and urinary source. The progress note documented the left scrotal abscess was also likely contributing to the sepsis. On 2/20/20 at 12:01 PM, the Medical Director said Resident #19 had a groin mass or something and was being followed by urology for that. The Medical Director said Resident #19 was at risk for infection due to the bacteria in the environment and the fact he had a catheter, a feeding tube, and his immobility. On 2/20/20 at 9:19 AM, Resident #19 said he was very ill and had to go to the hospital in January, but he did not remember how he became ill. Resident #19 said staff did not clean his catheter every day. On 2/20/20 at 10:03 AM, the DON said Resident #19's abscess was not visualized and detected by staff because it was in an area that was not easily seen. On 2/20/20 at 4:14 PM, the DON said skin checks were done weekly, and Resident #19's abscess was not noticed until his catheter was replaced at the hospital. The facility did not identify Resident #19's scrotal abscess.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, and staff interview, it was determined the facility failed to ensure residents were provided with the levels of supervision necessary to prevent falls. This was true for 1 of 2 residents (Resident #25) reviewed for falls. This failure resulted in harm to Resident #25 with a fracture to his left femur. Findings include: The facility's Accidents and Supervision to Prevent Accidents policy and procedure, dated 4/4/19, documented the facility provided an environment that was free from accident hazards over which the facility had control and provided supervision and assistive devices to each resident to prevent avoidable accidents. This included systems and processes designed to: * Identify hazards and risks. * Evaluate and analyze hazards and risks. * Implement interventions to reduce hazards and risks. * Monitor for effectiveness and modify approaches when necessary. The policy also stated the facility was obligated to provide adequate supervision to prevent accidents, which was determined by assessing the appropriate level and number of staff required, the competency and training of the staff, and the frequency of supervision needed. This determination was based on the individual resident's assessed needs and identified hazards in the resident environment. Resident #25 was admitted to the facility initially on 5/21/19 and readmitted on [DATE], with multiple diagnoses including Alzheimer's disease, diabetes mellitus Type 2, cognitive social or emotional deficit following other cerebrovascular disease, and dementia with behavioral disturbance. Resident #25's MDS Assessment, dated 11/28/19, documented he was severely cognitively impaired and he required extensive assistance with two or more persons for bed mobility, toilet use, and transfers between bed, chair and standing. The assessment also documented Resident #25 required supervision with one-person physical assist when he walked between locations in his room. The Fall History section of the MDS assessment was not completed. Resident #25's MAHC-10 Fall Risk Assessments, used to determine a person's risk for falls, dated 8/4/19, 8/12/19, 9/28/19, 10/7/19, 11/27/19, and 12/6/19, documented Resident #25 was at risk for falls. A score of 4 or more out of 10 was considered at risk for falls. Resident #25 received a score of 7 to 10 on the days of his falls. Resident #25's care plan documented he was at risk for falls related to confusion, diminished safety awareness, gait and balance problems, and history of falls and significant dementia. The care plan was initiated on 6/3/19. The interventions included the following: * Wear non-skid footwear, initiated on 6/3/19 and revised on 8/3/19. * Staff need to anticipate his needs, initiated on 6/3/19 and revised on 8/3/19. * Resident #25 needs his door open, so staff can see him, initiated on 8/5/19 and revised on 12/2/19. * Encourage Resident #25 to use the grab bar near the bathroom to help balance himself, initiated on 12/2/19. Resident #25's care plan documented he had an activities of daily living (ADL) self-care performance deficit related to dementia, impaired cognition related to advanced dementia, impaired balance, and history of fall with left hip fracture, initiated on 5/22/19 and revised on 12/16/20. Interventions included the following: * Toilet use: he was not to be toileted. He had a catheter and was incontinent, initiated on 5/22/19 and revised on 9/18/19. * Transfers: He needed extensive assistance from staff, using a gait belt with transferring, initiated on 5/22/19 and revised on 9/18/19. * Bed Mobility: He required extensive 2 staff participation to reposition and turn in bed, initiated on 5/22/19 and revised on 9/18/19. * Physical Therapy and Occupational Therapy were to provide evaluation and treatment per physician orders, initiated on 5/22/19. * He needed to eat all meals in the dining room, initiated on 8/5/19. Facility Incident and Accident reports for Resident #25 documented he fell 8 times from 8/4/19 to 12/6/19, with the last fall resulting in a major injury. Resident #25 had documented falls on 8/4/19, 8/11/19, 9/4/19, 9/28/19, 10/7/19, 10/11/19, and twice on 12/6/19. The reports documented the following: a. A Post Fall Investigation report documented Resident #25 had an unwitnessed fall without injury on 8/4/19 at 8:15 AM. Resident #25 was found alone and unattended in his room during meal time, laying on his back parallel and next to his bed, with his arms at his sides, his legs straight out, and with stockings on his feet. The report documented Resident #25 had a history of falls on 5/25/19, 6/1/19, and 7/30/19. The investigation documented Resident #25 had dementia, was impulsive, lacked safety awareness, and had an unsteady gait. The physician and family were notified of the fall. An Incident Conclusion and Performance Improvement Follow-Up report, dated 8/5/19, documented the Performance Improvement (PI) Recommendations post fall were to place Resident #25's bed in the low position, he was not to eat in his room, and he was to be out of his room when out of bed. Resident #25's care plan did not document his bed should be placed in the low position, or that he was to be out of his room when he was not in bed. On 2/20/20 at 1:26 PM, the DON said after the 8/4/19 fall they looked at the cause, and wanted Resident #25 to spend his time out of his room to eat and for staff to observe him. She said the care plan was changed to keep Resident #25's door open, so staff could see him due to his poor safety awareness. b. A Post Fall Investigation report documented Resident #25 had an unwitnessed fall with injury on 8/11/19 at 11:30 PM. Resident #25 was found alone and unattended in his room, laying on his right side on the floor between the two beds, with gripper socks on, and verbally expressing he was in pain. The report documented Resident #25 rolled off the bed hitting the bridge of his nose resulting in a ¾ centimeter (cm) superficial cut and no other injuries. The report documented Resident #25 had been laying on his bed 15 minutes prior to the fall. The Incident Conclusion and Performance Improvement Follow-Up, dated 8/12/19, documented the PI Recommendations were to identify where the staff were at the time for better oversight of Resident #25, and for Occupational Therapy to screen Resident #25. Resident #25's care plan did not include documentation of new interventions related to this fall. Resident #25's record did not include an Occupational Therapy evaluation and treatment for the month of August. On 2/20/20 at 1:26 PM, the DON said after Resident #25's 8/11/19 fall they evaluated where the staff was at the time of the fall, and requested Occupational Therapy to work with Resident #25, and made a therapy referral for bed safety. c. A Post Fall Investigation report, dated 9/4/19 at 2:00 PM, documented the RN was alerted by staff Resident #25 was on the floor of his room. The RN documented Resident #25 had a skin tear to his left arm which measured 2 cm x 2 cm, he had no pain, and was unable to describe how he fell. The RN wrote it looked like he was on his bed and was heading to the bathroom but fell on his back, with his arms and legs by his side, his feet were towards the bathroom door, with nonskid socks on, he did not use his wheelchair or call light, and did not wait for help. The report documented predisposing factors were a wet floor, Resident #25's recent illness, gait imbalance, impaired memory, and he was ambulating without assistance. The RN documented there was some water on the floor by the bathroom door, and Resident #25's socks were wet. The Incident Conclusion and Performance Improvement Follow-Up, dated 9/5/19, documented the PI Recommendation was to not leave Resident #25 unattended in his room. Resident #25's care plan did not include documentation of new interventions related to this fall. On 2/20/20 at 1:26 PM, the DON said the 9/4/19 fall interventions were Resident #25 was to not be left unattended when up in his room and he was to be in the line of sight. The Administrator said they liked to keep him in the hall and busy. d. A Post Fall Investigation report, dated 9/28/19 at 12:48 AM, documented after hearing a loud door slam, Resident #25 was found sitting on the floor outside of his bathroom, with his shorts around his knees, leaning on his right elbow with a 1 cm skin tear. Resident #25 said he did not hit his head and requested help. The report documented he was assessed for injury, assisted up by 3 staff members, provided first aid to his skin tear, and was assisted into bed. The report documented Resident #25 was oriented to self and situation. The report documented predisposing factors were Resident #25's confusion, gait imbalance, impaired memory, non-compliance, and ambulating and transferring without assistance. The report documented the fall was unwitnessed. The Incident Conclusion and Performance Improvement Follow-Up, dated 9/30/19, documented PI Recommendations were to change Resident #25's straight catheter times, and to scan his bladder for urine and use the straight catheter as needed in order to keep his bladder empty so he did not attempt to get up to the bathroom without assistance. Resident #25's care plan did not include documentation of new interventions related to this fall. A progress note, dated 9/30/19 at 11:24 PM, documented Resident #25 had increased confusion, he continued to self-transfer, and was unsteady on his feet. On 2/20/20 at 1:26 PM, the DON said Resident #25 had a straight catheter at this time and they reviewed the time of the straight catheterization and did routine bladder scans. The Clinical Resource Nurse said they started his straight catheterizations on 6/19/19, and they were done at 8:00 AM, 2:00 PM, and 8:00 PM. The Clinical Resource Nurse said the report indicated they changed the straight catheterization times, but no change was made in the care plan or Treatment Administration Record (TAR). e. A Post Fall Investigation report documented Resident #25 had an unwitnessed fall on 10/7/19 at 4:40 AM. The report stated Resident #25 was found laying on his right side on the floor of his bedroom between the bed and the wall. The report stated Resident #25 said he rolled out of bed and hit his head. The report documented Resident #25 was assisted up, no bumps or bruising were noted, he was moving all his extremities, his vitals were taken, and his neurological checks were normal for him. The report documented Resident #25 was oriented to person, place, situation, and time. The report documented predisposing factors were Resident #25 was confused, drowsy, incontinent, he had a gait imbalance, and impaired memory. An Incident Conclusion and Performance Improvement Follow-Up report, dated 10/9/19, documented the PI Recommendation was to review Resident #25's straight catheterization timing. Resident #25's care plan did not include documentation of new interventions related to this fall. Resident #25's TAR documented his straight catheterization at 8:00 AM, 2:00 PM and 8:00 PM was discontinued on 10/7/19 and changed to three times a day at 5:00 AM, 1:00 PM and 9:00 PM on 10/7/19. On 2/20/20 at 1:26 PM, the DON said for the 10/7/19 fall they again reviewed the straight catheterization times and an order was placed on 10/7/19 for time changes to 5:00 AM, 1:00 PM, 9:00 PM, and as needed. The Clinical Resource Nurse said the time change did not make it into the care plan, but it was changed on the TAR. f. A Post Fall Investigation documented Resident #25 fell in the dining room on 10/11/19 at 10:30 AM. The report stated Resident #25 stood up from his wheelchair, turned, lost his balance, and fell hitting his head on the edge of the table. The report stated Resident #25 was immediately assessed for injuries with none found and was assisted up and back into his wheelchair. The report documented predisposing factors were Resident #25's confusion, incontinence, weakness, gait imbalance, impaired memory, and ambulating without assistance. The Incident Conclusion and Performance Improvement Follow-Up report, dated 10/14/19, documented a PI Recommendation of Resident #25 is impulsive. Resident #25's care plan did not include documentation of new interventions related to this fall. g. A Post Fall Investigation report documented Resident #25 had an unwitnessed fall on 12/6/19 at 4:08 AM. The report documented the RN found Resident #25 in his room laying on the floor on his right side near the wheelchair with his right hand under his head, and his legs extended down. The report documented Resident #25 was confused, had no skin tears, and was able to move his upper and lower extremities. The report documented he was immediately assessed for injury, was assisted up off the floor with a Hoyer lift (a mechanical lift) by three staff members. The report documented predisposing factors as being Resident #25's confusion, gait imbalance, impaired memory, and ambulating without assistance. The report documented Resident #25 became agitated when told to use the wheelchair, and at times was hard to redirect. Resident #25's care plan did not include documentation of new interventions related to this fall. h. A Post Fall Investigation report documented Resident #25 had an unwitnessed fall with major injury on 12/6/19 at 4:15 PM. The report documented Resident #25 was found after staff heard a loud crash and found him in his room on the floor on his left side on the left side of his bed and yelling I broke my hip. Resident #25 was assessed for injury and found to have his left leg shorter than the right leg and it was turned outward. Predisposing factors for the fall were documented as being Resident #25's confusion, incontinence, gait imbalance, impaired memory, improper footwear, and ambulating without assistance. An Incident Conclusion and Performance Improvement Follow Up report, dated 12/9/19, documented the PI Recommendation was to reassess Resident #25 when he returned from the hospital. A Fall with Injury report documented Resident #25's fall on 12/6/19 at approximately 4:00 PM. The report documented Resident #25 was found on the floor, 20 minutes after the RN last saw him, was assessed and transported to the hospital. The hospital reported Resident #25 had a complex fracture of the left hip from the event. The report documented Resident #25 was severely cognitively impaired and was recently treated for a urinary tract infection. The report's concluding documentation said Resident #25's fracture most likely occurred when he left his bed and fell on the floor. The wheelchair was properly positioned on the other side of the bed, and ready for self-transfer. He left the surface of the bed from the opposite side. A Final Report from the hospital, dated 12/13/19, documented Resident #25's diagnosis was a failed left total replaced hip due to a femur fracture. Resident #25 was discharged and returned to facility on 12/13/19. On 2/20/20 at 2:38 PM, when asked about Resident #25's two falls on 12/6/19, the DON said there was no injury in the morning and it was not reported and provided the second fall report commenting it was reportable because he broke his hip. On 2/20/20 at 1:26 PM, the DON said for the 10/11/19 fall Speech Therapy and Occupational Therapy became involved related to balance equipment. The DON said Resident #25 kept trying to stand up, so they looked at assistive devices for mobility, including a grab bar which was placed on the wall of his room by the bathroom. The Administrator said therapy was working with Resident #25 on sequencing and his inability to complete tasks without assistance, tactile cues and proper hand placement for a slow decent into a chair. The Administrator said they were trying to work with his memory. The Administrator said Resident #25 furniture surfed to move along and stand, and he was able to use the grab bar. When asked about their discussions about supervision as a potential intervention, the Administrator said increased supervision took the form of encouraging Resident #25 to be out of his room or in activities, and on 12/6/19, the day of his fall with hip fracture, he was particularly active, fidgety, and he changed his habits by getting out of bed on his non-usual side, the opposite side of his wheelchair. The facility failed to ensure Resident #25 received the level of supervision and assistance necessary to protect him from injury.