**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and resident, resident representative, and staff interview, it was determined the facility failed to ensure transfer notices were provided in writing to the residents and residents' representatives. This was true for 2 of 2 residents (#13 and #29) reviewed for transfers. This created the potential for harm if residents were not made aware of or able to exercise their rights related to transfers. Findings include: The facility's transfer and discharge policy, revised 11/2016, documented residents' records were to include the reason for transfers. The policy did not document that residents or residents' representatives were to receive a written notification of the reason for transfers. a. Resident #13 was admitted to the facility on [DATE], with multiple diagnoses including type 2 diabetes. Resident #13's Nurse's Progress Notes documented she was transferred to the hospital for evaluation on 3/9/19 and was readmitted to the facility on [DATE], with diagnoses of sepsis (a systemic infection) and stroke. Resident #13's record did not include a written notice of transfer to her or her representative. On 6/3/19 at 2:16 PM, Resident #13 said she did not remember receiving a transfer notice when she was transferred to the hospital. b. Resident #29 was admitted to the facility on [DATE], with multiple diagnoses including Alzheimer's disease. Resident #29's Nurse's Progress Notes documented she was transferred to the hospital for evaluation on 5/26/19 and was readmitted to the facility on [DATE], with a diagnosis of urinary tract infection. Resident #29's record did not include a written notice of transfer to her or her representative. On 6/5/19 at 10:13 AM, Resident #29's representative said the facility notified him via phone of the hospitalization. On 6/6/19 at 9:18 AM, RN #1 said when residents were transferred to the hospital their representatives were notified via phone, and they were not provided a written notice of transfer. On 6/6/19 at 9:37 AM, the Administrator said when residents were transferred to the hospital, the facility had not been providing written transfer notices to residents or their representatives.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, it was determined the facility failed to ensure a resident was appropriately assessed by a nurse after it was reported they had a seizure. This was true for 1 of 12 residents (Resident #4) reviewed for quality of care. This failure created the potential for harm should residents experience undetected changes in neurological status related to their disease process. Findings include: The Lippincot Manual of Nursing Practice, tenth edition, documented after a seizure a patient should be assessed for the degree of memory of recent events and coordination, paralysis, or weakness. The Lippincot Manual also stated the nurse needs to assess the length of time of the postictal state (the time after a seizure until the condition returns to normal) and pupil reaction. Resident #4 was readmitted to the facility on [DATE], with multiple diagnoses including epilepsy and repeated falls. Resident #4's quarterly MDS assessment, dated 2/27/19, documented the following he had moderate cognitive impairment, required extensive assistance of 2 persons with bed mobility and transfers, and had two or more falls since admission or the prior assessment, with one fall resulting in injury. Resident #4's care plan documented the following: * He had a seizure disorder related to epilepsy. Interventions, initiated on 7/22/17, included assessing asap (as soon as possible) if seizure activity occured, and after seizures check vital signs and neurological assessments. Resident #4's physician orders documented he took two medications to prevent seizure activity, as follows: * Keppra (medication to control seizures) 750 mg daily and 1000 mg at bedtime, ordered on 4/11/18. * Lamotrigine (medication to control seizures) 150 mg twice a day, ordered on 4/11/18. An I&A Report, dated 6/1/19 at 5:34 AM, documented Resident #4 had seizure like activity which caused him to land on his hands and knees on the ground next to his bed. A Nursing Progress Note, dated 6/1/19 at 5:35 AM, documented Resident #4 complained of dizziness and nausea. The nurse told him she would return with medication to help the dizziness and nausea. When the nurse returned to the room, Resident #4 was on his hands and knees on the floor, and he stated he had a really bad seizure. A Nursing Progress Note, dated 6/1/19 at 9:51 AM, more than 4 hours after the reported seizure activity, documented Resident #4 did not have further seizure activity. There was no documentation his condition was monitored or assessed after the reported seizure until that time. There was no documentation in Resident #4's record a neurological assessment or physical assessment was completed after he was found on his hands and knees and reported to the nurse he had a seizure on 6/1/19. On 6/5/19 at 10:16 AM, RN #1 said neurological assessments were done only if a resident hit their head when they fell. On 6/5/19 at 11:18 AM, the DNS said if a resident was not able to say whether they hit their head, then neurological assessments should be done, but if the resident said they did not hit their head then she probably would not do neurological assessments. The DNS said Resident #4 was able to tell staff whether he hit his head, and if he said he did not hit his head she would not do neurological assessments. On 6/5/19 at 2:06 PM, the DNS presented the policy for Neurological Assessment, dated 8/22/97, and said that was the way the nurses were trained. The DNS said neurological assessments should be done if there was evidence of head trauma or if the resident said they hit their head, and otherwise neurological assessments were not needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure fall prevention interventions were consistently implemented following resident falls. This was true for 2 of 2 residents (#4 and #45) reviewed for falls. This failure created the potential for harm should residents experience injuries from falling. Findings include: The facility's policy for Fall Protocol, revised May 2007, documented if any significant, pertinent measures to reduce risk for falls have not been taken, and in a timely manner, then deficient practice may exist. 1. Resident #4 was readmitted to the facility on [DATE], with multiple diagnoses including dementia, muscle weakness, abnormalities of gait and mobility, psychotic disorder with delusions, schizophrenia, Parkinson's disease (a progressive nervous system disorder that affects movement), epilepsy, cerebral palsy (a disorder that affects a person's ability to move and maintain balance), repeated falls, and dizziness. Resident #4's quarterly MDS assessment, dated 2/27/19, documented the following: * He had moderate cognitive impairment. * He required extensive assistance of 2 persons with bed mobility and transfers. * He had two or more falls since admission or the prior assessment, with one fall resulting in injury. Resident #4's physician orders included the following: * Keppra (medication to control seizures) 750 mg daily and 1000 mg at bedtime, ordered on 4/11/18. * Lamotrigine (medication to control seizures) 150 mg twice a day, ordered on 4/11/18. Resident #4's care plan documented he was at risk for falls related to a history of falling, generalized weakness, unsteady gait and balance, impulsive behaviors, and poor safety judgment. Interventions included the following: * One person assistance with transfers, initiated on 2/5/19 and revised on 5/6/19. * 4-P hourly rounds (hourly checks for pain, position, potty, and possessions), and ask if any assistance was needed, initiated on 10/31/17. * He wished for simple signs to remind him to call nursing for assistance, initiated on 5/16/18. * Non-skid strips in front of the toilet in the bathroom, initiated on 7/30/17 and revised on 9/19/17. * Safety notes that he could read to be posted in his room, initiated on 2/20/18. Resident #4's Fall Risk Evaluations documented he was at high risk for falls on 2/2/19 at 6:04 AM, 2/4/19 at 4:27 PM, 5/21/19 at 12:25 PM, and 6/2/19 at 2:23 PM. Resident #4's I&A Reports documented the following falls: * On 2/1/19 at 9:15 PM, he was found on the floor in his room. He attempted to self-transfer to get to the bathroom. * On 2/3/19 at 9:40 PM, he slipped and fell when attempting to self-transfer. Resident #4's care plan was updated to include one person assistance with transfers on 2/5/19. * On 2/21/19 at 1:00 AM, he was found on the floor in his room. He lost his balance when he self-transferred to the bathroom, and sustained abrasions to his forehead and right wrist. Additional interventions were not added to Resident #4's care plan following the fall. * On 6/1/19 at 5:34 AM, he was found on the floor on his hands and knees after the nurse told him she would return with medication for nausea. It was determined he had seizure like activity which caused him to land on his hands and knees on the ground. Resident #4's care plan was not updated to include new fall prevention interventions. Resident #4 was observed in his room self-transferring from his wheelchair to his recliner or bed on 6/3/19 at 2:02 PM, 2:25 PM, and 2:30 PM. On 6/5/19 at 9:34 AM, Resident #4 was in his room leaning far forward in his wheelchair as he grabbed his recliner chair and moved it. Resident #4 leaned toward the floor, looked around the floor and room, and attempted to get behind the recliner while in his wheelchair. A male staff member entered the room and asked Resident #4 if he needed help. Resident #4 said he was trying to find the remote control for his television. The 4-P hourly rounds were documented once per shift on Resident #4's ADL (Activities of Daily Living) flowsheet section with a staff member's initial and time. The flowsheet did not contain documentation of the time each round was completed. Resident #4's Fall Prevention Devices flowsheet documented visual checks were completed by staff on two occasions from 5/8/19 through 6/6/19, on 5/26/19 at 10:05 AM and 6/2/19 at 3:29 PM. The non-skid strips were not present in Resident #4's bathroom, and safety notes were not posted in his room, as directed in his care plan, on 6/5/19 at 10:47 AM. On 6/5/19 at 10:52 AM, CNA #2 said she checked on Resident #4 a lot, and she was always looking to see where he was and reminding him to call if he needed anything. CNA #2 said Resident #4 usually tried to self-transfer into his recliner. CNA #2 said she checked on residents who were at risk for falls every hour, and Resident #4 was to be checked every 30 minutes or hourly. On 6/5/19 at 10:57 AM, RN #1 said Resident #4 was on every 15 minute checks in the past, but at the present time there was no direction regarding how often he should be checked. RN #1 said staff constantly walked by Resident #4's room to see what he was doing, and he knew how to use his call light but sometimes he would not use it. RN #1 said there were no posted signs or notes in Resident #4's room. On 6/5/19 at 11:18 AM, the DNS said the facility did just about everything they could think of to prevent Resident #4 from falling, including signs in his room to call the nurse for assistance. The DNS said staff were to do hourly 4-P checks, place his bed in low position, and keep slick blankets off his bed. The DNS said Resident #4 required one person assistance with transfers and he was not safe to self-transfer. The DNS said if staff saw Resident #4 go to his room they would try to catch him, but he may try to do what he wanted to do and he moved fast. The DNS said Resident #4 may not have signs in his room anymore because sometimes he took the signs down, and the facility was told signs could not be placed if resident information was displayed. The DNS said she did not know what to say about the non-skid strips not being in Resident #4's bathroom, there may have been a room change and the non-skid strips did not get moved. On 6/5/19 at 11:34 AM, the DNS said it was documented once a shift that Resident #4's hourly 4-P checks were done. On 6/5/19 at 12:07 PM, RN #1 said she was just reminded Resident #4 was on hourly 4-P checks, and the CNAs documented it. On 6/5/19 at 12:12 PM, CNA #2 said she was just informed by RN #1 that staff were to check on Resident #4 hourly, and they were to document it. CNA #2 said the hourly checks should not be documented just at the end of the shift, and they were previously documented on a sheet of paper but now it was entered in the computer. CNA #2 said there was no documentation of the times the hourly checks were completed for Resident #4. On 6/6/19 at 3:16 PM, the DNS said it was not possible to document hourly checks in the electronic medical record, so it was set up to document it each shift.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure staff performed appropriate hand hygiene during medication administration. This was true for 1 of 12 residents (Resident #32) reviewed for infection control. This failure placed residents at risk of infection from cross-contamination. Findings include: The facility's policy for Hand Washing, revised May 2007, documented hand washing was the most important procedure to prevent facility-acquired infections. The Center for Disease Control and Prevention website, accessed 6/10/19, documented hand hygiene should be performed after touching a patient or their immediate environment, after contact with blood, body fluids, or contaminated surfaces, and immediately after removing gloves. On 6/6/19 at 11:41 AM, LPN #1 administered eye drops to Resident #32, removed her gloves, and did not perform hand hygiene. LPN #1 then picked up a blood glucose meter (a machine used to check the resident's blood sugar level) from Resident #32's bedside tray and returned to the medication cart. LPN #1 obtained an alcohol wipe from the medication cart and returned to Resident #32's room with the blood glucose meter. LPN #1 placed the blood glucose meter on the bedside table on a paper towel, cleansed the blood glucose meter with a disinfectant wipe, removed her gloves, and did not perform hand hygiene. LPN #1 applied new gloves and performed a blood glucose test on Resident #32's right third finger. The blood glucose meter read error. LPN #1 removed her gloves, did not perform hand hygiene, applied new gloves, obtained a new blood glucose test strip, and performed a blood glucose test on Resident #32's left index finger. At the end of the observation, LPN #1 said she did not perform hand hygiene after removing her gloves in Resident #32's room. On 6/6/19 at 2:40 PM, the DNS said she expected staff to perform hand hygiene with any contact with a resident when they might contact bodily fluids, before applying gloves, and after removing gloves.

**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 a) Residents were provided accurate information regarding Advance Directives upon admission, and if necessary they were assisted to formulate Advance Directives, b) Residents' records included a copy of the Advance Directives, or documentation of their decision not to formulate an Advance Directive, c) Residents' Advance Directives were recognized and honored, and d) The physician's order regarding code status was consistent with the resident's wishes documented in the record. This was true for 4 of 4 residents (#7 #13, #40 and #148) reviewed for Advance Directives. These failures created the potential for harm should residents not have their decisions documented, honored, and respected when they were unable to make or communicate their health care preferences. Findings include: The State Operations Manual, Appendix PP, defines an Advanced Directive as .a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated. The State Operations Manual also states a Physician Orders for Life-Sustaining Treatment (POLST) is a form designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency, taking the patient's current medical condition into consideration. A POLST paradigm form is not an Advance Directive. The facility's policy for Advance Directive Documentation, revised [DATE], documented the following: * At the time of admission, the facility provided written information to residents regarding Their right under State Law to accept or refuse medical treatment and the right to formulate Advance Directives such as the Natural Death Act, Durable Power of Attorney for Health Care Decision, or living will, in accordance with the Resident Self Determination Act. * The facility included documentation in the resident's record that written information was provided upon admission regarding Advance Directives and whether the resident had completed an Advance Directive. * The facility provided education to staff and residents related to Advance Directives. * The admission Coordinator, Social Service Director or designee inquired whether the resident completed an Advance Directive and provided the Concerning Life Prolonging Procedures form if an Advance Directive did not exist. * When an Advance Directive was completed, it was reviewed to ensure it was signed and dated by the resident and it reflected their wishes. If the resident was no longer capable of making decisions independently, the Advance Directive was accepted. * Copies of the Advance Directive and conservatorship/guardianship were obtained and placed in the resident's record. * A written order was obtained from the physician to carry out the Advance Directive. * If the resident was capable of making decisions independently, assistance was provided to complete the desired documents if they wanted to complete an Advance Directive. * If the resident was not capable of making decisions independently, their decision maker was asked to document their wishes regarding initiating an Advance Directive for the resident. * All Advance Directive orders were reconfirmed monthly in the physician's orders. On [DATE] at 11:02 AM, the DNS said the facility was trying to get rid of the POST (Physician Orders for Scope of Treatment, Idaho's version of POLST) form, so a new form was put in place by the facility, titled Request Concerning Life-Prolonging Procedures form. The top portion of the form included space for the resident's or the resident's legal guardian's name and date. It stated the resident or legal guardian requests the following care in the event that the attending physician determines that [the resident's] condition (be it injury, disease or illness) is terminal, incurable and irreversible, and that death is imminent): The form stated You must indicate Yes or No for each listed procedure. Yes means to do the procedure, No means DO NOT do procedure. The procedures listed for which the resident or resident representative was to indicate yes or no to, included: *Cardiopulmonary resuscitation (CPR) *Use of respirators or ventilators *Blood transfusion *Administration of medications other than those necessary to prevent infection, provide comfort, or alleviate pain *Transfer to an acute care hospital *Other, with two lines to document specific information The form documented I fully understand the impact and potential consequences of this document and wish to emphasize my desire to have the procedures performed or withheld (as indicated above) if death is imminent. The bottom portion of the form included spaces for the dated signature of the resident or guardian, physician, and a witness, and space for the attending physician's comments. The form addressed residents' wishes when death was imminent. It did not address residents' healthcare wishes if they were to become incapacitated and death was not imminent. The form did not address the right to establish a Living Will and/or Durable Power of Attorney for Healthcare. Idaho Code, Title 39, Chapter 45, The Medical Consent and Natural Death Act, specifies the required contents of a Living Will and/or Durable Power of Attorney in Idaho. It states the following: Any competent person may execute a document known as a Living Will and Durable Power of Attorney for Health Care. Such document shall be in substantially the following form, or in another form that contains the elements set forth in this chapter. The facility's Request Concerning Life-Prolonging Procedures form did not address residents' wishes regarding the administration of artificial or non-artificial hydration and nutrition, an element required for a living will under Idaho Code, Title 39, Chapter 45, The Medical Consent and Natural Death Act. 1. Resident #40 was admitted to the facility on [DATE], with multiple diagnoses including stage 3 chronic kidney disease. Resident #40's Request Concerning Life-Prolonging Procedures form, dated [DATE], documented his code status was DNR and he did not want respirators, ventilators, blood transfusions, or sent to an acute care hospital. Resident 40's record included a Living Will and Durable Power of Attorney for Health Care, dated [DATE]. Resident #40's Living Will documented his code status was DNR. On [DATE] at 4:02 PM, the SSD said the facility copied residents' living wills and power of attorney documents and they were kept in the residents' records. She said the facility's Request Concerning Life-Prolonging Procedures form superseded residents' Living Wills and DPOA documents. The SSD said residents and their families had been educated that the Request Concerning Life-Prolonging Procedures form was the Advanced Directive. Resident #40's Living Will and Durable Power of Attorney for Health Care, were not recognized by the facility as his Advance Directives. 2. Resident #148 was admitted to the facility on [DATE], with multiple diagnoses including an old myocardial infarction (heart attack). Resident #148's physician orders documented CPR/Full Code was ordered on [DATE]. Resident #148's care plan documented he wished his code status to be Full Code, initiated on [DATE]. Resident #148's Request Concerning Life-Prolonging Procedures form, dated [DATE], documented he wished to receive CPR, blood transfusion, medications other than those necessary to prevent infection, provide comfort, or alleviate pain, and transfer to the hospital. He did not wish to receive respirators or ventilators. The form was signed by Resident #148 on [DATE]. Resident #148's Social Services Assessment/Evaluation, dated [DATE] at 1:30 PM, documented his Advance Directive wishes included Full Code. Resident #148's record did not contain documentation an Advance Directive was offered, explained, or discussed with him. An Advance Directive was not present in Resident #148's medical record. On [DATE] at 4:15 PM, the SSD said the Request Concerning Life-Prolonging Procedures form was the documentation of Advance Directive information for Resident #148, and his code status was documented on the Social Services Assessment. 3. Resident #7 was admitted to the facility on [DATE], with multiple diagnoses including dementia and moderate intellectual disability. Resident #7's annual MDS assessment, dated [DATE], documented she had severe cognitive impairment. Resident #7's POST documented her code status was Full Code (resuscitate), and it was signed by her legal guardian on [DATE]. On [DATE] at 11:55 AM, Resident #7's physician orders documented CPR (cardiopulmonary resuscitation)/Full Code was ordered on [DATE]. Resident #7's record did not contain documentation an Advance Directive was offered, explained, or discussed with her legal guardian. A Progress Note, dated [DATE] at 3:23 PM, documented a care plan conference was held via phone call to Resident #7's guardian. Her code status was reviewed and it was Full Code at that time. A Request Concerning Life-Prolonging Procedures form was sent to her guardian by e-mail to replace her POST. Resident #7's Request Concerning Life-Prolonging Procedures form, dated [DATE], documented no CPR and was signed by her guardian on [DATE]. Resident #7's record did not contain documentation an Advance Directive was offered, explained, or discussed with her legal guardian. On [DATE] at 4:09 PM, the Social Services Designee (SSD) said after the Request Concerning Life-Prolonging Procedures form was completed, she thought the nurse may have overlooked the need to update the physician's order to change Resident #7's code status to Do Not Resuscitate (DNR). On [DATE] at 11:02 AM, the DNS said Resident #7's form came back to the facility after being completed by her guardian, and the physician's order regarding her code status was not changed until [DATE]. Resident #7's legal guardian was not provided information regarding Advance Directives and Resident #7's physician's orders were not updated in a timely manner to reflect her current code status of DNR. 4. Resident #13 was admitted to the facility on [DATE], with multiple diagnoses including type 2 diabetes. Resident #13's Request Concerning Life-Prolonging Procedures form, dated [DATE], documented her code status was Full Code. Resident #13's POST, dated [DATE], documented her code status was DNR. Resident #13's physician orders, dated [DATE], and her care plan, documented her code status was DNR. On [DATE] at 3:24 PM, Resident #13 said when she came to the facility she wanted to be resuscitated but had since changed her mind and wanted to her code status to be DNR. Resident #13's record did not include an Advanced Directive. On [DATE] at 2:45 PM, RN #1 said she would find residents' Advanced Directives in the electronic medical record under the documents tab. RN #1 demonstrated how she looked for residents' Advanced Directives and navigated to where the Request Concerning Life-Prolonging Procedures form was located. On [DATE] at 4:02 PM, the SSD said Resident #13's record should have contained a new Request Concerning Life-Prolonging Procedures form when she changed her code status from Full Code to DNR. The SSD said the POST was not an Advanced Directive and staff should have filled out a new Request Concerning Life-Prolonging Procedures form for Resident #13. The facility failed to ensure residents' and residents' representatives were educated that their living wills and powers of attorney were Advance Directives and failed to educate them on what an Advance Directive was. The facility failed to honor residents' Advance Directives when they were directed to complete the Request Concerning Life-Prolonging Procedures form as the facility's recognized Advanced Directive.