**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident's discharge hospital orders were followed for medication administration, and discharge procedures and appointments. The facility failed to assess and monitor a resident with a known vision impairment, and a known facial infection on antibiotic therapy. The facility failed to monitor and assess a central venous catheter site. This failure resulted in a resident with a vitreous hemorrhage having no surgical intervention and follow up care, and the resident continuing to complain of decreased vision, facial pain, and swelling. This applies to 1 of 17 residents (R59) reviewed for quality of care in the sample of 17. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 6/12/23 when R59 was re-admitted to the facility with a vitreous hemorrhage. V1 Administrator was notified of the Immediate Jeopardy on 9/12/23 at 3:55 PM. The surveyor confirmed by observation, interview, and record review, the Immediate Jeopardy was removed on 9/12/23; however, noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: On 09/10/23 01:45 PM, R59 was walking down the hall with his walker, looking upward. R59 said he had right cheek pain pointing from his right cheek by his nose to his ear. R59 pointed to his right upper chest and said he had an infection, and they were supposed to change his line. R59's right cheek was swollen with some slight redness as compared to R59's left cheek. R59 had a central venous catheter (CVC) on his right upper chest covered with a transparent dressing. The dressing was not dated, and the ends of the catheter were exposed. R59 said he had an infection in his ear and teeth and finished his medications 2 months ago. R59 said the doctor said he was supposed to have this (pointing to his chest) out a month ago, but the nurse doesn't know anything. R59's Progress Notes dated 6/5/23 at 10:03 AM, shows writer called to dialysis den by staff. Upon entering room, R59 is visibly shaking and crying. R59 reports a headache that has increased pressure and pain. R59 stated the pain was radiating into his jaw, down his neck, and into his chest. Given cardiac history 911 was called. R59's After Hospital Care Plan dated 6/12/23 shows Active Issues Needing Follow UP: Follow up appointment for Intraocular Pressure check. Please schedule a follow up appointment with your Primary Care Provider. This appointment should take place within 2 weeks of your hospital discharge. Appointments Scheduled: 7/7/23, Procedure with V21 (Ophthalmology) at hospital inpatient operating room. 7/8/23 at 9:30 AM, Office Visit with V21. This same Care Plan shows R59 is to start 6 new eye drop medications (acetazolamide daily for acute angle-closure glaucoma, brimonidine tartrate three times a day for increased intraocular pressure, dorzolamide hcl three times a day for increased ocular pressure, latanoprost at bedtime for open-angle glaucoma, rhopressa at bedtime for ocular hypertension, and timolol maleate twice a day for increased ocular pressure). R59's Hospital Progress Note dated 6/8/23 shows intraocular pressure greatly elevated on admission with hyphema and unreactive pupil. Discussed at length with cardiology and anesthesia the possibility of doing bedside versus operating room glaucoma procedure to lower the pressure. Both teams agree that this would be very high risk given R59's pulseless electrical activity arrest after cataract surgery but before developing a vitreous hemorrhage. Therefore, it is possible that he still has overall good vision potential even if we do not operate on his left eye urgently. Vitreous hemorrhage: both eyes, right eye greater than left eye, will plan for vitrectomy with V21. R59's Progress Notes dated 6/12/23 at 6:30 PM, written by V2 Director of Nursing (DON) shows R59 was admitted from the hospital with a diagnoses: increased intraocular pressure, bilateral vitreous hemorrhage. This same note does not contain documentation of follow up appointments or procedures needed or an assessment of R59's vision or pain. R59's Progress Notes dated 6/19/23 written by V13 Registered Nurse (RN) shows patient requesting to go to emergency room with complaints of headache, ear pain, and jaw pain. Tylenol administered patient persistent on going to emergency room. Ambulance called patient sent to hospital for further eval. R59's Hospital Discharge Packet dated 6/29/23 shows R59's admission diagnoses: mastoiditis of right side, facial cellulitis, infection of external ear, right, and chronic renal failure. The same packet shows a Central Venous Tunneled Catheter was inserted 6/29/23. The discharge medication list in this packet shows Meropenem 1 gram intravenous every 24 hours for 21 days and Vancomycin 500 mg intravenously every Monday, Wednesday, Friday for 20 days. R59's After Hospital Care Plan in this same packet shows Appointments Scheduled: 7/7/23 Procedure with V21, 7/8/23 at 9:30 AM post op with V21 and 7/18/23 at 1:30 PM office visit with V16 Infectious Disease Doctor. R59's Progress Noted dated 6/29/23 at 5:30 PM, written by V13 shows admitted from hospital, diagnosis Mastoiditis of right side. This same note does not contain an assessment of R59's pain, or R59's right cheek and does not show follow up appointments. R59's Infectious Disease Progress Notes dated 6/28/23 and faxed to the facility on 7/14/23 shows Catheter Care line maintenance per protocol: Normal saline flush 5 ml pre/post use. R59's Infectious Disease Progress Note dated 7/18/23 shows Completed antibiotic treatment for mastoiditis, Follow up with V21 Ophthalmology, Follow up with Ear Nose and Throat Doctor, will schedule removal of central line on Friday 7/21/23. R59's Instructions for Procedure 8/16/23 (CVC removal) was faxed to facility on 8/10/23 and shows tunneled central line catheter has been scheduled for Wednesday, 8/16/23. Pre-admissions nurse will call by 3 PM the business day before the procedure. On 9/11/23 at 11:40 AM, R59 was in his room in bed. R59 stated I need to go to the eye doctor. My right eye has a little bit of shadows, and my left eye sees shadows only. I have pain to my right cheek and ear (motioning with his hand on the right cheek from his nose to his ear) No doctor has seen me here. My eyes are getting worse. I'm supposed to get this line out (touching his right upper chest), but no one knows nothing. I'm not sure if its set up, they don't tell me. The nurses don't touch the catheter except for today. The doctor said when I finished the medicine it's supposed to come out (touching the catheter on his right chest). I gave the papers from the doctor to them. It was supposed to come out the 16th. When the 16th came, I asked, and they don't know. I can't see well. I can't see TV. I walk with a walker, but I have to look for the light and I remember the path. R59's CVC had a new transparent dressing dated 9/11/12 with gauze dressing over the catheter ports. R59's Minimum Data Set, dated [DATE] shows R59 is cognitively intact, has moderately impaired vision, and requires supervision for activities of daily living. On 9/11/23 at 8:15 AM, V10 RN said she was not sure who makes appointments or schedules transportation for residents. V10 said she didn't know anything about R59's catheter and had not assessed it. On 9/11/23 at 8:18 AM, V11 Certified Nursing Assistant (CNA) Supervisor said the nurses are supposed to make resident appointments and transportation. On 9/11/23 at 8:21 AM, V12 Social Services said the nurses schedule appointments and transportation. V12 said nurses review the resident's discharge paperwork and orders for medications and appointments. V12 said sometimes V2 Director of Nursing (DON) helps with the orders. V12 said resident appointments are on the home screen of the computer so nurses and CNAs can see. On 9/11/23 at 8:30 AM, V10 RN, with this surveyor, viewed the computer home screen and R59 had an appointment listed for 9/20/23 at 12 PM for his CVC removal (2 months after finishing the antibiotics) and a hearing screening on 10/12/23 at 11 AM. There were no other appointments listed for R59. On 9/11/23 at 9:06 AM, V13 RN said she vaguely recalled R59's hospitalization and didn't remember making any appointments for R59 or could not recall doing anything with R59's CVC. V13 said V9 Facility Physician is R59's doctor and either V9 or V17 Nurse Practitioner (NP) sees R59. V13 said when a doctor or NP see a resident, they document in the progress notes. V13 said R59 is alert and oriented and not a big complainer, so if he complains something is wrong. V13 said R59 has no chronic pain, but has vision problems, he can only see out of one eye. V13 said nurses set up appointments and communicate via shift to shift report if they need to arrange appointments or transport. On 9/11/23 at 9:15 am, V14 Ophthalmology Surgery Clinic Scheduler said R59 had surgery scheduled for his eyes, but it was canceled due to resident not getting a surgical clearance. V14 said R59 didn't go for his preop surgical clearance that had been scheduled locally. V14 said she had reached out to the physician's office where the surgical clearance was scheduled and R59's appointment had never been rescheduled. V14 said R59 was seen urgently in the hospital and was scheduled for a vitrectomy of his right eye due to a vitreous hemorrhage. V14 said R59 was supposed to have this surgery within 2-8 weeks from hospital discharge (6/12/23). V14 said R59 does not have an appointment scheduled currently. V14 said she would have V21 Ophthalmology Doctor call this surveyor. R59's July Medication Administration Record (MAR) shows R59 missed antibiotic (Meropenem) doses on 7/10/23, 7/12/23, and 7/19/23. The same MAR shows acetazolamide eye drop was missed on 7/12/23, 7/17/23, 7/17/23, and 7/19/23; latanoprost eye drop missed on 7/2/23, 7/6/23, 7/15/23, 7/16/23, 7/19/23, 7/24/23, and 7/28-7/30/23; rhopressa eye drop missed on 7/2/23, 7/6/23, 7/15/23, 7/16/23, 7/19/23, 7/24/23, and 7/28-7/30/23; timolol eye drop missed on 7/2/23, 7/6/23, 7/15/23, 7/16/23, 7/19/23, 7/24/23, and 7/28-7/30/23; brimonidine tartrate eye drops missed on 7/2/23, 7/6/23, 7/12/23, 7/10/23, 7/12/23, 7/15-7/17/23, 7/19/23, 7/24/23, and 7/28-7/30/23 and Dorzolamide eye drop missed on 7/2/23, 7/6/23, 7/10/23, 7/12/23, 7/15-7/17/23, 7/19/23, 7/24/23, and 7/28-7/30/23. R59's Progress Notes from 6/19/23 to 9/11/23 do not contain any progress notes from V9 (R59's facility Physician) or V17 Nurse Practitioner. These same notes do not contain any documentation on R59's appointment or procedures with V21, or R59's CVC removal or any assessments on R59's CVC or assessments of R59's vision or face or missed medication doses. On 9/11/23 at 12:51 PM, V17 NP said she had not seen R59, V9 (MD) sees him. V17 said the facility has a policy on CVC care and they should be monitoring/assessing for signs of infection of the site. V17 said orders for medications including intravenous antibiotics and eye drops should be followed as prescribed and if medications are not given as ordered or doses are missed it should be reported to the physician. V17 said if antibiotics are not given as ordered there is a risk of the infection not being treated correctly, the resident can develop antibiotic resistance. On 9/11/23 at 1:27 PM, V13 RN said she had never set up eye appointments for R59 and she was not sure why R59's CVC removal appointment on 8/18/23 was missed. V13 said the hospital called to reschedule the CVC removal for 9/20/23 and she put the appointment in the home screen of the computer, not in the progress notes. V13 said there is usually a doctor's order regarding catheter care, when to flush, monitoring for signs and symptoms of infection and dressing change. V13 said there wasn't any orders for R59's CVC and she didn't know why. V13 said if a medication is missed or not given the doctor should be called and there should be a progress note. On 9/11/23 at 1:37 PM, V1 Administrator and V4 Nurse Consultant reviewed R59's progress notes and said R59 was seen by physiatrist and psychology, but they didn't see any physician notes. V1 said physicians should see the resident within one week of re-admission to the facility. V1 said nurses should review the discharge orders and appointments and put them in the computer. V1 said there is facility policy for CVC care and the nurses should follow the policy. V1 was not sure why there were no orders for CVC care for R59 until today. V1 said he was not sure why R59 missed his appointments including the 8/16/23 CVC removal, it wouldn't have been a transportation issue because the facility bus would transport R59. V1 said nurses should follow physician orders as prescribed. V1 said floor nurses review the hospital discharge papers when the resident is admitted , and the DON should review the orders as well. V4 said the Interdisciplinary team should look at this, this is a process problem. On 09/11/23 at 01:04 PM, V9 MD said he couldn't recall R59 without looking him up and he would be in the facility tomorrow. V9 said he is at the facility almost weekly to see residents. V9 said residents should be seen within a few days when re-admitted from the hospital and should be seen at least every two months. On 09/12/23 at 08:03 AM, V21 Ophthalmology was called, and a second message left to speak with V21. There was no return call from V21. On 9/12/23 at 9:20 AM, V1 Administrator said R59 had his CVC catheter out last night (26 days after it was scheduled to be removed). V9 MD walked into V1's office and said he located his notes and shook papers in the air. V9 said he was behind due to medical problems and was catching up. V9 said he would put his notes into the computer that day and said he did see R59 after his hospitalization. V9 said he was not aware of R59 missing any appointments or medications doses. On 09/12/23 at 10:50 AM, V6 Licensed Practical Nurse said R59 gets eye drops for glaucoma. V6 said R59 had cataract surgery and his vision was better for a while, but now it is worse again. V6 said you have to guide R59 with the walker, R59 doesn't see well at all. On 9/12/23 at 11:50 am, V2(DON) said R59 was supposed to go to a preop appointment and didn't because he was in the hospital, so R59's surgery was canceled. V2 said she was unaware of R59's surgery even though she admitted R59 on 6/29/23 and the appointments were in the hospital discharge paperwork. V2 said the nurses should review admission orders, enter the orders, and look at follow up appointments. V2 said R59's eye surgery had not been rescheduled and there was no follow up appointment to the eye doctor scheduled for R59. V2 said she was not sure why R59's catheter was not removed on 8/16/23, but the hospital had called, and it was rescheduled for 9/20/23. V2 said V9 MD saw R59 today and asked to get R59 sent out to hospital as a precaution for his right cheek. V2 said we are looking into doing a 24 hour audit and they currently don't know why R59's appointments were missed. V2 stated they generally double check; we're going to work on that. There is no admission/re-admission procedure in place until now for the nurses. Today and moving forward we will have a plan. V2 said V9 had not documented his June visits for R59 yet, and she had discussed R59's missed eye appointments and CVC with him. V2 said there was no order for CVC care, and she was not sure if there ever was, she hadn't dug that far yet. V2 said a CVC should have an order for flushes, dressings changes weekly, and to monitor for signs and symptoms of infections every shift. V2 was not aware of any missed IV medications or eye drops for R59, but she spoke to V9 about it, and she was investigating it. V2 said physician orders are to be followed and if medications are missed the doctor should be called and documented. On 09/12/23 at 10:34 AM, V18 RN for V16 Infectious Disease Physician, said R59 was treated for mastoiditis and there was destruction of the bone involved. V16 said the importance of intravenous antibiotics is to stop the spread of infection and the length of treatment is important to get rid of infection so there is no more destruction of the bone. V16 said she would expect the nurses to call the doctor if doses of treatment are missed. V16 stated as long as a CVC is in, they should be doing catheter care and assess for signs and symptoms of infection and doing dressing care. R59's CVC is a tunneled catheter and should be surgically removed. R59 was scheduled for 8/16/23 but I'm not sure why it was not done. The area around the catheter should be maintained and assessed, and they should call the doctor and inform us of any right side swelling or pain to R59's face. They should monitor R59's face for increased redness, tenderness, pain or warmth to touch and report it to us. The complication of not receiving catheter care is infection and the line is a straight shot to the heart, so there is an increased risk for sepsis. R59's Physician Orders from June to Current 2023 shows CVC to right upper chest: weekly dressing changes and as needed if becomes soiled or dislodged every day shift every Monday for Catheter Care, IV Type: Right CVC, IV: flush all ports with 10 ml normal saline every 24 hours when not in use, with a start date of 9/11/23. (Order was placed 74 days after R59 was admitted with a CVC). R59's Progress Note dated 9/11/23, written by V3 Wound RN shows this writer has completed weekly and as needed dressing changes to the CVC right chest site since the antibiotic was discontinued. There have not been any signs or symptoms of infection, no redness, no pain, or complications. On 09/13/23 09:23 AM, V2 DON said V3 did not document catheter care in the medical record and there were no documents to provide showing catheter care was done. V2 said catheter care should be documented in the medical record when it is completed, and resident appointments should be documented in the resident's progress notes. R59's Physician Progress Note dated 9/13/23 at 12:26 PM, shows asked to see resident 9/12/23 due to new complaint of right face tingling and swelling. Resident in dialysis, comfortable and in no distress. Resident with recent history of right face cellulitis and mastoiditis treated with intravenous antibiotics. Right side of face with mild swelling compared to left side, no erythema. Due to acute change and the history of right face cellulitis and mastoiditis, resident transferred to emergency room for workup and further care. R59's Progress Note dated 9/13/12 at 11:58 AM, shows R59 has been admitted for facial swelling. R59's Physical Examination dated 9/11/23 from V9 shows examined 7/11/23, hx of right face cellulitis, treated with 2 IV antibiotics, plan- continue the IV antibiotics per Infectious Disease, continue supportive care, meds reviewed please note: pharmacy able to remove the line for the antibiotics 9/11/23 without complication, blood loss or difficulty, monitor. R59's Physician Note dated 9/11/2 shows late entry. examined 8/1/23 for long term care, plan-continue current supportive care, increase activity, meds reviewed. R59's Care Plan does not address R59's assessment and care needs after R59's hospitalization for vitreous hemorrhage or right cheek mastoiditis and treatment with antibiotics. The facility's Physician Orders Policy dated 11/22 shows to provide guidance to ensure physician orders are transcribed and implemented in accordance with professional standards. The facility's Central Venous Catheter Policy dated 11/8/22 shows to provide guidance in the care of central venous access devices: monitor site for signs of infection (e.g., inflammation, purulent drainage at catheter insertion site, tenderness, erythema, and duration; flush catheters at regular intervals to maintain patency and dressing changes. The facility's admission and Assessments Policy dated 4/2022 shows a primary purpose of our admission policies is to establish uniform guidelines for personnel to follow in admitting residents to the facility. The facility's Frequency of physician visits policy dated 12/20 shows a physician visit is considered timely if it occurs not later than 10 days after the date the visit was required. The facility's Medication Administration Policy dated 3/2022 shows medications must be administered in accordance with a physician's order, e.g., the right resident, right medication, right dosage, right route, and right time. R59's Vascular Access Solutions Consult Note shows R59's CVC was removed on 9/11/23 at 6:16 PM without difficulty. The facility's unlabeled document dated 9/13/23 show R59 is scheduled for a prep screening on 10/20/23 for surgery with V21 on 11/14/23 and post op appointments scheduled 11/15/23 and 11/22/23. The Immediate Jeopardy that began on 6/12/23 was removed on 9/12/23 when the facility took the following actions to remove immediacy. R59 was sent to the hospital on 9/12/2023 as a precaution, due to a medically complex history regarding swelling to the right cheek. Tunneled IJ catheter was removed by Pxxxxxx on 9/11/2023 at approximately 18:16 and was successfully removed; R59 tolerated the procedure well without complications. An appointment for ophthalmology surgery was made for November 14, 2023, with V21. Time to be determined. Careplan has been updated and will be revised upon anticipated return to the facility. All licensed nursing staff, certified nursing staff, administrative nursing staff and Administrator were re-educated on the following topics: 1. Ensuring a residents discharge hospital orders were followed for medications and discharge procedures and appointments. 2. Ensuring a resident is assessed and monitored with a known vision impairment, a known facial infection on antibiotic therapy and monitor and assess a central venous catheter site. 3. Ensure the residents receive treatment for vitreous hemorrhage and increased intraocular pressure and red swollen cheek. 4. Ensure Residents central venous catheter is assessed and removed as ordered. 5. Ensure all residents follow up appointment are scheduled and arranged and prescribed medications are administered. 6. Ensure policies and procedures are in place for new admissions and readmission orders are carried out. Education initiated on 9/12/2023 and completed on 9/12/23 by the Administrator, DON and MDS RN. All licensed nursing staff and C.N.As were educated via phone with the same training as the staff educated in person, however, the staff who received training over the phone were notified that they will also be required to attend an in-person training prior to the beginning of the next shift worked. Upon completion of this in-person training, staff will sign education sheets. Evidence for education that took place over the phone is provided by specifying the name of the employee educated, the time the employee educated was called, and who conducted the training. This will include staff on vacation or out due to illness. Spot education will continue to ensure compliance. Licensed nursing staff new hires will be educated during orientation. A baseline house audit was completed on 9/12/2023 to ensure compliance with monitoring a resident, discharge hospital orders were followed for medications and discharge procedures and appointments. Ensuring a resident is assessed and monitored with a known vision impairment, a known facial infection on antibiotic therapy and monitor and assess a central venous catheter site. Ensure the residents receive treatment for vitreous hemorrhage and increased intraocular pressure and red swollen cheek. Ensure Residents central venous catheter is assessed and removed as ordered. Ensure all residents follow up appointments are scheduled and arranged and prescribed medications are administered. Ensure policies and procedures are in place for new admissions and readmission orders are carried out. A QA tool was developed to ensure all admission and readmissions will be completed by the Director of Nursing or designee to ensure compliance to ensure orders are carried out to include: Ensuring a residents discharge hospital orders were followed for medications and discharge procedures and appointments. Ensuring a resident is assessed and monitored with a known vision impairment, a known facial infection on antibiotic therapy and monitor and assess a central venous catheter site. Ensure the residents receive treatment for vitreous hemorrhage and increased intraocular pressure and red swollen cheek. Ensure Residents central venous catheter is assessed and removed as ordered. Ensure all residents follow up appointment are scheduled and arranged and prescribed medications are administered. Ensure policies and procedures are in place for new admissions and readmission orders are carried out. QAPI audits will be completed for 3 months. All audits will be analyzed and reviewed in monthly QAPI. This is overseen by the Medical Director and Administrator. Audits will continue for no less than 3 months. The QAPI committee will determine if the audits will continue at that time. Medical Director is aware and in agreement with the abatement plan.