B. Based on observation, interview, and record review, the facility failed to follow their fall prevention protocols by not completing an accurate fall risk assessment evaluation, failed to implement individualized interventions related to the root cause of falls to minimize the risk, and failed to implement fall prevention interventions. This affected two of three residents reviewed for fall and fall preventions. These failures resulted in R3 falling from a wheelchair with no non-skid pad applied. R3 sustained a laceration to the left eyebrow resulting in sutures. The findings include: 1.R3's diagnoses include, but are not limited to, Epilepsy, Hypertension, Convulsions, and Alcohol Use. R3's cognition is documented on 4/23/24 as severely impaired. R3's physician orders includes orders for daily administration of Escitalopam (antidepressant) and Clonazepam (benzodiazepine). R3's Medication Administration Record documents R3 received the ordered medications on 5/20/24 and 5/25/24. R3's behavior assessment, dated 4/23/24, documents he has no behaviors. Review of R3's falls include falls on 5/20/24 and 5/25/24. R3's notes on his fall report of 5/20/24 documents interventions to minimize the potential for falls non skid pad to his wheelchair. R3's notes on his fall report of 5/25/24 documents interventions includes non skid pad to wheelchair. Fall requires suture repair. R3's care plan denotes 5/23/24 non skid pad to the wheelchair. R3's progress notes, dated 5/25/24, documents R3 returned from emergency room. R3 noted to have seven sutures over his left eyebrow. R3 has steri strip/ wound closures across the bridge of his nose. R3's hospital records, dated 5/25/24, documents R3 presents status post fall complaining of a 2cm laceration to middle of R3's forehead. Upon chart review this is the second fall within the past week as the patient had a fall two days ago when he was seen in the hospital. Face location: Nose Length: 2cm. Steri-strips and sutures (sutures for forehead laceration and strips for nose laceration). Facility Reported Incident report from 5/26/24 documents R3 had a fall and was sent to the emergency department for evaluation and received sutures to left brow area. On 6/28/24 at 12:40PM, V2, Licensed Practical Nurse (LPN) said R3's falls are related to his confusion. V2 said, (R3) had one fall from his wheelchair and the Aide, (V6), was taking (R3) to from the lobby into the dining room. (R3) fell forward. (R3) did not have his feet on the wheelchair pedals or have pedals on his wheelchair. V2 said R3 got sutures on the upper eyelid. V2 said, (V6) said to me, (R3's) feet got stuck. V2 said R3 was not able to pedal himself in the wheelchair before the fall; he was dependent on staff. On 6/28/24 at 1:04PM, V5, Certified Nursing Assistant/CNA, said, (R3) can stand and pivot and he is on fall precautions. (R3) wears hipsters, a helmet, and is kept in common area when he is in his chair. (R3) gets restless and he is alert and confused. (R3's) fall prevention interventions are on the closet door. V5 showed the surveyor the closet with a document that includes hipsters, helmet, keep in common area, and non slip pad for wheelchair. At 1:09 PM, V5 stood R3 up. R3 was sitting on a wheelchair cushion, but no non slip pad on the seat on or under the wheelchair cushion. On 6/28/24 at 1:11PM V6, CNA, said, I was getting (R3) to take him into the dining area from the sitting area. (R3) was sitting in his wheelchair in the sitting area. When I moved (R3), he dropped his feet and fell forward; he hit his head. (R3) was dependent on me to move him in the wheelchair; he could not move it himself. On 6/28/24 at 1:03PM V4, Director of Nursing, said, (R3) had seizures with some of his falls. The next time (R3) fell, he became very confused. I think all of (R3's) falls surround his seizures and dementia. (R3) is not educatable, not redirectable, and we try to protect him from injuring himself. The CNA was pushing (R3) in the wheelchair and he was able to follow commands, but he put his feet down and fell. On 7/2/24 at 12:55PM, V10, Nurse Practitioner, was asked what medications can place residents at risk for falls. V10 replied, Antihypertensives, Narcotics, Benzodiazepines, and Antidepressants. Midodrine can place a resident a risk because of changes in blood pressure. Clonazapam is a Benzodiazepine. Lexapro is an Antidepressants. Both trade names or generics can be a risk. The nurses should know these medications can cause increased risk of falls for the residents. 2.R2's diagnoses include, but are not limited to Atrial Fibrillation, Acute on Chronic Diastolic (Congestive) Heart, Multiple Myeloma Not Having Achieved Remission, Anemia in Chronic Kidney Disease, End Stage Renal Disease, Type 2 Diabetes Mellitus, Hypertensive Heart and Chronic Kidney Disease with Heart Failure and with Stage 5, End Stage Renal, and Moderate Protein Calorie Malnutrition. R2's fall scale evaluation, dated 2/7/22, indicates the resident has never fallen; a score of 51. R2's fall scale evaluation, dated 2/22/24, indicates the resident has never fallen; a score of 26. Low risk is identified as a score of 0-24; moderate risk 25-44; high risk 45 or more. Review of R2's physician orders includes orders for daily administration of Escitalopam (antidepressant) and blood pressure regulating medications (Cardizem, Midodrine, and Metoprolol Tartrate). Review of R2's Medication Administration Record documents R2 received the ordered medications on 2/22/24. Progress Notes written by V8, dated 2/22/24, documents, resident observed on the floor in room in a sitting position. Patient is awake and alert follows direction but could not state how she fell. Appears weak. Fall report, dated 2/22/24, documents R2 on the floor in room in a sitting position. Blood pressure 142/73; heart rate 108; Oxygen saturation 91%; Temperature 101. Weakness was indicated as predisposing factor. Root cause analysis, dated 2/23/24, stated R2 sent to the hospital and will be reviewed upon return. Remind to use her call light, upon return. Progress Notes written by V8, dated 3/19/24, documents, resident observed on the floor in room during nursing rounds by RN. Resident lying on floor in left lateral position. Fall report, dated 3/19/24, written by V8 documents R2 was observed on the floor during nursing rounds. Blood pressure 130/64; heart rate 66; temperature 101.4; oxygen 89% placed on oxygen. Root cause analysis dated 3/20/24 documents following chemotherapy and dialysis R2 has weakness. R2's care plan, initiated on 3/19/24, states call don't fall added on 2/23/24. On 6/28/24, V7, Restorative Nurse, said, For hygiene, toileting, dressing, and transfers, (R2) required 1 person assist. For bed mobility, (R2) was able to complete that with supervision. (R2) was able to participate in her cares. If a resident falls, we might look at root cause analysis. V7 read the root cause documented on R2's fall report, dated 3/19/24. V7 said R2 denied falling, if she fell she could not remember. V7 read the resident received chemotherapy and dialysis. V7 said R2 had been placed in bed immediately after treatment. V7 said, The follow up interventions were draw labs, urine culture, place floor mats, use a low bed, and place the call don't fall sign. (R2) had weakness. V7 said before 3/19/24, R2 had no falls. V7 said, The fall prevention interventions were the basics, keep everything in reach. For safety on everyone we say keep everything in reach, keep call light in reach, falling leaf for high risk. V7 said R2 was not on the falling leaf program. V7 said R2 was not high risk upon admission for falls. V7 said R2 had a fall on 2/22/24. The surveyor asked V7 if R2's fall scale evaluations are accurate. V7 said she can't answer for the nurse completing the evaluation. On 6/28/24 at 3:23PM, V8, Registered Nurse/RN, said, On 3/19/24, (R2) was observed on the floor during rounds. She was status post chemo and had returned to the facility. The last time I saw her, before the fall, she was in the bed. I found (R2) on the floor. Generally, (R2) did not use the call light often. This was (R2's) first fall that I was aware of. After a fall occurs we put new measures in place. On 7/2/24 at 9:54AM, V4, Director of Nursing, said, I was not employed here when (R2) fell on 2/22/24. At 10:08AM, V4 said the cause of R2's fall on 2/22/24 was being symptomatic and anemic. V4 said, Symptomatic means (R2) was having shortness of breath, dizziness, and weakness. Specifically (R2) was experiencing weakness and then she received dialysis earlier that day, which caused more weakness. On 7/2/24 at 11:43AM V7, Restorative Nurse, was asked what medications may place R2 at risk for falls. The surveyor presented V7 R2's physician orders. V7 said, I can't answer that, I would have to look them up to know the side effects. The Fall Prevention Program, dated 11/28/12, states, The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Care plan incorporates Identification of all risk issues; addresses each fall; interventions are changed with each fall as appropriated; preventative measures. Deficiencies at this level require more than one Deficient Practice Statement. A. Based on interview and record review, the facility failed to follow their practice and provide a staff escort to an appointment for a resident R1 diagnosed with dementia, BIMS (Brief Interview for Mental Status) score of 5, identified not capable of unsupervised outside pass privileges. R1 was dropped off by transportation company on 5/8/24 at approximately 2:00pm, unknown drop off point. R1 was later found by family in streets trying to self-propel over a curb ramp approximately 3:30pm. This affects 1 of 1 resident (R1) reviewed for supervision. The Immediate Jeopardy which began on 05/08/2024 when R1 was dropped off at around 2:00pm at an outpatient appointment alone, without a staff escort, and later found in the community approximately 1.5 hours later by his daughter in the streets. V3 (Administrator) was notified of the Immediate Jeopardy on 07/09/2024 at 1:44 pm. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 07/09/24 but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the training. Findings include: R1's face sheet denotes R1 has diagnoses of dementia, unspecified convulsions, anxiety disorder, and history of falls. R1's MDS (Minimum Data Set), dated 3.29.24, section C for cognitive pattern denotes R1's BIMS score of 5 (cognitively impaired), section GG for functional abilities denoted mobility devices wheelchair is checked. R1 community survival skills assessment, dated 3/29/24, denotes the resident is sufficiently alert oriented coherent and knowledgeable allowing him or her to be considered for independent outside past privileges, the box for no is checked. Outcome/ recommendations denotes, the resident does not appear to be capable of unsupervised outside past privileges at this time. R1 most recent care plan, dated 5/24/24 denotes R1 has impaired cognitive function/dementia, or impaired thought process related to dementia. R1 is at risk for falls r/t (related to) decreased mobility, balance, and endurance. Facility incident report, dated 5/8/2024, denotes, incident no injury, during transportation, per resident daughter, resident did not make the appointment and was located outside the hospital and taken with her. Interviewed daughter and inquired of residents' well-being and per daughter resident uninjured. Mental status - orientated to person, orientated to situation. Level of consciousness, alert, mobility- wheelchair bound. Predisposing physiological factors- impaired memory, other. Predisposing situation factors- during transfer. Other behaviors, transport. Resident 73 y/o (year old) AA (African American) male who is alert and oriented to name and situation with confusion related to diagnosis of dementia with behavioral disturbance. PMH (Primary Medical History) includes, HTN (hypertension, HF (Heart failure) ischemic heart disease, HLD (high density lipoprotein), and anxiety. During transport to appointment, resident was not transported to office suite by driver, who cited that resident began to display behaviors on arrival and refused to share paperwork and did not know what suite appointment was located. Per resident daughter, resident did not make the appointment and was located outside the hospital and taken home with her. Investigation and review of facility practice regarding escort appropriateness to ensue. V1 (Unit clerk) statement denotes, 10:00 AM (V12, Transportation Driver) called and asked if he can change R1 appointment time to 1:00 PM so he (V12) has time to get back south in time to pick up his other riders. I (V1) told him yes, if it was okay with the daughter who was meeting him at the appointment. 1:00 PM (V12) called facility to say he was about 20 minutes out. 1:04pm I (V1) called V11 (R1 family) and told her about the new pickup time. She said it was OK because she lives around the corner from there about five minutes away. Daughter stated since he will be there early, she will get him something to eat before he goes to his appointment at 3:45pm. I told her I will call her once the transport actually arrives and leaves our facility. 1:32pm I called (V11) and told her they picked up her dad and he's on his way to the appointment. 3:00 PM (V11, R1's family) called and told me he wasn't there. 3:15pm made my first call to (clinic name). I told them the daughter called and said her father (R1) was not at the appointment. (Medical Insurance company) then made their first attempt to contact the transportation company which I found out is (transportation company name). They were unable to reach them. I was told they were escalating it to the supervisor; I (V1) will get a call back. 3:45 PM I called the doctor's office to see if the patient had checked in, I was told he hadn't. 4:00 PM I called (V11), but I did not receive an answer. I called (clinic name) back and I stayed on the phone for about 45 minutes while the supervisor tried repeatedly to contact the transportation company as well as other supervisors. 4:45 PM I called doctor's office again and was told the office was closed and he had not checked in. 4:55 PM I received a call from the driver (V12) telling me he was on his way to pick up (R1), I explained to him the situation he told me that he dropped the patient off at (outpatient clinic address). That he went to the desk relations and spoke to a man named (name noted) in a red shirt and told he was dropping (R1) off and that his daughter was meeting him there. I stayed on the phone with him while he went in the building spoke to the guest relation person. They went to the 4th floor to see if (R1) or (V11) was there, and they were not. 5:30PM- 6:00 PM (V11) called the building and said she (V11) had (R1). I stayed on the phone with (V12) to see if he needed to go and pick him (R1) up from wherever they were. 6:00 PM I called (V11) to see if she wanted us to pick him up and she did not answer so I left a voicemail. Signed (V1). On 6/28/24 at 10:46 AM, V1 (Unit Clerk) said, (R1) had a scheduled appointment, pick up time was at 2:45pm on 5/8/24. (R1's) appointment was on the 4th floor of the building. (R1) has managed Medicaid and the insurance schedules the residents' transportation. The driver called the facility and asked if he could pick (R1) up early so that his other clients were not late for their appointments. V1 said she got approval from R1 daughter for early pick up. V1 said she called R1 daughter when the driver picked R1 up because the daughter was going to meet R1 at the clinic for his appointment. V1 said she got a call from R1's daughter inquiring about R1 whereabouts because R1 had not made it to the appointment. V1 said she hung up and immediately called the insurance company because the insurance company scheduled R1's transportation. V1 said although the driver contacted her for early pick up, she did not have his contact information. V1 said she was able to contact the insurance company and they were calling the driver. V1 said she stayed on hold while the insurance company tried to contact the driver. V1 said she may have been on hold for more than an hour. V1 said she called R1's daughter back with no response. V1 said V13 (Assistant Director of Nursing) was aware of the situation. V1 said V13 did not give her any directives. V1 said she figured V13 was aware because she was standing around when she was on the phone with the daughter. V1 said around 4:55PM, V12 (Transportation Driver) called her and said he was going to pick R1 up for his scheduled pick up. V1 said that was unusual because the drivers never call and say they are picking up the residents. V1 said at that time she asked V12 where he dropped R1 off too, because R1's daughter said R1 did not make it to his appointment, and she could not find R1. V1 said V12 was not aware R1 did not make it to his appointment. V1 said V12 informed her that he took R1 inside the building and R1 was having behaviors and would not give him (V12) the paperwork to determine where he supposed to go. V1 said the driver did not contact the facility or her to inform them R1 was having behaviors. V1 said the driver should have contacted the facility if R1 was having behaviors and would not give the paperwork to determine R1's drop off location/point/destination. V1 said R1's daughter called her sometime after 5:30PM and stated she found R1. V1 said at that point, management was involved and she doesn't know the details surrounding where R1 was found. V1 said the drive to R1's appointment was about 20-minute drive. V1 said she doesn't know if the driver escorts the residents to the clinic or just to the entry door of the building. V1 said she doesn't know the process. V1 said she doesn't know who should know the process. On 6/28/24 at 12:39 PM, V11 (R1's family) said on 5/8/24 around 9:00 AM, V1 (Unit clerk) called her and confirmed R1's appointment and confirmed she will be meeting R1 at the appointment. V11 said V1 called her back at 11:00AM, and stated the driver will be picking R1 up at 1:00PM instead of 2:45PM because he had multiple clients to pick up and did not want them to be late for their appointments. V11 said she was agreeable. V11 said V1 suggested that she (V11) wait for R1 on the fourth floor where the scheduled appoint was planned. V11 said she arrived at the appointment, and she waited. V11 said time passed and R1 never arrived. V11 said she asked the receptionist if R1 had checked in, and was informed R1 had not checked in. V11 said she waited because she was aware the driver had other clients to drop off and or maybe they were running late. V11 said the appointment time had arrived and R1 was not there. V11 said she went downstairs to look for R1 and she did not see R1. V11 said she called the facility and spoke to V1 to inquire about R1 whereabouts. V11 said V1 informed her R1 was picked up and she would call the insurance company so they could contact the driver. V11 said she went back to the clinic building to look for R1; she did not see R1. V1 said she began to worry, and her nerves were bad because she did not know where her father was. V11 said she got in her car to look for a local convenience store to buy cigarettes to calm her nerves, V11 said there was a lot of traffic, the cars were at a standstill. V11 said as she got closer to the intersection, she saw her father crossing the street in his wheelchair, trying to self-propel over a curb ramp. V11 said the cars was honking their horns for R1 to get out the way. V11 said she immediately got out her car to help R1. V11 said R1 was upset stating the driver just left me. V11 said she called 911 but they never arrived. V11 said she later got a call from the driver stating \he was going to pick R1 up from his appointment. V11 said she informed the driver he will not be picking R1 up because she did not trust R1 in the care of that driver. V11 said she took R1 home. V11 said she was very upset about the situation. V11 said the facility should have sent R1 with a staff escort because R1 has dementia, and R1 could have been hurt. V11 said R1 told her the driver just left him. V11 said she doesn't think the driver took R1 inside the clinic building. V11 said R1 should not be in the community alone, R1 has dementia. R1 could have been hit by a car. On 6/28/24 at 12:11PM, V14 (Insurance company rep) said the transportation drivers do not take clients inside of facilities for scheduled appointments; the drivers do not register clients for their appointments. V14 said the driver can open the door to the clinic if they choose to do so. V14 said the expectation is drop off /pick up only. On 6/28/24 at 1:52PM, V15 (transportation company) said the transportation company provide curb to curb service only, drop off and pick up. V15 said the drivers do not take clients inside of the buildings/ facilities. V15 said it's for insurance purposes. V15 said escorts can accompany the client during the trip. V15 said he recommend clients are escorted during a trip. V15 said V12 is no longer with the company; he is not available for interview. V15 said he doesn't recall the situation with R1. On 6/28/24 at 2:00PM, V4 (Director of Nursing) said she was aware R1 did arrive to his appointment. The facility investigated and concluded (R1) should not have gone to an appointment without a facility staff escort. (R1) has dementia and his community survival assessment show he can not be in the community alone. Due to the incident, the facility has put practices in place. On 7/2/24 at 11:55AM, V13 (ADON- Assistant Director of Nursing) said V1 (unit clerk) did not inform her R1 did not arrive to his appointment; V1 did not inform her R1's daughter called the facility concerned about R1's whereabouts. V13 said she was passing by V1 going to the standdown meeting, and she heard V1 on the phone and made a statement what do you mean you can't find your father. V13 said she did not stop to inquire about what she heard because V1 was on the phone and could have been discussing anything. V13 said R1's situation was not discussed in the standdown meeting. V13 said she was not aware of the situation. V13 said after the meeting, she did her task of ensuring the facility had enough staff on duty because there was a call off. V13 said some time after 5:30PM, she was made aware R1 was found, and that's when she learned R1 did not arrive to his doctor's appointment. V13 said the Director of Nursing was involved at that time. V13 said V1 did not inform her of the situation with R1 missing from his appointment. V13 said V1 should have informed her, the DON, or the charge nurse immediately. V13 said she would have contacted management and initiated the missing resident protocol. V13 said V1 should have not tried to handle that situation by herself. On 7/2/24, V4 (Director of Nursing) said she was made aware of R1 not arriving to his scheduled appointment on 5/8/24 sometime after 5:30PM. V4 said V1 did not notify her when she was initially notified of R1 being missing, and she (V1) should have notified her immediately. On 7/2/24 at 1:34PM, V16 (Licensed Practical Nurse/LPN) said she was R1 nurse on 5/8/24 for the morning shift, and she was not aware R1 did not make it to his appointment and R1 was missing. V16 said she became aware of this today because staff was standing around talking about. On 7/2/24 at 3:51PM, V17 (Registered Nurse) said she was R1 nurse on 5/8/24 for the evening shift. V17 said no one informed her that day R1 did not arrive to his scheduled appointment and R1 was missing. V17 said someone did inform her R1 would not be returning to the facility after his appointment; she documented that. Facility missing resident/elopement policy, with last review date of 11/15/2018, denotes all personnel are responsible for reporting a cognitively impaired resident attempting to leave the premises or suspected of missing to the charge nurse as soon as practical this includes any resident that did not sign out on pass and or did not notify a staff member of his or her leaving. Should an employee discover that a resident is missing from the facility he or she should immediately report the missing resident to the charge nurse or nursing supervisor. Review physician order to determine if the resident is out on an authorized leave or pass. Alert staff by announcing code green over the paging system. Inform staff of the name of the resident and visualize pictures of resident if available. Make a thorough search of the building and the premises. Notify administrator and director of nursing immediately if the resident is not found after the search the administrator and director of nursing will evaluate the situation and develop a plan of action based on the individual resident. The Immediate Jeopardy that began on 05/08/24 was removed on 07/09/24 when the facility took the following actions to remove the immediacy: * R1 returned to the facility by daughter. R1 reassessed without any adverse negative outcome. * R1's appointment has been rescheduled. * All facility contracted Medi-car and ambulance companies were contacted and reviewed facility's expectations during transportation, including ensuring the resident is safely transferred and reported to the receiving appointment staff. Contact was initiated and concluded on 7/9/2024. * All residents with scheduled appointments have the potential to be affected by the alleged deficiency. * The facility has conducted a comprehensive review to identify any other residents with scheduled appointments and has established corresponding staff escorts. Initiated 5/9/2024 and on-going. * The facility has conducted a comprehensive review to identify residents with a BIMS under 11 and those which cannot safely access the community independently, additionally, each resident is reviewed for additional factors such as behaviors, physical challenges and assistive devices as appointments arise to ensure a facility escort is assigned. Initiated 5/9/2024 and is on-going/updated on a weekly basis. * The Unit Clerk will communicate upcoming appointments 72 hours prior to appointment date with confirmed staff escort name to nursing staff during morning meeting utilizing the appointment communication log. Initiated and completed 5/9/2024. * Emergency QA meeting conducted on 7/9/2024 at 4:30pm. * Residents with upcoming scheduled appointments will be evaluated by nursing and social service departments to ensure resident is cognitively appropriate for independent community access. Initiated 5/9/2024 - on-going. * Family members of residents with upcoming scheduled appointments who require an escort, will be contacted to, optionally, assist with escorting/accompanying residents during transport if available. If family is not available, the facility will ensure a staff escort will accompany residents for all non-contracted transportation companies for residents who have been determined to require an escort. Initiated 7/9/2024 - on-going. * The Director of Nursing or designee educated the facility transportation coordinator/unit clerk on communicating upcoming appointments 72 hours prior to appointment date, including the name of the confirmed staff escort communicated to nursing staff during morning meeting utilizing the appointment communication log. Initiated and completed 5/9/2024. * Facility has developed a Transportation Communication Form which is being provided to all transportation companies at the time of scheduled resident appointments, which communicates pertinent transportation information, including resident drop off points, contact information for physician office and facility, to ensure resident safety. 7/9/2024 - on-going. * The Director of Nursing or designee educated the facility staff on the new Transportation Communication Form to be provided to transportation drivers at the time of resident pick-ups for scheduled appointments. 7/9/2024 - on-going. * The Director of Nursing or designee educated the facility staff who may accompany residents on appointments that Escort must call the facility to inform/confirm resident's arrival to appointment location office/Suite with Unit Clerk immediately to verify safe arrival. Knowledge check to be completed with staff escort prior to leaving the facility for verification/clarification. Initiated 7/11/2024 and on-going. * The Director of Nursing or designee educated the facility staff on immediately implementing the missing resident policy and procedure once a resident has been identified as missing. 7/9/2024 - on-going. * Staff, including agency, not present in the facility will be educated prior to starting their next shift. This training will be ongoing for new hires in the orientation process and has been added to the agency staff orientation folder. Initiated 7/9/2024 - on-going. * The Director of Nursing or designee will audit 3 random residents with scheduled appointments twice a week for 3 months or until compliance has been determined thereafter, to ensure safe transport and delivery of cognitively impaired residents to scheduled appointments. Initiated 5/9/2024 - on-going. * The Director of Nursing or designee will audit 3 random staff, twice a week for 3 months, for knowledge checks of previous education related to missing resident policy and Transportation Communication Form to ensure safe transport and delivery of residents who have been determined to require a staff escort to scheduled appointments. Initiated 7/11/2024 - on-going. * Findings of the quality review audits will be brought to the facility QA meeting until such time as the committee has determined substantial compliance has been achieved and recommends ongoing monitoring. Initiated 5/9/2024 - on-going. Completion date of systemic Corrections: 07/11/2024

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their Emergency Care policy and procedure by not immediately calling 911 for residents identified to be in need of emergency medical assistance. This failure applied to two (R9, R12) of two residents reviewed for emergency services, and resulted in R9 noted to be experiencing symptoms of a stroke for over an hour before being transferred to the hospital; R12 experienced acute respiratory distress for over 40 minutes before 911 was called. The Immediate Jeopardy began on 7/4/23 when the facility failed to immediately call 911 for R9, who was experiencing symptoms of a stroke. V1 (Administrator) was notified of the Immediate Jeopardy on 8/31/23 at 11:07AM. The survey team verified by observations, interviews, and record review, that the Immediate Jeopardy was removed on 9/5/23, but noncompliance remains at Level Two because additional time is needed to evaluate the effectiveness of the interventions implemented. Findings include: 1. R9 is identified as a [AGE] year old female who originally admitted to the facility on [DATE], and was discharged on 7/4/23. R9 has multiple diagnoses including but not limited to the following: acute embolism, type II DM, hyperlipidemia, CHF, HTN, and CKD. Progress note written by V8 (Licensed Practical Nurse/LPN) reads: 7/4/23 8:47AM - (R9) alert with confusion. Progress note written by V10 (Wound Care Nurse) reads: 7/4/23 12:57PM - (R9) with altered mental status, assessment in progress per assigned nurse. Progress note written by V8 (LPN) reads: 7/4/23 2:27PM - (R9) slow to respond. Hand grasp to right hand strong, left hand grasp absent. Flaccid to left side denies pain. MD (medical doctor) made aware of clinical finding new orders to send to hospital for evaluation. Daughter at bedside, made aware of change of condition. (R9) being transferred to hospital by ambulance service. Per hospital record, dated 7/4/23, R9 was brought to the emergency room due to new aphasia and weakness of the left upper extremity. R9 was diagnosed with having a stroke and left hemiparesis. R9 was a poor candidate for thrombectomy due to poor functional status. Progress note written by V10 (Wound Care Nurse) reads: 7/5/23 7:42AM - (R9) admitted to hospital with a stroke. On 8/21/23 at 3:30PM, V30 (Family Member) said, I would visit (R9) every day while she was at the facility. On 7/3/23 when I saw her, she was perfectly fine. She would typically talk with me, laugh, using her phone, and was very alert and oriented. On 7/4/23 at around 1:45PM, I came in to bring (R9) lunch. When I walked in her room, she was lying in bed, flat on her back, staring at the ceiling. I tried to talk to her, but she would not respond to me. (R17) was her roommate, and she told me she has not spoken or made any noise at all today. I asked (V8, Licensed Practical Nurse/LPN) what was going on with (R9). She told me at this time she believes she has a urinary tract infection (UTI) because she was not responding and seemed very confused. I asked (V8) to call an ambulance and send her to the hospital. (V8) said she would call one, and it would take them around 30 minutes to an hour to arrive. At the hospital they let me know that she had experienced a stroke. She now cannot swallow, has a gastric tube, and is paralyzed on her left side. She is barely communicating and is not as alert and oriented as she was prior to this incident. On 8/22/23 at 10:23AM, V8 (LPN) stated, I was the nurse on duty on 7/4/23 and was assigned to (R9). Prior to this day, (R9) was alert, oriented, and able to converse with others. I saw her in the morning and she was fine. She ate breakfast and I gave her morning medication. Later on that day, I went in her room and she was not recognizing me. She wasn't responding to me, and couldn't tell me my name. She was talking, but was not her normal self. I checked her vitals at this time and they were stable, however, her mental status was not at baseline. At this time, I noted she had weakness to one side, which was new for her. She did not look as if she was in distress, but just having a change in mental status and weakness. That triggered me to call the doctor. When I spoke with the doctor, they told me to send (R9) to the hospital. The family arrived during me attempting to call the doctor, and they were notified of the situation. I called 911 and sent her out to the hospital. Her clinical situation indicated a need to call 911, it was an emergency. I cannot remember who showed up, if it was just the paramedics or the whole 911 team. The fire department is down the street from the facility and arrives typically in a couple minutes. V8 also said V10 (Wound Care Nurse) came into R9's room at some point to provide wound care treatment, and also thought R9 was having a change of condition. V8 was asked how she would respond to or recognize a change of condition. V8 said, I typically will check their vitals to make sure they are stable, their level of consciousness, and will do a full body assessment. I will check their pupils, hand grasp, lung sounds, etc. If I identify that a resident who is normally talking and later they are not aware of anything or saying things they do not normally say; this would trigger me that the resident is having a change of condition. If I note anything that is abnormal, I immediately notify the doctor. From there, depending on the situation, I follow the physician's orders whether it is a new medication, treatments, or to send the resident out to the hospital. If the resident's consciousness, pulse, or oxygen is dropping, we would call 911. If a resident is in a critical condition, you would want to monitor them constantly and call 911. There is no time to wait for an ambulance service. V8 said, Strokes can happen quickly and every minute counts. Private ambulance services are typically called when the resident is stable, and not in distress and are called when it is appropriate to wait 30 minutes to an hour. 8/23/23 at 10:45AM, surveyor contacted local fire department and confirmed no 911 call or response team was dispatched on 7/4/23 to the facility. The fire department is 800 feet away from the facility. Review of ambulance run sheet documents a private ambulance service was called at 2:27PM and arrived at the facility to R9 at 3:00PM. Ambulance runsheet shows that the ambulance was dispatched due to altered mental status and stroke protocol was initiated upon arrival. On 8/22/23 at 3:09PM, V10 (Wound Care Nurse) said, I was familiar with (R9) and provided her with wound care treatment regularly. On 7/4/23, I walked into (R9's) room to provide wound care treatment when I observed her to be laying on her back, eyes wide open, and looking fearful. There was no other staff member in the room prior to me entering the room. She looked as if she wanted to speak but could not talk. This was a change for (R9) since we usually speak every day. I ran down to the nursing station, where (V8) was sitting, to let her know about (R9's) change of condition. (V8) said she was working on it and had already notified the doctor. V10 said, When I saw (R9), I could immediately identify that she was having or experiencing stroke-like symptoms. If I was the nurse on duty that day, I would have notified the doctor and called 911 immediately. V10 was asked why she did not do an assessment of the resident and respond herself, and V10 responded she notified V8, who was the assigned nurse, and had been assured that the situation was being taken care of. On 8/23/23 at 4:00PM, V20 (Medical Director) stated, I was not notified of this incident, and am not sure who (V8) called on this day. (R9) was at an increased risk for stroke due to multiple diagnoses. I would expect the staff to notify the doctor and initiate the orders that the physician orders. If the physician says to send a resident to the hospital, we expect they will be sent out 911, not with a private ambulance service. Treatment window for a stroke is generally four hours. If they are able to be evaluated and are a candidate for certain types of treatment post stroke. The sooner you can treat a resident that is having a stroke, the better the outcome for that resident. 2. R12 was an [AGE] year old male admitted to the facility 4/10/23, with diagnoses that included corrosion of esophagus, Dementia, and Dysphagia. admission orders included dietary status of NPO (nothing by mouth), and on 4/24/23, an order was placed for oral suctioning every shift and every two hours as needed. According to the Physician's Order Sheet, R12 did not require any oxygen. On 7/30/23, R12 was emergently transferred from the facility to the hospital in acute respiratory distress. V9, LPN (Licensed Practical Nurse), was the nurse on duty and documented while rounding at 11:15AM, R12 was observed having difficulty breathing and difficulty releasing sputum (thick oral secretions). After suctioning R12, V9 took vital signs that included an Oxygen Saturation rate of 76% (on room air) and assessed crackles (abnormal lung sounds) to the left side. V9 applied 2L (Liters) via Nasal Cannula and paged the physician. At 11:54, V9 documented Oxygen Saturation at 88% via 2L Nasal Cannula, repositioned R12 to the left side, and provided oral suction. V9 wrote orders had been received from the doctor (unnamed) to send R12 to the hospital. At 12:02PM, V9 documented that a private ambulance company was called for transport, with an expected arrival time of 30-35 minutes (approximately 12:32-12:40PM). Oxygen Saturation remained at 88% via the Nasal Cannula. At 12:31PM, V9 wrote upon reassessment, R12 was noted to be clammy and sweaty, using all accessory muscles, and Oxygen Saturation had decreased to 33%. V9 activated a Rapid Response and called 911. Fire Department run sheet indicated the facility called at 12:35PM, and Paramedics arrived at 12:38PM, and provided advanced life support to R12. When Paramedics arrived, they found R12 to be responsive to pain, with an oxygen saturation of 78%. They applied a Non Rebreather Oxygen mask at 15L, and after applying the oxygen mask, R12 still exhibited low saturation levels of 88 and 87%. R12 was taken to the ambulance, where he was placed on a CPAP (Continuous Positive Airway Pressure) and transported to the hospital. Paramedics and R12 arrived at the hospital at 1:05PM. Hospital record noted in the emergency room, at 2:34PM, R12 was placed on sedation and mechanically ventilated. R12 was diagnosed with acute hypoxic respiratory failure, aspiration pneumonia, sepsis secondary to aspiration pneumonia, hypoxemia, metabolic encephalopathy, and anemia. On 8/23/23 at 1:21PM, V34, Representative of a private ambulance company, confirmed a call was received from the facility at 12:02PM for R12, who was noted to be in respiratory distress. The ambulance was dispatched at 12:23PM, and arrived at the facility at 12:55PM. On 9/1/23 at 9:46AM, V51, Paramedic, said he was one of the first from the Fire Department to arrive on scene. V51 said, (R12) was on oxygen, (although could not determine how much), and was still displaying substandard oxygen saturations. The team placed (R12) on a non-rebreather mask, which is used to deliver a higher concentration of oxygen, but (R12) continued to saturate in the 70's and 80's. Because of this, the CPAP was administered to provide additional breathing support because the oxygen alone was not an effective measure to increase saturation. V51 said this was implemented quickly, because if left for a prolonged time, lack of oxygen could cause organ system failure. On 8/23/23 at 12:58PM, V35, Medical Doctor for R12, said, I don't have a Nurse Practitioner or a Physician's Assistant, and I don't recall the nursing staff calling me to notify me that (R12) was having respiratory distress symptoms. Optimally an oxygen saturation for a resident without COPD (Chronic Obstructive Pulmonary Disease) should be greater than 90% on room air or oxygen. If (R12) was administered oxygen and it remained below this range, that means he was not getting enough oxygen. Oxygen can be administered via nasal cannula or face mask. Oxygen levels should improve immediately within applying the oxygen, and if it does not improve within 5-10 minutes, 911 should be called. Nurses are allowed to give up to 6L of oxygen via the nasal cannula. With the Non Rebreather mask, you can go up to as much as you can on the oxygen tank- there is no limit to how much oxygen you give a resident who is in need if they are already in respiratory distress. The Nonrebreather Mask would have been a better option if it was available, once it was determined the Nasal Cannula was not getting the resident to the optimal level. On 8/29/23 at 11:13AM, V32, LPN/Nurse Supervisor, said on 7/30/23 she was the supervisor on duty for the morning shift. V32 said she was alerted to R12's condition when V9 called a Rapid Response over the intercom. V32 was not alerted R12 was in respiratory distress prior to the announcement, and said by the time she arrived at the bedside, 911 Paramedics were coming behind her. When V32 said she had worked as an LPN over 30 years in the hospital and long term care settings. Later in the interview, when asked about administering oxygen to a resident experiencing respiratory distress, V32 said, I would give 4L of oxygen to see if that helps. Using sound nursing judgement, we can give more than 2L without an initial order because the goal is to help the patient and get them to breathe- which is the priority. If I can't get the oxygen saturation to increase with a nasal cannula, I would place a non-rebreather mask and call 911. The fire department is around the corner and takes like two to three minutes to arrive. I don't know what the situation was before I arrived, so I can't say how long the resident was in distress or if anything else could have been done differently at the time. The nurses know to contact me when they need me. On 8/21/23 at 11:51AM, V49, Family Member, had difficulty communicating during the interview, due to being distressed and sobbing throughout. V4 said, I came to visit (R12) on 7/30/23 and he looked awful! The nurse told me that she had called non-emergency ambulance and that his oxygen levels had ranged from 30-80%. He was sweating and buck eyed. He was left without oxygen and the nurse was doing sternal rubs and suctioning him. She said that the facility didn't have enough staff to suction regularly and that she called the doctor, but he wasn't answering the phone. Eventually she called 911. The ambulance came and they took him to the hospital put him on a ventilator and he never came out. V49 went on to say R12 passed away 8/16/23 due to complications related to lack of oxygen. The facility was unable to provide policies related to oxygen administration and Rapid Response. Facility Procedure titled Emergency Care (no revision date) states in part; Emergency medical care refers to the care given to residents with urgent and critical needs. The circumstances under which the care given may or may not be optimal; whatever facilities are at hand are used in the most effective manner.Principles of Emergency Management: To preserve life To restore the resident to useful living To prevent deterioration before a more definite treatment can be given. o 1. Maintain a patent airway, employing resuscitation measures, if necessary o 4. Assess for chest injuries and airway obstruction o 7. Assess the resident's vital signs, monitor blood pressure, pulse, and respirations at frequent intervals and document o 8. Allay anxiety and keep resident as comfortable as possible o 9. Observe and re-evaluate resident at frequent intervals In the event of emergencies requiring medical support not available in the facility, staff will immediately call 911 for emergency assistance. Facility policy titled Emergency Care states in part but not limited to the following: Emergency medical care refers to the care given to residents with urgent and critical needs. The Immediate Jeopardy that began on 7/4/23 was removed on 9/5/23 when the facility took the following actions to remove the immediacy: 1. Residents R9 and R12 no longer reside within the facility. 2. Performance Improvement Plan initiated, titled: Emergency Care. Initiated 9/1/23. 3. All Nursing staff in-serviced by Director of Nursing on Emergency Care. 4. Medical Director Notified on 8/31/23 at 11:50 AM. 5. The Nurse consultant/Clinical Managers will provide training and in-servicing to all nursing staff on identifying residents with urgent and critical needs and are able to identify when to call 911 to respond to emergency situations. 6. The Nurse consultant/DON will provide in-servicing and training for agency and nursing staff who have not been scheduled to work (PRN staff, vacation, or medical leave). All will be required to complete in-service and training prior to the start of their shift before reporting to their assigned units. 7. The DON/nurse supervisors will provide in-servicing and training for newly hired nursing staff and newly scheduled agency staff assigned to the facility. They will be required to complete in-service and training prior to reporting to their assigned units. 8. Clinical nursing staff and staff members including agency staff will not be permitted to work until they have been in-serviced and trained on Emergency Care immediately. Staff on vacation or on leave will be contacted and educated via telephone with documentation that such education was conducted. 9. An audit was conducted to identify any current residents who have the potential of having a stroke, heart attack or other medical emergency. The care plans of these residents were revised. 10. To ensure compliance, DON will audit/investigate all hospital transfers from 8/31/23 and ongoing to ensure policy and procedure were followed. 11. Findings of the QA (Quality Assurance) audit shall be used to determine the level of compliance. If needed, additional training will be completed immediately and shall be submitted to the QAPI Committee for review and follow-up. 12. An emergency QA meeting was held with the facility Medical Director (via Telephone) on 8/31/2023 at 1:00 pm. Attendees were Elevate Regional Nurse Consultant, facility Administrator, Director of Nursing, Assistant Director of Nursing, Nurse Practitioner to review abatement plan and plan of correction. 13. Facility Medical Director to conduct an in-service to clinical staff on Emergency Care. 14. QA committee will review this plan of correction until such time consistent substantial compliance has been met as determined by the QA committee. Audit findings will be discussed by the QA committee and monitoring will be adjusted as determined by the QA committee.