**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Based on clinical record review, family, staff and physician interviews, and facility competency and policy review, the nursing staff failed to adequately assess a resident, provide timely interventions, and notify the physician of a resident's change in condition for 1 of 13 residents reviewed (Resident #34). The nursing staff's failure to adequately assess, intervene, and notify the resident's physician resulted in the nursing staff failing to take actions to address Resident #34's urinary tract infection, which resulted in Resident #34's hospitalization and later death due to the systemic spread of the urinary tract infection. The facility's administrative staff identified a census of 37 residents. Findings include: 1. The resident's comprehensive admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 had diagnoses including Parkinson's disease, heart disease and renal insufficiency. The MDS documented the resident had a brief interview for mental status (BIMS) score of 15, which indicated an intact cognition. Per the MDS, Resident #34 required assistance of 2 staff members for bed mobility, transfers, walking and toileting. One person staff assistance was needed for dressing and personal hygiene. A review of the discharge MDS, dated [DATE], revealed a significant decline in urinary continence from the prior MDS of [DATE]. Documentation upon admission revealed Resident #34 was occasionally incontinent of urine while documentation in the discharge MDS revealed Resident #34 was frequently incontinent. The MDS revealed the resident had no hallucinations or delusions on either MDS. 2. The Care Plan, initiated [DATE], revealed Resident #34 needed assistance to complete his Activities of Daily Living (ADL) due to his diagnosis of Parkinson's Disease. An intervention for toilet use directed staff to promote continence by toileting Resident #34 every 3 hours and to wake Resident #34 during the night to use the toilet. The review of the care plan lacked documentation of the resident having any history of hallucinations or anxiety. 3. A review of the resident's progress notes from the facility revealed the following: - [DATE] at 8:45 pm, Resident #34 was experiencing hallucinations - [DATE] at 7:21 pm, Resident #34 was experiencing anxiety requiring 1 on 1 care. Resident #34 also complained of being cold, required extra blankets and complained of pain (both potentially signs of a urinary tract infection). Resident #34 received as needed Tylenol. - [DATE] at 7:56 am, Resident #34 complained of abdominal pain and received as needed Tylenol. - [DATE] at 3:10 pm, Resident #34 experienced a fall (minor injury of skin tear). The note revealed Resident #34 required a 2 person staff assist to transfer to the toilet and back to the recliner using a gait belt and manual wheelchair. - [DATE] at 3:34 pm, Resident #34 received as needed Tylenol. - [DATE] at 4:00 pm, Resident #34 walked unassisted in the hall and was assisted by a staff member safely back to his room. - [DATE] at 6:46 am, a CNA summoned the nurse to Resident #34's room to assess Resident #34. Resident #34 was found sitting in his recliner, mouth breathing with his mouth open, appearing pale in color. Vital signs were taken. Per the note, the CNA had reported to the nurse Resident #34 had complained of pain during transfer and also required 2 person staff assist for the transfer when he normally only required 1 person to assist and was able to walk with a walker. The CNA also reported Resident #34 had tea colored urine and had experienced this for the last few days (a potential sign of a urinary tract infection). The nurse noted there was an odor in the room. Resident #34 was unable to answer the nurse's questions. It was noted Resident #34 had made raspy audible sounds with mouth breathing. The documented vital signs were temperature of 97.0 degrees Fahrenheit, pulse of 67 beats per minute, respirations of 20 breaths per minute, blood pressure of 127/85 mmHg (millimeters of mercury) and pulse oximetry of 93% on room air. - [DATE] at 6:58 am, the nurse notified the nurse practitioner of the change of condition and received orders to send Resident #34 to the emergency room if the family desired. Additional orders were received for treatment in the facility if Resident #34's family declined sending Resident #34 to the hospital. - [DATE] at 7:04 am, Resident #34's daughter indicated in a phone call she wished for Resident #34 to be sent to the Emergency Room. - [DATE] at 7:08 am, the nurse called emergency dispatch and requested an ambulance to transport Resident #34 to the hospital. - [DATE] at 7:29 am, paramedics left the facility with the resident. (per hospital notes, paramedics noted a pulse oximetry level of 68% on room air upon arrival to the facility and the emergency room recorded a temperature of 101.3 degrees Fahrenheit) - [DATE] at 3:17 pm, the Director of Nursing and the Social Worker had a phone conversation with the resident's daughter. Resident #34's daughter informed the facility that Resident #34 would not be returning to the facility and it was anticipated Resident #34 would transfer to a hospice house. 4. A review of Resident #34's progress notes from his hospitalization revealed the following: a. emergency room notes dated [DATE] revealed the resident was hypoxic (low levels of oxygen in the body tissues) with oxygen saturation of 68% on room air (normal values are 90% or higher). The resident was not able to answer any questions during the exam. Blood drawn during the emergency room visit showed the resident to have a white blood cell count of 25.4 (Normal range is 4.5 to 11.0. An elevated result is an indication of an infection), a creatinine of 2.4 and a blood urea nitrogen (BUN) level of 64. Prior labs drawn [DATE] showed creatinine of 1.91 and BUN of 29. These labs indicate a decline in kidney function. Lactic acid was 2.29 (normal levels are 4.5 to 19.8). Synopsis of the emergency department course stated the resident had significant leukocytosis (increased white blood cell count) and worsened renal (kidney) function. The likely cause of resident's altered mental status from a urinary tract infection (UTI). Blood cultures were drawn. The impression of the Emergency Department provider was that Resident #34 had a urinary tract infection, acute on chronic renal insufficiency, and encephalopathy (brain swelling) b. Internal Medicine notes revealed the hospital physician had multiple bedside discussions with the resident's family. These discussions included the resident's wishes to have a Do Not Resuscitate status and his wishes of no invasive measures. They understood the resident was considered to be critically ill. Palliative care was consulted and the family chose to deactivate the resident's implantable cardioverter defibrillator (ICD) [a device implanted in a patient's chest to shock the heart to restore a normal heart beat]. The hospital diagnoses for the resident were listed as severe sepsis secondary to E. coli urinary tract infection, hypoxic respiratory failure, acute metabolic encephalopathy (brain swelling due to metabolic changes), and acute kidney injury on chronic kidney disease with metabolic acidosis. The family wanted to see if Resident #34 would have any meaningful recovery in 24 hours. The family then opted to proceed with hospice/comfort measures on [DATE], and Resident #34 was accepted to the hospice house on the same day. 5. Review of Resident #34's Death Certificate indicated Resident #34 died on [DATE] and listed the cause of Resident #34's death as Severe Sepsis due to a Urinary Tract Infection. 6. During an interview, on [DATE] at 1:15 pm, the Director of Clinical Services for the Corporation revealed that if a resident displays any signs of an infection (such as a urinary tract infection), the nurse should complete a report through the facility's Abilities Infection Watch (a software program used to monitor falls, infections, incident reports, etc .) 7. During an interview on [DATE] at 1:35 pm, the Infection Control Registered Nurse/QA Nurse verified that the nursing staff had not entered any Infection Watch reports for Resident #34 during 9/2022. The most recent Infection Watch report for Resident #34 was created in 7/2022. 8. During an interview on [DATE] at 1:40 pm, the Director of Nursing (DON), revealed she had been in frequent contact with the family members of Resident #34 several times prior to his hospitalization. Resident #34 had a noted decline she felt was due to his Parkinson's disease. She further revealed that Resident #34 had been out on pass in the days prior to his hospitalization, and his daughter had wanted to take the resident to the hospital at that time, but the resident refused. 9. Review of Resident #34's progress notes shows the resident out on pass with his family on [DATE] (10 days prior to Resident #34's hospitalization). 10. During an interview on [DATE] at 2:20 pm, Staff I, Certified Nurse Aide (CNA) revealed that for several days, Staff I had reported to Staff M, Licensed Practical Nurse (LPN) that Resident #34 had dark urine and increased confusion and lethargy (possible signs of a urinary tract infection in the elderly). Staff I was emotional during the interview and didn't feel anyone was listening to her when she reported Resident #34's symptoms. Staff I could not recall the exact dates she reported her concerns, but she knew she had reported her concerns at least twice prior to her shift on [DATE]. She further revealed that, on the morning of [DATE], she again brought her concerns about Resident #34's condition to Staff M, but Staff I did not feel that Staff M was being responsive to Staff I's concerns. Staff I then spoke to Staff D, Registered Nurse (RN) and requested Staff D assess Resident #34. Following the assessment completed by Staff D, Resident #34 was sent to the hospital. 11. During an interview on [DATE] at 2:30 pm, Staff J, RN, confirmed he authored a progress note, dated [DATE] at 8:45 pm, indicating that Resident #34 was witnessed by Staff J exiting his room unattended and asking for help. Resident #34 stated he had dropped his belongings on the floor and needed help to pick them up. When Staff J entered Resident #34's room there, was nothing on the floor and Staff J documented Resident #34 was hallucinating. Staff J further confirmed he also authored a progress note, dated [DATE] at 4:00 pm, that Resident #34 was walking without his walker unattended and Resident #34 was assisted safely back to his room by a CNA. Staff J did not consider these behaviors to be unusual for Resident #34. Staff J revealed these types of behaviors were the reasons Resident #34's family moved him to long term care. 12. During an interview on [DATE] at 2:55 pm, Staff K, RN, confirmed she had a noted a general decline in Resident #34 since he moved to the East hallway of the facility in 7/2022. She worked with Resident #34 on [DATE] on the 2 pm to 10 pm shift and Resident #34 was extremely anxious and complained of pain. She administered Tylenol, which was effective for pain relief. She further revealed that she spent a lot of time with Resident #34 during this shift and he remained calm when she spent 1 on 1 time with him, but he became anxious when left alone. She noticed him declining, but did not notice anything that was an acute change. Staff L, CNA, reported to Staff K, towards the end of the shift, Resident #34's urine was foul smelling (a potential sign of a urinary tract infection). Due to this report happening at the end of the shift, Staff K indicated the only action she took in regards to the report of Resident #34's foul smelling urine, was to pass this information on to the oncoming shift, Staff D, RN. 13. During an interview on [DATE] at 3:40 pm, Staff D, RN confirmed she worked the overnight shift on [DATE] and received report from Staff K. Staff D further confirmed she recalled Staff K told her Resident #34's urine had a strong odor (a potential sign of a urinary tract infection). Staff D monitored Resident #34 during the shift and assisted him to the restroom. She denied she had any concerns with Resident #34 during this shift and denied that his urine was abnormal in color or had a smell. This was the last shift Staff D worked with Resident #34 prior to assisting on [DATE]. Staff D then revealed that she was working the 6 am to 2 pm shift on [DATE], working on the opposite hall of where Resident #34 resided. Staff D was in another resident's room, performing a skin assessment, when Staff I called over the walkie talkie and asked for a nurse to come to Resident #34's room. Staff D stepped into the hallway and noted that Staff M, LPN, was walking towards Resident #34's room, so Staff D completed her skin assessment on the other resident. After Staff D completed her assessment, Staff D asked over the walkie talkie if assistance was still needed for Resident #34 and Staff I responded yes. Staff D proceeded to Resident #34's room and immediately noticed Resident #34 was very pale and not verbally responsive. Staff D assessed his vital signs, which were stable. Staff D revealed Staff I told her Resident #34 had tea colored urine (a possible sign of a urinary tract infection) and Staff I had reported the tea colored urine to other staff members for days, but nothing was done. Staff D reported the change of condition to the Nurse Practitioner and received orders about Resident #34's care. Staff D then notified the family and called for emergency transportation to the hospital. 14. During an interview on [DATE] at 8:20 pm, Staff L, CNA, revealed he noted a strong odor in Resident #34's urine (a potential sign of a urinary tract infection) when he worked the 2:00 pm-10:00 pm shift on [DATE]. He reported the strong odor of Resident #34's urine to Staff K, RN, towards the end of his shift. When Staff L returned to work the following day, Resident #34 had further symptoms of discharge from his penis and seemed more confused than the prior shift (potential signs of a urinary tract infection). Staff L reported these symptoms to Staff J, RN. 15. During an interview on [DATE], Resident #34's Family Member reported in the week or so prior to Resident #34's hospitalization, Resident #34 was complaining of a lot of pain and this was not normal for him. She kept in contact frequently with both the DON and the social worker regarding her concerns about Resident #34's care, but Resident #34's Family Member did not feel things were improving. She recalled she sat in a meeting with the social worker and the DON on [DATE] regarding Resident #34's decrease in appetite and increase in pain. Resident #34's Family Member requested that Resident #34 be seen for an acute visit by the nurse practitioner. The next morning, she received a phone call regarding Resident #34's status and that Resident #34 was sent to the hospital. Resident #34's Family Member was informed by hospital staff Resident #34 was diagnosed with sepsis due to a urinary tract infection (a body wide infection which starts in the urinary system and then spread to the rest of the body). The hospital staff recommended that Resident #34 transfer to a hospice house. Resident #34 passed away on [DATE]. 16. During an interview on [DATE] at 11:30 am, Staff M, LPN, revealed she had no memory of Staff I reporting any concerns regarding Resident #34's urine being dark. She did confirm Staff M worked with Resident #34 for several days leading up to Resident #34's hospitalization. She denied any concerns regarding Resident #34 prior to his hospitalization. 17. During a follow up interview on [DATE] at 1:10 pm, Staff I, reviewed the September schedule and indicated she thought Saturday [DATE] was the first day she reported to Staff M that Resident #34 had dark urine (a potential sign of a urinary tract infection). Staff I worked [DATE], [DATE], and [DATE]. 18. During a follow up interview on [DATE] at 2:00 pm, Staff J, RN, revealed he was aware that several staff members knew Resident #34 was experiencing urinary symptoms. Staff J confirmed it was reported to him the resident had strong smelling urine and penile discharge (both possible signs of a urinary tract infection). Staff J confirmed he did not report that Resident #34 had strong smelling urine and penile discharge to the nurse practitioner or physician. The symptoms Resident #34 experienced were a known issue and there was no need to report them to the resident's physician or nurse practitioner, since everyone already knew about the symptoms. 19. During an interview on [DATE] at 2:10 pm, Staff O, CNA, recalled she worked with Resident #34 on [DATE]. On [DATE], Resident #34 was too weak to use his walker (a possible sign of a urinary tract infection) and Staff O assisted him to transfer into his wheelchair to use the restroom. Staff O reported Resident #34's weakness and increased need for assistance during a transfer to Staff J. 20. During an interview on [DATE] at 3:01 pm, the Nurse Practitioner (NP) revealed she had not received any notifications regarding any urinary symptoms or change in condition regarding Resident #34, prior to the morning of [DATE]. Upon receiving the call on [DATE], the Nurse Practitioner gave treatment orders and orders to transfer to the hospital, pending the decision of Resident #34's family on which course of action they chose. 21. During an interview on [DATE] at 1:02 pm, the emergency room physician who treated Resident #34 on [DATE] revealed that, per his notes, the paramedics documented the LTC facility's nursing staff had reported Resident #34 had been experiencing weakness and altered mental status, starting the night of [DATE]. The physician revealed, based on this information, in his opinion, Resident #34 may have benefited if the LTC facility's nursing staff had obtained emergency medical care for Resident #34 sooner. 22. During an interview on [DATE] at 1:30 pm, Resident #34's Family Member revealed Resident #34 appeared ill when she picked Resident #34 up and took him to his house on [DATE]. On that visit, Resident #34's Family Member wished to take Resident #34 to the emergency room but he refused. Resident #34's Family Member wrote down on her calendar what days Resident #34 was out of the facility. Per her records, the last time Resident #34 was on pass out of the facility was [DATE]. On [DATE], Resident #34 called a different family member and told her that he was having a lot of pain. 23. During an interview on [DATE] at 2:12 pm, an Internal Medicine physician indicated that she did not personally care for Resident #34 during his hospitalization, but she reviewed the notes about Resident #34's medical care. Resident #34 was already septic (when an infection has spread through the body, including the blood stream) upon Resident #34's arrival to the hospital. She revealed the chances of Resident #34 recovering from the infection certainly would have been better if he had received treatment soon rather than later. 24. During an interview on [DATE] at 7:06 pm, Staff U, CNA, revealed she worked a night shift with Staff T, LPN, and received a shift report from Staff L. Staff L told them Resident #34 had not been getting toileted on the night shift as he was supposed to be and Resident #34 had developed a thick yellow crusty buildup on the head of his penis (possibly due to the discharge from the tip of Resident #34's penis, a possible sign of a urinary tract infection). Staff U revealed Resident #34 was uncircumcised and Staff L reported Resident #34 had been unable to pull back the foreskin of his penis due to the thick yellow crusty buildup on the head of Resident #34's penis. Staff L had been doing peri care on his shift but advised Staff U to continue performing peri care through her shift. Staff U could not recall the date of this shift. (Per a review of time cards, [DATE] was found to be the only night in this time frame that these three staff members all worked the same day) Staff U revealed the nursing staff was supposed to wake up Resident #34 and ensure Resident #34 used the bathroom during the overnight shift. 25. During an interview on [DATE] at 11:50 am, Staff T, LPN, reported she received a report from Staff L that Resident #34 had not been getting toileted on the overnight shift and that Staff L had done an excessive amount of peri care during his shift. 26. During an interview on [DATE] at 2:20 pm, Staff V, LPN, reported the nursing staff do not have access to the policy or procedures for the facility. If staff needed to know a policy or procedure, they had to request it that a member of management print the policy off for the staff member. The policies and procedures are not otherwise accessible for staff to read. 27. During an interview on [DATE] 1:00 pm, the Infection Control Registered Nurse/QA Nurse reported she checked with the DON, and the DON verified that the nursing staff have to ask the DON or the Director of Clinical Services to enter PowerDMS (a software program the facility utilizes for policy and procedures) to access policies and print off policies or procedures for staff. 28. Review of the policy Change in Resident Condition or Status Policy, revised 2/2021, revealed the policy directed the nursing staff to notified the resident's attending physician, or on-call physician, whenever there had been a significant change in the resident's physical/emotional/mental condition or the nursing staff needed to alter the resident's medical treatment significantly. The policy defined a significant change in a resident's condition as a major decline or improvement in the resident's status that . will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions. Prior to contacting the resident's care team, the nursing staff should make detailed observations and gather relevant and pertinent information for the provider. Except in medical emergencies, notifications are made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. The on-site survey team provided the facility staff with the IJ Template on [DATE] at 9:30 AM. The facility staff removed the immediacy on [DATE] by providing education to the nursing staff about resident assessment and interventions when a resident experienced a change in condition, education on the signs and symptoms of a urinary tract infection, and the education on notifying the resident's provider when a resident experienced a change in their condition. At the time of the survey, the deficiency was at the scope and severity of a J level. Following the staff actions, the deficiency reduced to a scope and severity of a D, due to the facility staff ensuring they followed their protocols and education for resident assessment and intervention, especially for residents with the signs of a urinary tract infection. II. Based on document review, observation, and staff interview, the facility's administrative staff failed to ensure the nursing staff followed adequate infection control practices for 1 of 4 residents observed for incontinence care (Resident #28) and ensure the nursing staff kept the catheter bag off the floor for 1 of 2 residents observed with catheters (Resident #28). Failure to ensure the staff followed infection control practices could potentially result in the staff spreading bacteria from the resident's feces into the resident's urinary area, potentially resulting in the resident developing a urinary tract infection. Failure to ensure the nursing staff kept the catheter bag off the floor could potentially result in the catheter bag becoming contaminated and allowing bacteria to move up the catheter, and into the resident's body, potentially resulting in a urinary tract infection. The facility's administrative staff identified 8 residents with indwelling catheters upon entrance. Findings include: 1. The Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #28 had a diagnoses of renal insufficiency, obstructive uropathy, and hip fracture. The MDS revealed Resident #28 had an indwelling catheter and had bowel incontinence, and required extensive assistance of 2 for toileting. 2. The care plan, revised on [DATE], revealed Resident #28 had a self-care deficit in activities of daily living (ADL), and required staff assistance for toileting. The care plan revealed the resident had a Foley catheter. 3. During an observation on [DATE] at 8:37 AM, the lower half of Resident #28's catheter urine collection bag was laying on the carpeted floor, by the resident's bed. The catheter bag lacked a dignity cover or other covering over the catheter urine collection bag. 4. During an observation on [DATE] at 8:42 AM, Staff E, Certified Nursing Assistant (CNA), removed Resident #28's pants and brief. Staff F, CNA, picked up a trash can and placed the trash can by the resident's bed. Staff F pulled disposable wipes from a package and handed the disposable wipes to Staff E using the same gloves previously used to handle the trash can. Staff E took the disposable wipes and cleansed the resident's peri-area. Staff F continued to hand disposable wipes to Staff E. Staff E took wipes and cleansed the resident's catheter tubing. After Staff E cleansed the resident's bottom, Staff F placed a clean brief under Resident #28 and attached the brief tabs. Staff E then opened a closet door, obtained clothes for Resident #28 to wear, then closed the closet door. Staff E pulled the catheter bag and tubing through the pants and then pulled the resident's pants up. Staff E took the bed remote and raised the head of the bed, then lowered the bed toward the floor. Staff E offered the resident a drink of water, then assisted the resident to change her top. 5. On [DATE] at 8:40 AM, Staff E, CNA, reported the clip on the catheter bag was broken and Staff E planned to obtain another catheter cover to go over the catheter bag. 6. During an interview on [DATE] at 10:30 AM, the Director of Nursing (DON) reported she expected the staff to change their gloves when the gloves became visibly soiled and when the staff moved from cleaning a dirty area (such as the resident's bottom) to a clean area (such as a resident's catheter). The DON expected the nursing staff to place a catheter bag in a dignity bag and not leave the catheter bag laying on the floor. 7. Review of the Handwashing /Hand hygiene policy, revised 8/2019, revealed all staff shall follow hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. The staff should perform hand hygiene before they move from providing care at at contaminated body site (such as the resident's bottom) to a clean area (such as a resident's catheter) during resident care. The staff should also perform hand hygiene after they made contact with objects in the immediate vicinity of the resident. 8. Review of a competency assessment for urinary catheter care, revised 9/2014, revealed the urinary drainage bag must be positioned or held below the resident's bladder at all times to prevent urine from flowing back into the bladder, and the staff must keep the catheter tubing and drainage bag off the floor.