**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, staff interview, and policy review, the facility failed to conduct accurate Skin assessments, report the development of a pressure ulcer, and notify the Physician of pressure ulcer development for one of three sampled residents with pressure ulcers (Resident #171). This failure to conduct accurate Skin Assessments, report the development of a pressure ulcer, and notify the physician of pressure ulcers resulted in an Immediate Jeopardy (IJ) at F686-J; Pressure Ulcers due to the increased likelihood of serious, severe, systemic infection and serious pain. On 05/16/23 at 8:57 PM, the Administrator and Director of Nursing (DON) were notified of the IJ at F686 Pressure Ulcers. The Immediate Jeopardy began on 05/12/23 when an Agency Certified Nurse Aide (CNA 4) reported observing the untreated pressure ulcer and explained reported the finding to a facility CNA (CNA 1), a Licensed Practical Nurse (LPN 2), and a Nurse Practitioner (NP 1). The facility provided an acceptable Removal Plan on 05/17/23. The removal plan included: a. Conducting skin assessments for all residents in the facility. b. Reviewing Braden Scores for all residents to identify other residents at high risk for skin breakdown. c. Retraining all nursing staff on pressure ulcer prevention, reporting, and treatment. d. Updating the agency orientation checklist to include pressure ulcer prevention, reporting, and treatment. e. Completed risk management evaluations. Through interviews with facility staff, skin observations, and review of staff in-services, the Survey Team verified all elements of the facility's IJ Removal Plan and therefore removed the IJ, effective 05/17/23 at 5:35 PM. The scope lowered from a J to D at the time of the Survey after ensuring the facility implemented education and their policy and procedures. The facility reported a census of 82 residents. Findings Include: Review of Resident #171's Clinical Census, located in the Electronic Medical Record (EMR) under the Census tab, revealed Resident #171 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure, lung cancer, and dysphagia. Review of Resident #171's admission Skin Assessment, dated 04/27/23 and located under the Evaluations tab of the EMR, indicated Resident #171 had no skin breakdown. Review of Resident #171's Braden Scale for Predicting Pressure Sore Risk, dated 04/27/23 and located under the Evaluations tab of the EMR, indicated Resident #171 scored a 14, indicating the resident at moderate risk for skin breakdown. Review of Resident #171's Care Plan, dated 04/30/23 and located under the Care Plan tab of the EMR, indicated Resident #171 was at risk for skin impairment. Interventions included to report abnormalities. Review of Resident #171's 5-Day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/03/23 and located under the MDS tab of the EMR, revealed Resident #171 had a Brief Mental Status (BIMS) score of 14 out of 15, indicating cognitively intact, required extensive assistance with most activities of daily living, was frequently incontinent of bladder and bowel, and had no pressure ulcers. Review of Resident #171's Skin Observation Tool, dated 05/15/23, completed by the Director of Nursing (DON), and located under the Evaluations tab of the EMR, indicated Resident #171 had no new skin issues. Review of Resident #171's Physician Orders, dated 04/27/23 through 05/16/23, indicated no treatment orders for any skin breakdown. On 05/16/23 at 11:30 AM, Certified Nurse Aide (CNA) 1 was observed retrieving Licensed Practical Nurse (LPN) 1 to look at Resident #171. CNA 1 and LPN 1 entered Resident #171's room and observed the resident lying in her bed. CNA 1 asked LPN 1 a question that was inaudible and LPN 1 replied with a confirmation that she was aware. CNA 1 and LPN 1 left Resident #171's room. On 05/16/23 at 1:41 PM, the Surveyor observed Resident #171 with LPN 1 and CNA 1. Resident #171 was observed to have a tear drop shaped pressure ulcer to her coccyx. The perimeter of the wound was red. The upper wound bed, from approximately 10:00 o'clock to 2:00 o'clock and extending approximately 0.5 centimeters (cm) onto the wound bed was black eschar. An area of white slough was noted around the bottom perimeter of the wound, from approximately 4:00 o'clock to 7:00 o'clock and onto the wound bed by approximately 0.25 cm. The rest of the wound bed was brown eschar. LPN 1 confirmed CNA 1 had asked her about the wound at 11:30 AM and that she had told CNA 1 she would notify the Physician and get a treatment in place. LPN 1 confirmed that she had not contacted the Physician yet. On 05/16/23 at 1:51 PM, CNA 1 confirmed CNA 4, an Agency CNA, had told her about the pressure ulcer on 05/12/23. On 05/16/23 at 2:01 PM, the DON stated Resident #171 did not have any skin breakdown. The DON reviewed the electronic data on the tablet, an instrument used by the facility to photograph and measure pressure ulcers, and stated Resident #171 did not have any open areas. On 05/16/23 at 2:07 PM, Resident #171's skin breakdown was observed with the DON, LPN 1, and the Surveyor. The DON described the pressure ulcer's wound bed as soft eschar, with hardness to the center of the wound; dry, peeling, flaking edges; slough at the bottom perimeter; and hard redness all around the perimeter of the wound. The DON took a picture of the pressure ulcer and confirmed the measurements to be 13.0 cm x 6.3 cm. The wound depth was not measurable due to the eschar. On 05/16/23 at 2:10 PM, the DON and LPN 1 confirmed the facility's policy was to notify the Physician or Nurse Practitioner (NP) if a pressure ulcer was noted, get treatment orders, do skin and wound assessments, notify the Dietician and family, do a Risk Management Evaluation, and ensure interventions were in place. The DON confirmed the expectation was for these steps to be taken immediately. LPN 1 confirmed she had not looked to see if there were treatment orders in place. During an interview on 05/16/23 at 3:00 PM, the Medical Director confirmed he had observed Resident #171's pressure ulcer and stated it was his opinion that the ulcer was a Kennedy terminal ulcer. The Medical Director stated that his expectation was to be notified, pain management and treatments, as appropriate, be put into place. The Medical Director confirmed he had not been notified. During an interview on 05/16/23 at 5:18 PM, LPN 2, who had worked on Resident #171's hall on 05/12/23 through 05/14/23, denied knowledge of the pressure ulcer. During an interview on 05/16/23 at 5:23 PM, CNA 2 confirmed he worked with Resident #171 on 05/14/23. CNA 2 confirmed Resident #171 had an area that looked like a yellowish-brown scab on her coccyx on 05/14/23. CNA 2 confirmed he put a barrier cream on it and did not tell the nurse because he assumed the nurses already knew about it because it looked like it had been there awhile. During an interview on 05/16/23 at 5:51 PM, CNA 3 confirmed she had worked with Resident #171 on 05/15/23 and noted the breakdown to Resident #171's coccyx. CNA 3 confirmed she did not tell anyone because they already knew. During an interview on 05/16/23 at 5:57 PM, CNA 4 confirmed she had worked with Resident #171 on 05/12/23 and had told CNA 1 about the pressure ulcer. CNA 4 confirmed she also told LPN 2 and Nurse Practitioner (NP) 1 about the pressure ulcer and they were supposed to look at the wound and see if any treatments were in place. During an interview on 05/16/23 at 6:27 PM, NP 1 stated another Nurse Practitioner was seeing Resident #171 and denied being told of the pressure ulcer on 05/12/23. During an interview on 05/16/23 at 6:30 PM, the Administrator confirmed NP 1 was the only Nurse Practitioner in the facility on 05/12/23. During an interview on 05/16/23 at 7:10 PM, the DON confirmed she had completed the Skin Assessment for Resident #171 on 05/15/23 while the resident was sitting at the dining room table. The DON confirmed she did not look at the resident's buttocks or coccyx. Review of the facility's policy titled, Acute Condition Changes, dated 09/2017, recorded, .physicians shall help identify and manage causes of acute changes of condition .The nursing staff will contact the physician based on the urgency of the situation . Review of the facility's policy titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol, dated 04/2018, recorded, . the nurse shall describe and document/report . full assessment of pressure sore . pain assessment . mobility status . current treatments . all active diagnoses . the physician will, as needed, assist the staff to identify the type . of ulcer . as needed, the physician will order pertinent wound treatments .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident, family and staff interviews, the facility failed to document a complete assessment of a resident that fell and sustained a laceration to the head (Resident #10), failed to arrange for transportation for weekly blood draws for several weeks and to document an assessment on Resident #12 who had to be hospitalized with hemoglobin level of 4.8. The facility also failed to assess and to document an assessment of Resident #13 who had a UTI, failed to document the nurse practitioner or physician had been notified of UA results prior to the resident being sent to the hospital and passing away. These circumstances constituted an Immediate Jeopardy to resident health and safety. The facility reported a census of 84 residents. The Immediate Jeopardy began on 12/26/22. State Agency informed the facility of the Immediate Jeopardy (IJ) situation on 2/15/23 at 10:00 AM. The IJ was removed on 2/16/23 at 4:37 PM when the facility took the following actions: a. Resident #12's cancer clinic appointments have been coordinated as recommended by the Cancer Clinic. These appointments have been entered into the resident appointment book and also entered into PCC (Point Click Care) as an order b. Resident #13 no longer resides at the facility c. Facility staff and agency staff have been/will be educated to ensure the resident's physician progress note is received after outside appointments, noted by that nurse, and validated by a 2nd nurse. If there are no follow-up notes received after the appointment, staff will place a follow-up call to obtain the notes so appropriate follow-up has been made by the facility (orders/return appointment). Lab orders will be entered into PCC (the Electronic Medical Record, or EHR) in the orders section. Staff education also included appropriate assessment, intervention, and documentation of changes in condition and also timely physician notification of any abnormal lab results. d. The facility revised the agency orientation checklist to include assessment, intervention, and documentation protocols and also the protocol for physician appointments, lab monitoring, and follow-up. After the facility implemented education and their policy and procedures to remove the IJ, the scope was lowered from a K to a G. Findings include: 1. The Minimum Data Set assessment tool (MDS) dated [DATE] identified Resident #10 as cognitively impaired with a BIMS (brief interview for mental status) of 8 of 15 possible points. The MDS revealed the resident had diagnoses that included cancer, coronary artery disease and peripheral vascular disease. The MDS documented Resident #10 required extensive staff assistance with transfers, locomotion on and off the unit, toilet use, personal hygiene, and bathing. A review of the incident reports dated from 10/11/22 through 12/30/22 revealed the resident had a total of 11 falls: 7 occurred on night shift (10:00 PM to 6:00 AM), and 4 occurred on day shift (6:00 AM to 2:00 PM). On 11/7/22 at 10:45 AM, staff found Resident #10 on her knees near the bathroom yelling out and holding the handles of the wheelchair. The resident said she had to have a bowel movement and had called for help, but no one came. On 12/25/22 at 10:15 AM, a housekeeper told the nurse she found Resident #10 laying on the floor. The resident reported she attempted to transfer herself to bed. The resident sustained a bleeding laceration to the right side of her head; sent to the hospital ED (emergency department) for evaluation. On 10/12/22, the care plan identified the resident with the problem of being at high risk for falls and directed staff: 10/10/22 I have a sign in my room to remind me to call for help before getting up. 10/18/22 keep wheelchair near my bed for any attempts of self transfer 11/14/2022 Toilet resident approximately every two hours and prn 12/25/22 Educate to alert staff for assist. Frequent checks when in bed A review of the nurse's notes revealed the following: On 12/25/2022 at 10:15 AM, the housekeeper told the nurse Resident #10 was on the floor. When the nurse entered the room, she noted the resident lay on her right side with her head underneath her roommate's bed. The resident had hit her head and sustained a bleeding laceration to the right side of head. The nurse notified the family, called the physician, and obtained an order to send the resident to the ER for evaluation. On 12/25/22 at 11:00 AM The housekeeper told the nurse she found the resident on the floor. When the nurse entered the room, the resident lay on her right side with her head underneath her roommate's bed. The nurse called 911 as the resident had hit her head and sustained a bleeding laceration to the right side of her head. The resident reported she had tried to transfer herself to the bed. The nurse took the resident's vital signs, initiated neuro checks, and not move the resident until paramedics arrived to take the resident to the hospital for evaluation and treatment. The nurse also notified the resident's daughter, the hospice nurse, and the nurse practitioner. On 12/25/22 at 9:43 PM, staff documented Resident #10 had a fall today that caused a laceration to the back of her head. She ended up with 4 staples - bloodwork and UA both negative for abnormalities. The resident reported pain related to the injury on her head. Call light in reach and able to make needs known. Will continue to monitor. The assessment did not include documentation of the appearance of the stapled wound, any signs of bleeding, assessment of the resident's pain level, and if she required analgesics. A review of the neurological flow sheet revealed only one entry documented on 12/25/22 at 10:15 AM prior to Resident #10's hospital transfer at 11:00 AM. Observations of the resident revealed: On 1/30/23 at 9:53 AM, Resident #10 lay in bed with her call light in reach, properly positioned and she appeared to be comfortable. The resident reported she could not really remember what happened when she sustained her head injury, she remembered lost her balance when nobody was with her and she had to go to the hospital to get sutures. On 2/3/23 8:04 AM, Resident #10 sat up in wheelchair in the main dining room. Resident #10 was able to feed herself breakfast and appeared comfortable. In an interview on 2/7/23 at 1:36 PM, Staff H, LPN gave the following answers when asked the following questions: Q. When a resident is sent to the hospital and returns from the hospital after a fall to have a laceration stapled, what should the nurse document in the nurse's notes? A. She would document any orders that the resident came back with, what they did to the laceration - I remember doing that because I spoke to the nurse at the hospital. I would describe the way the skin looked, any bruising, any bleeding, mental status, and how she returned to the facility. Q. Can you remember what happened when Resident #10 had been sent to the ED on 12/25/22? A. She tried to self-transfer to the bathroom. She was not independent, Staff H could not remember how she was care planned, and she required at least the assistance of one staff. The housekeeper told her the resident fell. The resident lay by her roommate's bed with her head underneath the roommate's bed. She had a moderate amount of bleeding and no clots. Staff H reported she called 911 right away Q. How was she transported back from the hospital back to Lantern Park? A. She did not return during Staff H's shift. Q. Do you remember what happened on the day she fell in the bathroom on 11/7/22? A. She could not remember what happened exactly that day Q. Do you feel you have the help you need to meet the residents' needs? A. No, generally there is one nurse for each team, sometimes 2 nurses and a med aide and there's usually one aide per hallway. Each team would be responsible for 30 residents. There have been many residents who have complained that their call lights are not being answered timely. In an interview on 2/13/23 at 8:59 AM, Staff I, CNA gave the following answers when asked the following questions: Q. a. Can you remember what happened when Resident #10 had been sent to the ED on 12/25/22? A. She could not remember if worked that hallway, but remembered when she returned by ambulance, but could not be 100% sure. Q. Do you feel you have the help you need to meet the residents' needs? A. Typically there are 3 nurses for the whole building and there should be one CNA per hallway and one bath aide. We have been so short staff at least 3 times a week, we are short staffed when agency staff are scheduled but they will not always show up. In an interview on 2/14/23 at 1:39 PM, Staff X, housekeeper gave the following answers when asked the following questions: Q. Do you remember what happened when you found Resident #10 on the floor? A. She heard her yelling as she stood out in the hallway and she stood in the doorway and told her not to move until nursing staff to come help her. She saw her laying on the floor by the privacy curtain but 2 to 3 feet away from her bed. She could not see much as she lay behind the curtain. Q. What did you see? How much blood would you say was on the floor by her head? A. I couldn't see how much blood was coming from her head. Q. After you found her, what did you do? A. She went to get help from the nurses. They came right away, but she could not remember which nurse came to check on her. In an interview on 2/14/23 at 7:40 AM, the DON described the corrective actions the facility took: a. changed her bed to keep it in the lowest position b. started the toileting program where staff would go in there every 2 hours and at least offer to take her to the bathroom and as needed c. got her a new mattress d. assessed her bowel regimen medications e. talked to the staff in her hall to keep a closer eye on her as she continues to do things impulsively In a subsequent interview on 2/15/23 at 7:20 AM, the DON (Director of Nursing) reported: Q. Who was the nurse who assessed her after the fall? A. Staff H took care of her that day Q. With an unwitnessed fall and head injury - what is the protocol? How often are vitals and neuros checked, and where should that be documented? A. We do neuro checklist under evaluations tab in PCC every 15 min for an hour, then every 30 min for the next hour then hourly for the next four hours Q. Do you remember what time the ambulance took her to the hospital? Had it been more than an hour after her fall? A. The DON checked the electronic medical record to see the discharge form which showed the incident occurred at 10:15 AM. However, she verified she could not find documentation as to the time she left the facility. Q. What would you expect the nurse to chart for an assessment afterward? A. Document how she found her, if anyone else had in the room, what the head to toe assessment was of the resident, vitals, neuros, what was the resident trying to do, what did they do? Clean her up, call 911, and notify the NP, physician and family. This should also include the size of the laceration, the appearance, actively bleeding, presence of any clots, presence of any tissue coming out, amount of blood they saw? They need to paint the picture of what happened with the resident. 2. The MDS dated [DATE] identified Resident #12 as cognitively intact with a BIMS (brief interview for mental status) of 15 points. The MDS documented the resident had the following diagnoses: anemia, deep vein thrombosis (DVT) and limb girdle muscular dystrophy. The MDS also documented Resident #12 required extensive staff assistance with bed mobility, transfers, and toilet use, and totally dependent on staff for locomotion on and off the unit and bathing. On 4/27/21, Resident #12's care plan identified the resident required blood transfusions as needed related to anemia. The care plan did not include documentation of the frequency of the hematology appointments or mention that he had a port-a-cath for blood draws. During an observation and interview with the resident on 2/13/23 at 8:17 AM, the resident sat up at the edge of his bed, feeding himself breakfast. The resident's call light was in reach and he wore a clean t-shirt. The infusaport site on his right chest contained an intact, clean, and dry band aid and his skin appeared pink. A review of the After Visit Summary from the Cancer Center revealed the following documentation: a. Next appointment scheduled for 12/30/22 at 8:00 AM b. Next appointment at Cancer Center Infusion Site 12/30/22 at 9:00 AM c. CCC follow up scheduled for 1/6/23 - weekly lab and infusion services on Fridays d. Infusion appointments scheduled for: 1/20/23, 1/27/23 A physician order dated 6/25/21 directed when you receive Resident #12's labs (CBC) and if his Hgb is less than 7, you are to call the comprehensive cancer center. They will arrange for him to come in for his transfusion. He goes by CARE ambulance van or Yellow Cab wheelchair van. A review of the nurse's notes revealed the following: - On 1/23/23 at 7:33 AM Resident refused to have labs drawn this morning - will only allow labs to be drawn at the Cancer Center via his port. - On 1/27/23 at 2:00 PM Received a call from the Cancer Center and resident is being admitted to the hospital from his appointment. - On 2/4/23 at 5:59 AM no documentation of assessment of his infusaport site, signs of infection, etc. A hospital physician history and physical dated 1/27/23 revealed Resident #12 is a [AGE] year-old with a past medical history significant for pre red aplasia. The resident appeared disheveled and weak. He had also missed weekly appointments for desferal and blood transfusions for the past month. His hemoglobin was 4.8 and he was scheduled to receive two units of packed red blood cells, but did not receive those prior to arriving to the floor. On interview, the resident complained he felt cold, which is how he feels before he receives his transfusions on Fridays. He did note that he has missed prior appointments. In an interview on 1/31/23 at 10:12 AM, Staff E, LPN reported the following: a. She did not know how often he is supposed to have appointments at the Cancer Center. b. It is the responsibility of the nurse to enter appointments into the appointment book and making arrangements to and from the appointments. She admitted some days are really busy and sometimes she forgets to document. c. When a resident leaves the facility to go to an appointment, there usually is no documentation of an assessment. If the resident is being sent out to the hospital, should take their vital signs and neuros, not really sure. In an interview on 1/31/23 at 10:48 AM, Staff F, CNA reported the morning the resident went to the hospital, she helped clean him up before his appointment, however, she could not recall what his skin looked like. She could only recall that he had been able to feed himself. In an interview on 1/31/23 at 11:00 AM, Staff G, RN reported the ADON (Assistant Director of Nursing) usually schedules the appointments in the appointment book and makes arrangements for transportation for the residents. Some of the nurses will help her as she has new duties of being the ADON. In an interview on 1/31/23 at 11:23 AM, the nurse consultant reviewed the appointment book and could not find any documentation of appointments scheduled for Resident #12 for the month of January. Usually the DON or ADON is responsible for scheduling appointments in this book and making arrangements for transportation. In an interview on 1/31/23 at 11:29 AM, the nurse consultant reviewed the December appointment book and it showed documentation Resident #12 had an appointment on 12/2/22 and 12/30/22 and went to both appointments. In an interview on 1/31/23 at 12:04 PM, the ADON reported the following: a. When she had been the nurse manager, she recalled Resident #12 had weekly appointments, then it got switched to every 2 weeks, then it changed to monthly. b. When he comes back from the clinic, he usually will hand her paperwork from the clinic which would tell us when his next appointment is due. It's supposed to get scanned to PCC. c. When she had been the nurse manager, everyone brought her their papers and she would be the one to schedule appointments/transportation. But since she became the ADON in December 2022, the nurses took over that task and sometimes the DON or ADON will still make appointments. d. The nurse is responsible for writing the appointments in the schedule book and all the orders will be double checked by 2 nurses. After it's checked, a note should be entered into the nurse's notes by the nurse who processes the order. When the order is double checked, the two nurses will initial as being processed. e. When a resident leaves the facility to go to an appointment, there usually is no documentation of an assessment prior to them leaving. f. He may have missed appointments because the appointment itself did not get written in the schedule book, or we could not get him a ride, as he usually goes early in the morning and if that happened, we would try to reschedule. She had not been aware that he was supposed to have appointments once a week. g. We have a lot of agency nurses and I don't know that they would know to look for the paperwork from the clinic when he returns from there. In an interview on 1/31/23 at 1:56 PM interview, the DON reported the following: a. When Resident #12 went to his appointment 1/27/23, she recalled that he appeared a little pale in color, was able to eat breakfast in the main dining room and come to the front door for his appointment. b. For a while his appointments at the Cancer Center had been every 2 weeks, then every 3 weeks, however, now she did not know what his schedule should be. c. Beginning of December 2022, the process changed from the DON and ADON making the arrangements and scheduling it in the schedule book to the nurse who has the resident. There are days they do not have a nurse manager. d. The Cancer Center makes the appointments and they will send the information back with the resident who is supposed to give it to the nurse when he gets back so he or she can make arrangements for transportation and put the next appointment in the books. e. When a resident leaves the facility to go to an appointment, she would expect the nurse to put in some type of note in there and something did not look quite right. She would also expect them to make some type of note when they return from the appointment also. f. When he came back from his appointment 12/30/22, the packet he came back with said his next appointment at the Cancer Center was scheduled for 3/3/23. g. 50 to 75% of our staff are from agency. h. The nurses who take care of him should be responsible for following up on the labs that should be drawn at the Cancer Center every 2 weeks. i. The scheduling book did not have anything scheduled for him for the month of January. j. When he returns back from the Cancer Center, the process the staff should follow: The nurse that has him would need to ask him for the paperwork that came from the center Assess him, if he's ok, toilet him or take him to the next meal Double check his paperwork and see what the center did with him Put the scheduled appointments on the books If there had been medication changes, enter in the computer and fax to pharmacy The paperwork would get scanned by the medical records person or the business office assistant into PCC. This would be double checked by 2 different nurses. Shift report is done verbally but there is also communication in PCC. 3. The MDS dated [DATE] identified Resident #13 as cognitively intact with a BIMS (brief interview for mental status) of 14 points. The MDS contained the following diagnoses: heart failure, renal insufficiency (poor kidney function) and diabetes mellitus. The MDS revealed the resident required extensive staff assistance with transfers, locomotion on and off the unit and toilet use. The MDS identified the resident as occasionally incontinent of bladder and bowel. On 9/21/22 the care plan documented Resident #13 required assistance with all ADL's (activities of daily living) and directed staff to: 9/29/22 assist with routine toileting and repositioning 9/29/22 assist of one staff for all ADLs 10/18/22 one assist using EZ stand for transfers On 9/16/22, the care plan identified the resident was on diuretic therapy related to hypertension and directed staff to: a. Monitor for side effects (low sodium levels, headaches, dizziness, thirst, muscle cramps and low potassium) and effectiveness b. Monitor, document and report as needed any adverse reactions to diuretic therapy: dizziness, postural hypotension, fatigue and an increased risk for falls. A nurse's note dated 1/20/23 at 2:59 PM New order for UA (urinalysis) received, resident and family informed. The entry did not include documentation of an assessment related to the rationale for UA, vital signs, etc. The UA lab report dated 1/21/23 revealed a leukocyte esterase (suggests there are white blood cells indicating a urinary tract infection) of 3+ (normal negative) and a WBC (white blood cells indicating a urinary tract infection) of 1758 (normal range 0-3) The nurse's note dated 1/24/23 at 3:56 PM, staff called to invite the resident's daughter to care plan conference scheduled for Thursday. The entry did not include documentation that her physician, nurse practitioner or daughter had been notified of UA results after 1/21/23. The notes did not include assessments from 1/21/23 until 1/26/23. A review of the Hospitalist's history and physical dated 1/27/23 revealed documentation that indicated the resident had UTI with sepsis and a serum WBC (white blood count) of 24.6 (normal range 4.5 to 11). A review of the hospital Discharge summary dated [DATE] revealed documentation to show the UA showed pyuria bacteriuria with leukocytosis of 24 and pronounced clinically dead at 4:45 PM. The summary contained principal Diagnosis listed as Encephalopathy, Acute Hypoxemic Respiratory Failure. Conditions Directly Contributing to Death: Acute Hypoxemic Respiratory Failure, encephalopathy, A. fib with RVR, NSTEMI type II or I, UTI, sepsis. A review of the ADL documentation by the CNAs for transfers showed documentation this had been completed on: With supervision on January 18 at 10:36 AM, 20 on 7:19 AM, 23 at 8:32 AM, 25 at 10:55 AM With limited assistance required on January 16 at 9:36 AM, 18 at 3:24 PM, 23 at 8:23 PM Required extensive assistance January 16 at 9:59 PM, 18 at 3:24 PM, 24 at 9:43 AM and 8:42 PM A review of the ADL documentation by the CNAs for toileting showed documentation this had been completed on: Review of record for toileting showed documentation was completed on: With supervision on January 18 at 10:36 AM, 20 at 7:19 AM, 23 at 8:32 AM, 25 at 10:54 AM Required limited assistance on January 16 at 9:36 AM, 22 at 9:56 AM, 23 at 8:23 PM Required extensive assistance on January 16 at 9:59 PM, 18 at 3:24 PM, 20 at 2:54 AM, 21 at 2:16 AM, 24 at 9:42 AM and 8:42 PM Totally dependent on January 16 at 4:11 AM, 17 at 3:58 AM, 18 at 3:40 AM, 19 at 5:17 AM, 22 at 2:15 AM, 23 at 5:19 AM, 24 at 3:31 AM, 25 at 5:05 AM and 7:56 PM, 26 at 2:42 AM In an interview on 2/6/23 at 11:44 A, Staff Q, LPN reported the resident sleeps in her recliner and she remembered when the ambulance came to get her, she had a BM and she did not know how long it had been there. She asked the aides if any of them cleaned her up during the night, they said she had been peaceful when they tried to move her and they left her that way .they probably did not clean her up at night. Her daughter asked if they check and changed her and that's when the aides said they really didn't do anything with her. Staff should check and change residents every 2 hours. In an interview on 2/6/23 at 12:34 PM, the ADON (assistant director of nursing) reported she had actually worked as her aide that day. She saw her last at 7:30 AM and could not get her to wake up, felt warm, like she had a fever. When she checked her temperature it had read 97.7. She asked the nurse practitioner to see her and decided to send her to the hospital. The ADON reported she did not check her brief as she sat in the recliner. When she received report from night shift, they did not report that they had checked and changed her. In an interview on 2/7/23 at 4:30 PM, the resident's POA (power of attorney) reported the following: - On 1/22/23, she went to visit her mother and noted she did not feel well: she had to use the bathroom more often and now required assistance to get up with the use of a mechanical lift. She asked a nurse if they could test her for a UTI because she's going to the bathroom more. Her roommate reported that sometimes she would find blood on the toilet seat after Resident #13 had used the bathroom. No one had said anything to the resident's POA about this bleeding. - On 1/24/23, when she went to visit the resident, she appeared to be agitated and uncomfortable, and the POA thought someone would have followed up with her having a possible UTI. - On 1/25/23, she received a call from the administration staff saying they wanted to have a meeting on 1/26/23. There was no mention of any concerns about her, just that it had been for a quarterly meeting (care conference). - 1/26/23 when the ambulance came to take her to the hospital, the ambulance staff informed the POA that Resident #13 had been allowed to sit in her own urine for hours. - On 1/27/23, the emergency room nurses said she's soaked in urine in her robe and underwear and they had to clean her up and stabilize her. Later the same day, Resident #12's temperature went up to 105.8 F. At 5:00 PM, the staff woke me up to tell me she had passed probably around 4:00 PM. In an interview on 2/10/23 at 11:29 AM, Staff G, RN reported when a nurse sends a resident to the hospital ED (Emergency Department), she should chart a physical assessment which should include the appearance of the resident's skin color, respirations, etc. The nurse should also document what happened, why the resident had been sent out, and when they notified the doctor, called the ambulance, and notified the family. She also reported with the UA report Resident #13 had, she would have called the doctor and document in the progress notes. She would also take vital signs at least every shift; especially the temperature, urine color, odor, urgency, presence of pain, and usually if an antibiotic is ordered, monitor for signs of a possible allergic reaction. In an interview on 2/13/23 10:53 AM, Staff S, LPN reported a UA had been sent out, days before the resident had been sent to the hospital. She also reported when a nurse sends a resident to the hospital ED, she should document an assessment, vital signs, that orders had been obtained from the doctor and notify the family. In an interview on 2/13/23 at 11:09 AM, Staff Q, LPN could not recall when the resident began to show signs and symptoms of a UTI which would include: confusion, dark urine, odor to urine, dizziness, sudden incontinence, fever. When a resident shows these symptoms, the nurse should call the doctor, ask if he wants a UA, obtain the UA, and then chart this in the nurse's notes. They should be placed in hot charting. After the UA shows that they have an organism that needs to be treated with an antibiotic, staff should chart at least once a shift. She recalled when the medics wheeled passed her to take Resident #12 to the hospital, she noticed the resident had a strong odor of urine. She also reported when a resident is sent to the hospital, the nurse should obtain a set of vitals, find out what's going on, get a full body assessment, and notify the nurse practitioner. The assessment and vitals all should be charted in the nurses' notes. In an interview on 2/13/23 at 9:48 AM, Resident #14 (Resident #13's roommate) reported the night before Resident #13 went to the hospital, the aides only came in 2 or 3 times. They just looked at her. They didn't change her or touch her all night until her daughter came in the morning. When her daughter came in, she couldn't get a rise out of her or get her to move. When the ambulance came to get Resident #13, they took her temperature and it was over 102 F. In an interview on 2/14/23 at 10:11 AM, the medical director reported, he would have expected staff to document vital signs and assessments under hot charting at least daily. In an interview on 2/14/23 at 11:21 AM, Staff Z, Nurse Practitioner, reported she would have expected nurses, upon identification of a possible UTI, to document assessment and vitals which would also include a temperature. Staff Z reported the resident had a temperature of 102 F before she left the building. A review of the facility policy titled: Change in a Resident's Condition or Status last revised February 2021, directed the nurse will notify the resident's attending physician or physician on call when there has been a(an): a. accident or incident involving the resident; b. discovery of injuries of an unknown source; c. adverse reaction to medication; d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly; f. refusal of treatment or medications two (2) or more consecutive times); g. need to transfer the resident to a hospital/treatment center; h. discharge without proper medical authority; and/or i. specific instruction to notify the physician of changes in the resident's condition. 2. A significant change of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease- related clinical interventions (is not self-limiting); b. impacts more than one area of the resident's health status; c. requires interdisciplinary review and/or revision to the care plan; and d. ultimately is based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. 3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form. 4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: a. the resident is involved in any accident or incident that results in an injury including injuries of an unknown source; b. there is a significant change in the resident's physical, mental, or psychosocial status; c. there is a need to change the resident's room assignment; d. a decision has been made to discharge the resident from the facility; and/or e. it is necessary to transfer the resident to a hospital/treatment center.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, resident and staff interviews, facility policy review and physician interview, the facility failed to assure that staff provided appropriate tracheostomy care to include the assessment of the humidification system and failed to provide appropriate training to Nursing Staff on procedures during an accidental extubation (tracheostomy tube fall out) and having the obturator (used to insert a tracheostomy tube) readily available at bedside for 1 of 1 resident reviewed (Resident #1). This failure resulted in several visits to an emergency room for treatment for the resident, therefore causing an Immediate Jeopardy to the health, safety, and security of the resident. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of November 19, 2022 on December 28, 2023 at 10:45 a.m. The facility staff removed the Immediate Jeopardy on December 29, 2022 by implementing the following actions: a. Placement of emergency supplies in Resident #1's room to provide general trach care and emergency management as needed. b. Staff education on trach care by a local respiratory company with a competency review. c. Specific resident will be sent to hospital for tracheostomy tube changes until training and competency met and resident/staff comfortable for tracheostomy tube changes at facility. d. A Local Ear Nose Throat (ENT) Clinic has agreed to provide the tracheostomy tube changes in accordance with Physician Orders every 2 weeks. The scope lowered from J to D at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility identified a census of 84 residents. Findings Include: The Minimum Data Set (MDS) dated [DATE] for Resident #1 reveals diagnoses of heart failure, respiratory failure, tracheostomy, dependence of supplemental oxygen, obesity and obstructive sleep apnea requiring extensive assist with bed mobility, dressing and toilet use from 2 persons. Resident #1 had difficulty with breathing with activity, at rest and when lying flat. Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating an intact cognition. The Care Plan dated 10/18/22 for Resident #1 directed staff to monitor vital signs, perform oral care, keep extra trach tube and obturator at bedside, if unable to reinsert obtain medical help immediately. The Physician Orders for Resident #1 revealed to change oxygen tubing weekly and as needed, administer oxygen 3-5 liters continuously with heated humidity using a trach mask, give tracheostomy care and change the split gauze 2 times a day, offer to suction after administration of duoneb & normal saline nebulizer treatments 2 times per day and change the Bivona 7 XL trach with no inner cannula every 2 weeks. Interview on 12/27/22 at 9:51 AM, Resident #1 stated she had been in the hospital 3 times and the last time she was so dry that her lungs were bleeding. Resident #1 stated she had to wait 2 hours to be suctioned. Resident #1 stated, It makes me feel like they don't care if I can breathe or not. Resident #1 stated Staff H, Licensed Practical Nurse (LPN) was the only nurse who knew how to change her trach, I'm afraid the others will not be able to help if I need it. Resident #1 stated on 12/20/22 she could not breathe and requested to go to the hospital emergency room (ER) as she was squealing out of the trach. Resident #1 stated the Hospital (ER) Doctor got the blockage out but was unhappy since this was the third time she was there with a dried-out trach. Resident #1 stated, They were constantly running out of suctioning tubing, and had to reuse the suction catheters. Resident #1 stated sometimes the split gauze did not get changed and there was not an extra tracheostomy tube at her bedside at the facility. Observation on 12/27/22 at 9:51 AM, noted Resident #1 in room sitting in a wheelchair with blue tubing connected to Resident #1's neck, over the trach, draped down to a bag containing clear fluid then up to a half full of fluid humidifier machine, [NAME] Paykel, and O2 tubing connected to that down to Oxygen concentrator set on 4 liters, the tubing is not dated. The Suction machine on table next to Resident #1's bed, has 200 cc of yellow secretions in the bottle and the tubing is not dated. No extra trach at bedside, no obturator at head of bed, 3 suction tubings in bedside table drawer, no suction catheters, and suction equipment at bedside. A large black room humidifier on a stand next to #1's bed is not on. Observation on 12/28/22 at 8:20 AM, Resident #1 in room in the wheelchair, nebulizer tubing to tracheostomy, medication completed. Resident #1 stated she would need to be suctioned, crackling sounds heard when Resident #1 breathed. Staff F, LPN, entered room with suction catheters in hand. After hand hygiene, gloved, and removed nebulizer, Staff put on non-sterile gloves and suctioned the tracheostomy 2 times and used saline to clear tubing between the passes. The suction machine did not work right, new canister had nothing in it, nurse checked connections and adjusted the canister and a mucous plug with the saline came out of the tube and into the canister. Staff F checked Resident #1's O2 Saturation and noted at 94% and did not listen to lung sounds with a stethoscope, did not clean around the stoma, did not apply split gauze. Staff F turned on the portable O2 and a Certified Nurse Assistant (CNA) came in room and took Resident #1 to the dining room for lunch. The Medication Administration Record (MAR) dated December 2022 for Resident #1 revealed no documentation for the 12/6/22 tracheostomy tube change and not changed 12/20/22 either. Resident #1 had the tracheostomy tube change documented in her phone by Staff H, LPN on 12/11/22 and 12/25/22. Treatment Administration Record (TAR) dated December 2022 for Resident #1 revealed an order for trach care as follows: place split gauze around trach, change 2 times a day and as needed. On 12/28/22 the TAR revealed oxygen ordered continuously at 3-5 liters, verify obturator is visible at head of bed in case of emergent extubation, and heated humidity via trach mask, fill tank with distilled water every 4 hours. Document titled Hospital (Name Redacted) Report dated 11/19/22 revealed Resident #1 presented to the emergency room (ER) at 8:19 PM with shortness of breath and blockage of tracheostomy, lack of humidification to tracheostomy as a contributing factor to the condition with a recommendation to increase humidity and possible nebulizer with saline. Document titled Hospital (Name Redacted) Report dated 12/1/22 revealed Resident #1 presented to the ER at 1:47 AM with shortness of breath, difficulty breathing, wheezing. Document titled Hospital (Name Redacted) dated 12/20/22 revealed Resident #1 presented to the ER at 4:25 AM with shortness of breath, difficulty breathing, choking, dry secretions and wheezes, the resident stated the tracheostomy ran out of humidity solution and had gotten dry. Document revealed that this visit was most likely due to decreased humidity and dry secretions with discharge instruction: It is extremely important that the humidity is filled at all times, without the humidity the patient's trach will dry out and get obstructed. During an interview on 12/28/22 at 4:29 PM, the ER Physician stated he treated Resident #1 on 2 occasions for a dried out tracheostomy and Resident #1 stated that she was afraid it will happen again and no one was paying attention to it at the facility. Interview on 12/27/22 at 10:22 AM, Staff B, LPN, stated she had knowledge of trach suctioning and cleaning before working at the facility, but no further training. Staff B stated resident #1 had thick drainage suctioned after her nebulizer treatments. Staff B stated supplies were not available when resident #1 first arrived for tracheostomy care and stated the trach was changed 12/26/22 and there was not a tracheostomy tube at bedside. Staff B stated, My concern is that we need more training and only 1 nurse knows how to change her trach. Random observations on 12/27/22 revealed the following: a. At 10:30 AM, Staff B, LPN, went to the supply closet and gathered up a tracheostomy tube, Bivona XL, several suction tubing packages and took to Resident #1's room. b. At 2:30 PM Resident #1's oxygen system had a small amount of fluid in the heated humidifier. c. At 4:15 PM, Resident #1's heated humidifier filled to full line and room humidifier not on. Interview on 12/27/22 at 9:51 AM, Staff C, RN, stated there should be an extra trach and suction equipment at bed side and she does not know how to change a tracheostomy tube but can suction the tracheostomy. Staff C stated no training had been offered for tracheostomy care. Interview on 12/27/22 at 10:25 AM Staff A, LPN/Assistant Director of Nursing (ADON), stated this facility didn't use humidification with oxygen use unless they get a Physician Order or if a resident complains of dryness. Staff A stated she had knowledge of tracheostomy cares. Staff A stated the previous ADON was able to change the tracheostomy tube, no one had asked for training and they have not offered training to the Nursing Staff. Interview on 12/27/22 at 1:20 PM, the Director of Nursing (DON) stated she had not changed a tracheostomy tube, would need a refresher training before she can do one and had not offered training for tracheostomy care for Nursing Staff. During a phone interview on 12/28/22 at 8:36 AM, Staff I RN, stated Resident #1 was cooperative and followed recommendations. Staff I stated she had knowledge of tracheostomy care and provided training to Staff H, LPN and the facility did not offer training to other Nursing Staff for tracheostomy care. Staff I stated in November 2022, Staff H changed Resident #1's tracheostomy tube, the next day Resident #1 went to hospital with blood in the tracheostomy. Staff I stated after Resident #1 went to the hospital on [DATE] with the intervention put into place was a heated humidity. Staff I stated, A nurse on day shift did ask me once what to fill that with. Interview on 12/28/22 at 1:12 PM, Staff H LPN stated Resident #1 complained about and worried about staff suctioning in a timely manner. Staff H stated he was trained by Staff I to change the tracheostomy tube and he has done this 3 - 4 times for Resident #1. Interview on 1/4/22 at 8:20 AM, Resident #1 stated she has been congested over the last few days and the room humidifier was not on for the last 2 days. Resident #1 stated she went to the Ear, Nose and Throat (ENT) clinic and a new tracheostomy tube was placed that had an inner cannula. Interview on 1/4/23 at 9:44 AM, the DON stated the oxygen tubing should be dated when changed and the room humidifier in Resident #1's room should be filled and turned on. Review of the Oxygen Policy dated October 2010 revealed: a. Oxygen equipment needed at point #3 - humidification bottle. b. Assessment at point #2 - look for signs and symptoms of hypoxia (lack of oxygen). c. Steps in procedure at point #9 - check mask, tank and humidifying jar to be sure there is water in the humidifying jar and water level is high enough that the water bubbles as oxygen flows through. d. At point #11 periodically re-check water level in the humidifying jar and document oxygen flow rate. Review of Tracheostomy Care Policy dated 2013 revealed: a. General guidelines at point #2 - gloves are to be clean and sterile. b. At point #6 - a replacement tracheostomy tube must be available at the bedside at all times. c. At point #7 - Suction machine and a supply of suction catheters, sterile gloves and flush solution must be at bed side at all times. d. Procedure guidelines at point #7 - listen to lung sounds with a stethoscope. e. Site and Stoma Care at point #2 - clean stoma site with peroxide soaked solution, rinse with saline soaked gauze, and disinfect stoma with antiseptic gauze, single sweep for each side, air dry, apply gauze around stoma site.