**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to evaluate the placement of the urinary catheter after a routine catheter change with little to no urine output along with bloody urine for 2 days and then continued to have bloody urine for an additional 2 days before sending the resident to the hospital 4 days where it was found the balloon inserted in the urethra causing trauma and the resident diagnosed with a UTI (Urinary Tract Infection) for 1 of 3 residents reviewed for urinary catheters (Resident #1). The facility reported a census of 59 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The MDS revealed the resident had impairment in both lower extremities and used a wheelchair. The MDS revealed the resident was dependent on staff with toileting hygiene, and transferring to the toilet was not applicable due to not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury. The MDS revealed resident used an indwelling catheter. The MDS revealed medical diagnoses of heart failure, benign prostatic hyperplasia (BPH), and diabetes mellitus (DM). The Care Plan revealed a focus area dated 10/2/23 for an indwelling catheter related to urinary retention. The interventions dated 10/2/23 revealed monitored and documented intake and output as per facility policy; monitored/documented for pain/discomfort due to the catheter; monitored/recorded/reported to the MD (Medical Director) for s/sx (signs/symptoms) of UTI (Urinary Tract Infection) such as pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns; and catheter size and type per order. Position catheter bag and tubing below the level of the bladder and in dignity bag. The Electronic Medical Record (EMR) revealed the following diagnosis: a. Benign prostatic hyperplasia (BPH) with lower urinary tract symptoms The EMR revealed the following Physician Orders: a. Lasix oral tablet 20 mg- give 1 tablet by mouth one time a day b. sodium chloride irrigation solution- use 60 cc (milliliters) via irrigation two times a day for maintain patent Foley catheter flush c. 18 fr (french) 10 cc Foley change monthly and PRN (as needed)- every shift starting on the 19th and ending on the 19th every month for failing voiding trial, follow up with urology and as needed d. hydrocodone-acetaminophen oral tablet 5-325 mg (milligrams)- give one tablet three times a day The Indwelling Catheter Reassessment for Resident #1 signed by the provider on 7/3/24 revealed: a. diagnosis: BPH b. attempts at removal in the past resulted in: failed voiding trial, to follow up with urology c. This resident is not a candidate for surgical correction at this time. I feel that it is in the resident's interest to continue the catheter. I will reassess the need in 3 months and if any medical changes haven't taken place which would allow us to make any changes, I will consider discontinuing the catheter at that time. The Health Status Note dated 9/19/24 at 9:45 PM, revealed routine Foley catheter change. Removed 18 FR/10 mL catheter. Inserted new 18 FR/10 mL Foley catheter per sterile technique with immediate return of light amber urine. Res (resident) tolerated procedure well. The Nutrition/Dietary Note dated 10/19/24 at 6:46 PM, revealed Meal/Fluid Intake Fair or Poor or Refused for 2 or more meals in the day-Staff continue to encourage and assist as needed at meals. Snacks in room at times. Provide set-up assist with meals. The Health Status Note dated 10/19/24 at 10:00 PM, revealed Routine catheter change due. Removed 18 FR 10 mL catheter with large amount of sediment around catheter when removed. Inserted new 18 FR 10 mL catheter with immediate return of bloody urine. Res tolerated procedure well. The Health Status Note dated 10/20/24 at 5:10 AM, revealed continued to have hematuria. No c/o (complaints) pain or discomfort. Fluids offered and encouraged throughout night. The Nutrition/Dietary Note dated 10/20/24 at 6:34 PM, revealed Meal/Fluid Intake Fair or Poor or Refused for 2 or more meals in the day-Staff continue to encourage and assist as needed at meals. Snacks in room at times. Provide set-up assist with meals. The Health Status Note dated 10/20/24 at 7:35 PM, revealed T (temperature) 99.9, P (pulse) 100, R (respirations) 18, SPO2 (oxygen saturation) 95% room air, BP 121/75. Continues to have hematuria. Fluids offered and encouraged. No c/o pain or discomfort. Catheter flushes freely with Sodium chloride as ordered. The Encounter Note dated 10/21/24 at 00:00 revealed visit type: acute/follow-up Chief Complaint / Nature of Presenting Problem: Gross hematuria History Of Present Illness: [AGE] year old Caucasian male seen this day at [facility name redacted]. Patient awaiting shower at time of assessment. Staff report to this provider that catheter change was performed. Noted sediment around catheter removed. Inserted 18 Fr 10 mL with ease that patient tolerated well per [name redacted] electronic medical record. Noted gross hematuria on 10/20. Patient afebrile, asymptomatic. Denies pain or discomfort. Staff report catheter flushes with ease and patency. On call notified over the weekend of gross hematuria. Ordered UA with reflex to C&S. Staff utilized infectious disease processes protocol and did not obtain related to afebrile status and history of catheter change at time of onset. Poor appetite noted with refusal of more than one meal in one day and rejection of alternatives. GU: 18 French 10 cc Foley catheter present with gross hematuria ~50 cc. Plan: Gross hematuria: Initial evaluation. Large amount of bright red blood noted to cath bag. No clots noted. Suspected urethral trauma related to routine catheter changes. Continue to monitor. Benign prostatic hyperplasia with lower urinary tract symptoms, symptom details unspecified: Contributing to the above. Continue tamsulosin 0.4 mg daily. Continue finasteride 5 mg daily. Poor appetite: Encouraged oral intake as tolerated. Monitor hydration status. Continue weekly weights and report any changes as indicated. Offer alternatives as indicated at meals based on availability. Adult failure to thrive: Contributing to the above. May hinder infectious disease processes. Weight stable at this time. Continue current dietary recommendations. The Health Status Note dated 10/21/24 at 8:00 PM, revealed T 99.0, P 80, R 16, SPO2 96% room air, BP 110/64. Continues to have hematuria. Fluids offered and encouraged. No c/o pain or discomfort. Catheter flushes freely with Sodium chloride as ordered. The Nutrition/Dietary Note dated 10/22/24 at 6:30 PM, revealed Meal/Fluid Intake Fair or Poor or Refused for 2 or more meals in the day-Staff continue to encourage and assist as needed at meals. Snacks in room at times. Provide set-up assist with meals. The Health Status Note dated 10/22/24 at 8:30 PM, revealed T 98.6, P 110, R 18, BP 146/65, SPO2 95% on room air. Offered and encouraged fluids. Resident resting with no c/o pain or discomfort. Continues to have hematuria. The Encounter Note dated 10/23/24 at 00:00 PM, revealed visit type: acute/follow up Chief Complaint / Nature of Presenting Problem: Arterial wounds, gross hematuria History Of Present Illness: [AGE] year-old Caucasian male seen this day at [name of facility redacted]. Patient awaiting breakfast at time of assessment. Staff report to this provider that hematuria continues. At time of assessment bright red blood present to catheter bag with no improvement compared to Monday. Arterial wounds to third and fourth right toes have been stable for some time with Betadine to affected areas. Affected areas fluctuate from week to week. No gauze treatment noted at time of assessment. Patient denies pain or discomfort. Patient denies chest pain dizziness shortness of breath. Patient denies GI upset such as nausea or vomiting. Appetite per patient baseline per [name redacted] documentation. GU: 18 French 10 cc Foley catheter present with gross hematuria ~100 cc. Plan: Gross hematuria: Gross hematuria continues with no improvement compared to Monday. Large amount of bright red blood noted to catheter bag. No clots noted. Suspected urethral trauma related to routine catheter changes. CBC and CMP at next routine lab day. Benign prostatic hyperplasia with lower urinary tract symptoms, symptom details unspecified: Contributing to the above. Continue tamsulosin 0.4 mg daily. Continue finasteride 5 mg daily. Long-term use of aspirin therapy: Contributing to the above. Neuro improvement in hematuria. Discontinue aspirin 81 mg. Adult failure to thrive: Contribute to the above. Hinders infectious disease processes. Weight stable at time of assessment. Continue current dietary recommendations. Contributing to the above. May hinder infectious disease processes. Weight stable at this time. Continue current dietary recommendations. The Health Status Note dated 10/23/24 at 10:26 AM, revealed [name redacted] medical provider in for rounds with new orders for CBC (complete blood count) and CMP (comprehensive metabolic panel) r/t (related to) hematuria and to D/C Aspirin r/t hematuria. Resident aware of orders. The Health Status Note dated 10/23/24 at 3:24 PM, revealed CBC and CMP results sent to [name redacted]. Infection screen assessment completed and triggered for suspected UTI. BP 135/77, HR 118. Resident reports suprapubic pain/tenderness. [name redacted] Medical provider notified of lab results and infection screen assessment. Pending response for any new orders. The Health Status Note dated 10/23/24 at 3:24 PM, revealed new orders from [name redacted] (medical provider) for a UA (urinalysis) reflex to culture. Resident aware of orders. The Health Status Note dated 10/23/24 at 5:27 PM, revealed decrease in appetite and fluid intake, gross hematuria with decreased output, pale in color, elevated pulse rate [name redacted] medical provider 10/23/2024 3:00 PM [name redacted] emergency contact 10/23/2024 6:35 PM The Health Status Note dated 10/23/24 at 5:42 PM, revealed catheter clamped to obtain urine specimen. Resident pale and drowsy. The Health Status Note dated 10/23/24 at 6:15 PM, revealed unclamped catheter to obtain urine sample. Scant amount of bright red blood noted when sample obtained. Resident states he would like to go to the hospital and doesn't feel well. [name redacted], DON notified and began process to send resident to ER (emergency room). The Health Status Note dated 10/23/24 at 6:30 PM, Resident requesting to go to ER, urine bright red blood with minimal output, tachycardia noted, poor appetite and fluid intake. The Health Status Note dated 10/23/24 at 6:45 PM, EMS (Emergency Medical Services) called for transport, report called to [name redacted] nurse at [name redacted] (local hospital) ER, [name redacted] (emergency contact) notified and [name redacted] provider called. The POC (Plan of Care) Response History for Catheter Output revealed the following urinary outputs: a. 10/18/24: 5:55 AM- 400 ml (milliliters); 11:44 AM- 500 ml; 9:59 PM- 350 ml b. 10/19/24: 5:59 AM- 325 ml; 12:58 PM; 650 ml; 8:56 PM- 850 ml c. 10/20/24: 5:45 AM- 150 ml; 9:59 PM- 100 ml d. 10/21/24: 5:28 AM- 50 ml; 1:36 PM- 300 ml; 9:27 PM- not applicable e. 10/22/24: 5:37 AM- 250 ml; 1:43 PM- 575 ml; 9:41 PM- 650 ml f. 10/23/24: 5:18 AM- 800 ml; 1:33 PM- 700 ml The Change of Condition Evaluation V4.2 dated 10/23/24 at 5:27 PM revealed the following: a. situation: change in condition, symptoms or signs I am calling about are 1. abnormal vital signs (low/high BP (blood pressure), heart rate, respiratory rate, weight change) 2. bleeding (other than GI (gastrointestinal)) 3. food and/or fluid intake (decreased or unable to eat and/or drink adequate amounts) 4. functional decline (worsening function and/or mobility 5. started on 10/20/24 at night b. background general information: 1. resident long term in the facility 2. additional pertinent diagnoses: chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), diabetes 3. additional information as required: recent catheter change 10/19/24 4. specify other directives: indwelling catheter c. background (evaluation) 1. most recent vitals: BP (blood pressure) 135/77 on 10/23/24 at 3:20 PM lying left arm; pulse 118 beats per minute (BPM) on 10/23/24 at 3:20 PM; apical heart rate: 123 bpm; respirations 16 breaths/minute on 10/23/24 at 5:29 PM; temperature 97.9 Fahrenheit on 10/23/24 at 3:20 PM; most recent O2 (oxygen) saturation 98% on 10/3/24 at 5:43 PM 2. functional status change: general weakness 3. describe the change in weakness: general weakness without fever, change in level of consciousness, or other acute symptoms 4. describe the functional status signs or symptoms: non appetite, sleeping more 5. describe cardiovascular changes: resting pulse >100 or <50; tachycardia 6. describe abdominal/GI changes: decreased appetite/fluid intake 7. describe decreased appetite: significant decline in food and fluid intake in resident with marginal hydration and nutritional status 8. describe genitourinary changes: decreased urine output blood in urine 9. describe decreased output: decreased urinary output over 1-2 days, or new onset of post-void residual > 400 cc 10. describe hematuria: gross hematuria with pain, fever or other signs of bleeding at other sites 11. Laboratory tests/diagnostic procedures: abnormal results: chemistry 12. other chemistry values: creatinine, BUN (blood urea nitrogen), and GFR (glomerular filtration rate) dated 10/23/24 13. since the change of condition occurred have the symptoms or signs gotten: worse summarize observations and evaluation: decreased in appetite and fluid intake, gross hematuria with decreased output, pale in color, elevated pulse rate d. review and notify 1. reviewed and acknowledged the notifications: yes 2. reported to primary care clinician [name redacted] 3. date and time of clinician notification: 10/23/24 at 3:00 PM 4. recommendation of primary condition: UA with reflux 5. testing: urinalysis or culture The eInteract Transfer Form V4.1 dated 10/23/24 at 6:36 PM revealed the following: a. transfer/discharge details 1. sent to [name redacted] local hospital on 9/29/23 at 9:34 PM for abnormal kidney function for unplanned transfer b. conditions of return: nursing home would be able to accept resident back under the following conditions: 2. ED (emergency department) determines diagnoses, treatment can be done in nursing home c. devices and treatments: bladder (Foley) catheter- chronic d. additional relevant information: routine catheter change on 10/19/24, has had bloody urine since 10/20/24 that has progressively gotten worse. Increased heart rate, not eating or drinking, change in pallor, decline in kidney labs. The ED (Emergency Department) Physician Note dated 10/23/24 at 7:32 PM from [name redacted] local hospital revealed the following: a. Chief Complaint: 1. Patient arrives via EMS from [name redacted], complaints of bloody urine draining from Foley, complains of abdominal pain, EMS gave 50 mcg (micrograms) of Fentanyl in route and 4 mg of Zofran, Hx (history) of stroke b. history of present illness: 1. [AGE] year-old male brought from the nursing home with increasing abdominal pain over the past 4 days. Today he is having dark red bloody urine in his catheter. Patient is paraplegic due to stroke. c. Review of symptoms: 1. constitutional: denies fever, chills, or recent illness 2. Respiratory: Increased shortness of breath today no cough. 3. Cardiovascular: No chest pain, no palpitations. 4. Abdominal: Abdominal pain without nausea or vomiting. d. Physical exam: 1. vitals and measurements: T: 36.4 °C (Temporal Artery) HR: 79 (Monitored) RR: 10 BP: 94/59 SpO2: 100% HT (height): 170 cm WT (weight): 56.30 kg (Dosing) BMI (body mass index): 19.00 kg/m2 BSA (body surface area): 1.650 m2 e. General: Alert, no acute distress. f. ENT (ear, nose, throat): Oral mucosa moist, no LAD g. Cardiovascular: Regular rate and rhythm, Normal peripheral perfusion. h. Respiratory: Lungs are clear to auscultation, respirations are non-labored. i. Gastrointestinal: Abdomen distended, mildly firm, bowel sounds normal. j. Extremities: Contractions of bilateral lower extremities. No evidence of trauma k. Neurological: Soft but normal speech. Upper extremities show no motor or sensory l. deficits. Lower extremities are contracted but sensory is intact. m. Medical Decision Making 1. [AGE] year-old male presents with abdominal pain and frankly bloody urine. Differential diagnosis includes but is not limited to renal carcinoma, bladder carcinoma, intestinal-Bladder fistula, kidney stones, bladder stones, UTI, etc. 2. Review of laboratory work CBC (complete blood count) shows normal white count 9.4 H&H (hematocrit & hemoglobin) 10.5 and 31 platelets normal at 1.3. There is left shift of 84% neutrophils. Metabolic panel shows a slightly low sodium of 134 normal potassium at 4.1 CO2 is decreased at 17.5. There is an anion gap of 17.6 glucose of 223 BUN and creatinine elevated at 90 and 3.24, Most recent comparison 2 months ago shows BUN of 46 and creatinine of 1.95. Calcium slightly low at 8.2, albumin low at 2.3. Lipase normal at 48, lactic acid normal at 1.1. Urinalysis is red and cloudy with 250 glucose large amount of bilirubin 1+ ketones 3+ blood positive nitrites and large amount of leukocyte esterase, microscopic shows greater than 50 white blood cells greater than 50 red blood cells and 3+ bacteria. n. Review of radiology dated 10/23/2024 8:40 PM CT (Computed Tomography) Abdomen Pelvis WO (without) Contrast) with the following impression: 1. massively distended urinary bladder with air within the bladder lumen and extensive emphysematous changes to the wall of the bladder highly suspicious for emphysematous cystitis. Urology consultation is recommended. 2. Foley catheter has its balloon inflated in the urethra. recommend immediate removal and urology consultation. 3. right lower lobe pneumonia 4. other findings discussed o. The previous urinary catheter was removed and we were able to get a 16 French coudé in and patient did quickly empty 1500 mL of dark bloody. p. We do not have urology on-call in our system and for the next 4 days. I (Provider) called (tertiary hospital, name redacted) and they do not have any bed availability. q. After the bladder was completely drained patient's blood pressure did drop down to a MAP (mean arterial pressure) between 60 and 65. Patient was given 2 L (liters) normal saline IV (intravenous) and his MAP stayed above 70. r. We contacted [hospital name redacted] and I (provider) spoke with [doctor's name redacted] in urology. He felt that the patient would simply need to be treated as a severe UTI and did not need any specialty care. I (provider) spoke with [doctor's name redacted] Super (supervisor) triage and they do not have any beds available. With [doctor's name redacted] stating that the patient does not need specialty care, I (provider) talked with our Hospitalist here tonight [name redacted] and she agrees to accept the patient for admission at this facility. There was a slight delay in the patient getting over to the MedSurg unit as a nurse needed to be called in. Patient remained stable with heart rate of 75 blood pressure of 99/58 with a MAP of 72, O2 sats (saturation) of 100% on room air with a respiratory rate of 13-15. s. Assessment/Plan: 1. Emphysematous cystitis 2. AKI (acute kidney injury) 3. Right lower lobe pneumonia The Chemistry Report from the [name redacted] local hospital revealed the following lab results collected on 10/23/24 at 7:40 PM and resulted on 10/23/24 at 8:12 PM: a. BUN- 90 mg/dl (milligrams per deciliter) with reference range of (7-18) b. Creatinine Level- 3.24 mg/dl with reference range of (0.70-1.30) c. BUN/Creatinine ratio- 27.8 with a reference range of (9.0-21.6) The Urinalysis Report from the [name redacted] local hospital revealed the following results collected on 10/23/24 at 8:16 PM and resulted on 10/23/24 at 8:51 PM a. UA color: red with reference range of (yellow) b. urine clarity: cloudy with a reference range of (clear) c. urine pH: 8.0 with reference range of (5.0-8.0) d. specific gravity: 1.010 with reference range (1.001-1.030) e. glucose: 250 mg/dl with reference range (negative) f. bilirubin: large with reference range (negative) g. ketones: 1+ with a reference range (negative) h. urine HGB (hemoglobin): 3+ with a reference range (negative) i. urine protein >=300 mg/dl with a reference range (negative) j. nitrite: positive with a reference range (negative) k. leuk esterase: large with a reference range of (negative) l. Urine WBC (white blood cells) >50 with reference range (0-2) m. bacteria: 3+ with a reference range of (none) n. urine culture indicated? yes The CT Report from [name redacted] local hospital dated 10/23/24 at 8:40 PM revealed a. reason for exam: (CT Abdomen without contrast) abdominal pain, hematuria, abdominal distention b. Report: history: abdominal pain, hematuria, abdominal distention c. Findings: There is consolidation in the right lung base with air bronchograms compatible with right lower lobe pneumonia. There are intrarenal calcifications both kidneys compatible with kidney stones. This includes staghorn calculus on the right. There is mild bilateral hydronephrosis and hydroureter. There is air within the bladder wall with massively distended urinary bladder. This is highly concerning for emphysematous cystitis. Urology consultation is recommended. There is air within the urinary bladder consistent with infection. There is a Foley catheter with the catheter balloon inflated within the urethra. There is artifact in the pelvis associated with right hip prosthesis. There is mild stool in the colon with moderate stool within the rectum. There are degenerative changes lumbar spine there are changes of ankylosis. d. Impression: 1. massively distended urinary bladder with air within the bladder lumen and extensive emphysematous changes to the wall of the bladder highly suspicious for emphysematous cystitis. Urology consultation is recommended. 2. Foley catheter has its balloon inflated in the urethra. recommend immediate removal and urology consultation. 3. right lower lobe pneumonia 4. other findings discussed The Chemistry Report from the [name redacted] local hospital revealed the following lab results collected on 10/24/24 at 5:20 AM and resulted on 10/24/24 at 6:33 AM: a. BUN- 89 mg/dl with a reference range of (7-18) b. Creatinine Level- 2.99 mg/dl with a reference range of (0.70-1.30) c. BUN/Creatinine ratio- 29.8 with a reference range of (9.0-21.6) The Bacteriology Report from the [name redacted] local hospital revealed the final report dated 10/26/24 at 7:46 AM: a. Staphylococcus aureus isolated from both bottles b. Enterococcus faecalis isolated from 1 bottle Beta Lactamase test is negative The Gram Stain Report from the [name redacted] local hospital dated 10/24/24 at 2:06 PM revealed the following: a. gram positive Cocci in clusters Seen On Smear From Both Bottles b. Gram Positive Cocci in chains Seen on smear from anaerobic bottle The Infectious Disease Consultation dated 10/24/24 at 3:18 PM from [name redacted] local hospital revealed a. chief complaint: Pt is from [facility name redacted] and staff noticed the urine in his Foley was red so they called EMS. b. Pt (patient) arrived to the ED where they discovered that the balloon in the Foley was lodged in his urethra c. reason for consultation: bacteremia d. history of present illness: infectious disease consultation was done via telemetry from my remote office location here in [place redacted] using two-way audiovisual technology and assistance from bedside RN (Registered Nurse). Patient is located in [name of hospital and room number redacted] while I am located in my remote office here in [place redacted]. Consultation involved but not limited to chart review, history taking, physical examination, recommendation for workup as well as treatment. Treatment recommendation was communicated to the primary team. I personally examined patient using telemedicine video with assistance from bedside RN. Patient is a [AGE] year-old gentleman with multiple medical problems including CVA (cerebrovascular accident) with paraplegia, BPH with chronic urinary retention for which patient has chronic indwelling Foley catheter. Patient also has diabetes, osteoarthritis, hypertension and hyperlipidemia. Patient was brought to the emergency room from the nursing home of his residence because of hematuria. There was blood in his urine bag and by imaging it was discovered that the Foley catheter balloon is in the urethra resulting in the bleeding. It has been replaced but patient did have significant urine retention with massively distended urinary bladder seen on CT scan with extensive emphysematous changes to the wall of the bladder suspicious for emphysematous cystitis. Patient now has continuous bladder drainage which is quite bloody. Patient is very frail, and unable to give history and very somnolent. His blood culture is growing gram-positive cocci in clusters as well as gram-negative rod in one of the 2 blood culture bottles. Infectious disease service consulted for antimicrobial management. He has been having cough and chest imaging did show right lower lobe pneumonia e. Assessment 1. bacteremia with gram-positive cocci in clusters indicating staphylococcal bacteremia. There is also gram-negative rod isolated in one of the blood culture bottles. We will await identification of these organisms to opine on the other sources however with patient being admitted with acute urinary retention and hematuria, urinary source is worth considering. Patient also has right lower lobe pneumonia which could be a source of bacteremia depending on which 2. Right lower lobe pneumonia 3. Acute urinary retention with hematuria due to malpositioned Foley catheter. Catheter balloon was in the urethra f. Plan 1. Repeat blood culture x 2 2. Obtain transthoracic echocardiogram 3. Start IV vancomycin, target trough between 15 and 20 4. Continue IV Zosyn dosed per creatinine clearance 5. Will follow-up on the ID and sensitivity of the blood culture isolate; Will de-escalate antibiotics based on culture data and clinical course; Obtain sputum culture if patient can expectorate The Discharge summary dated [DATE] at 5:12 PM from [name redacted] local hospital revealed the following information a. admission date: 10/23/24 b. discharge date : [DATE] c. reason for hospitalization: blood in catheter d. diagnoses: discharge diagnoses: AKI (acute kidney injury); emphysematous cystitis; right lower lobe pneumonia. e. Summary of Events leading to admission: f. [name redacted] Resident #1 is a [AGE] year-old gentleman with past medical history of CVA with paraplegia, BPH and urinary retention with chronic indwelling Foley, hypertension, hyperlipidemia, type 2 diabetes mellitus, osteoarthritis, allergic rhinitis who presented to [name redacted] emergency room from [name redacted] nursing home when staff noticed urine in his Foley was red so they called EMS. When the patient arrived in the ED it was noted that the balloon and the Foley was lodged in his urethra and he had abdominal pain for last 4 days. Given that his Foley was noted to be in the urethra it was later removed in the ED. CBI (continuous bladder irrigation) catheter was attempted however could not be passed. Foley was replaced and 1.5 L (liters) of urine was drained with improvement of abdominal pain. Patient does also report a nonproductive cough and chills but denies any nausea, vomiting, shortness of breath, chest pain, fevers, chills. Patient's wife also present at bedside and patient also reports having abdominal pain and hematuria ongoing for 4 days. However he reports after Foley was replaced in the ED no further episodes of abdominal pain. g. Lab work on admission noted for WBC 10.3 with neutrophilic shift, hemoglobin 12.5, hematocrit 38, platelets 157, sodium 133, potassium 5.1, chloride 98, bicarb 19.8, anion gap 20.3, glucose 266, BUN 86, creatinine 3.43, calcium 9.1, total protein 6.9, albumin 2.8, total bilirubin 0.6, alkaline phosphatase 78, AST 10, ALT 20, lipase within normal limits at 48, lactic acid 1.1, UA is red and cloudy with 250 glucose large amount of bilirubin 1+ ketones 3+ blood positive nitrites and large amount of leukocyte esterase, microscopic shows greater than 50 white blood cells greater than 50 red blood cells and 3+ bacteria. h. CT abdomen pelvis without contrast noted for impression : 1. massively distended urinary bladder with air within the bladder lumen and extensive emphysematous changes to the wall of the bladder highly suspicious for emphysematous cystitis. Urology consultation is recommended. 2. Foley catheter has its balloon inflated in the urethra. recommend immediate removal and urology consultation. 3. right lower lobe pneumonia 4. other findings discussed i. The previous urinary catheter was removed and ED able to get a 16 French coudé in and patient did quickly empty 1500 mL of dark bloody. After the bladder was completely drained blood pressure did drop down to a MAP between 60-65 and the patient received 2 L of NS with improvement of maps staying above 70. Given lack of urology available in [town redacted] for the next 4 days ED physician reached out to [name of hospital] Hospital in [name of town and state redacted] and they do not have any bed availability. Later ED physician spoke with [hospital and name of doctor redacted] in urology. He felt that the patient would simply need to be treated as a severe UTI and did not need any specialty care. ED physician also spoke with [name of doctor redacted] super (supervisor) triage in [hospital name redacted] and they do not have any beds available. Given urologist at [hospital name redacted] said no need of specialty care patient was admitted to [town name redacted] for further management j. Plan: 1. Foley replaced in ED on 10/24 2. continue Zosyn inpatient 3. blood Cxes (cultures): Pending identification and sensitivities and will follow till completion 4. Gram Positive Cocci in clusters Seen On Smear From Both Bottles 5. Gram Positive Cocci in chains Seen on smear from anaerobic bottle 6. Gram Negative Bacilli Seen on smear from anaerobic bottle 7. urine cultures pending, follow till completion 8. Echocardiogram ordered for gram-positive cocci bacteremia 9. Consider transfer to facility which has urology inpatient for further evaluation to see if cystoscopy and CBI indicated 10. Also noted to have borderline low blood pressure-treated with 2 L IV fluids on admission to the ED, and also started some IV fluids inpatient and held antihypertensive medication. Will work with case management on transfer to tertiary care hospital given drop in hemoglobin and soft blood pressures 11. Infectious disease consult, appreciate recs (recommendations)- 12. Repeat blood culture x 2 k. Obtain transthoracic echocardiogram l. Start IV vancomycin, target trough between 15 and 20 m. Continue IV Zosyn dosed per creatinine clearance n Will follow-up on the ID and sensitivity of the blood culture is

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #165 chart had identified the resident having been evaluated on 3/3/2023 by a wound provider. The resident documentation had listed diagnosis to include morbid obesity, ventilator dependence at nighttime, spina bifida (a condition caused when a baby's spine and spinal cord does not develop properly in the mother's womb, causing the baby to be born with a gap in the spine and often causes paralysis in the lower limbs) and paraplegia (paralysis of the lower limbs). Review of the Minimum Data Set (MDS) dated [DATE] had shown Resident #165 had scored a total score of 15 on the Brief Interview Mental Status (BIMS) assessment indicating the resident had been cognitively intact. The MDS Section H had also documented the resident always being incontinent of bowel and needing two plus staffs to complete care after an incontinent episode. Section GG Functional Abilities and Goals had shown through documentation the resident being dependent on staff for all lower body cares. Resident #165 had been diagnosed with a non-pressure wound by a wound provider on 3/3/2023. The provider had documented the wound as an open boil (pus-filled bump that forms under your skin when bacteria infect and inflame one or more of your hair follicles). The reference of open boil had meant the wound (boil) had started to drain infection from beneath the skin on its' own. The wound provider had documented the location as inferior scrotum (a pouch of skin containing the testicles). The provider had documented the open boil size as 1.2 centimeters in length, 0.3 centimeters in width and 4.0 centimeters in depth. On 3/3/2023 the provider had ordered an oral antibiotic for the resident to take for ten days to aide in clearing the infection and had also ordered a gauze type material identified as Iodoform packing ¼ inch width size, apply to scrotum open boil wound topically every day shift for wound healing. The order read for every day shift, the nurse to remove the Iodoform packing from the day before and then cleanse the wound and repack as ordered. Review of the March 2023 electronic medication administration record (EMAR) and treatment administration record (TAR) had shown the 3/3/2023 Iodoform order had not been started until 3/8/2023. The reason documented on the record had been not available from pharmacy. Review of the Resident Progress Notes from 3/3/2023 through 3/8/2023 had lacked documentation to show the provider had been informed of the pharmacy not having the Iodoform ¼ inch packing. No new orders were obtained. There had been no documentation showing what action had taken place for the draining open boil. An interview had been completed on 3/7/2023 with the day shift licensed practical nurse (LPN) and the question had been asked if the wound provider had been notified of the pharmacy not delivering the Iodoform packing as order. The answer had been, no. When asked if getting supplies from the pharmacy had been an issue the LPN stated no. On 3/10/2023 the wound provider evaluated Resident #165 for a second time. The wound size remained unchanged. The provider ordered a larger size of Iodoform Packing increasing the ¼ inch to ½ inch. The provider had not documented being aware of the 3/3/2023 order not starting until 3/8/2023. 3. On 3/6/3023 review of Resident #38 electronic chart had shown the resident diagnosis: history of seizures, quadriplegia (paralysis of all four limbs) since 2008 following a motor vehicle accident with a cervical (neck) fracture at cervical 3 and 4 of the spinal cord (A column of nerve tissue that runs from the base of the skull down the center of the back. It is covered by three thin layers of protective tissue called membranes), high blood pressure and diabetes. The Minimum Data Set (MDS) Brief Interview Mental Status (BIMS) completed 1/16/2023 for Resident #38 had a total score of 15 which had indicated the resident had been cognitively intact. The resident had been dependent on staffs for all personal and medical care of daily living due to quadriplegia. Resident #38 had been assessed to be dependent upon a ventilator (machine to assist breathing) for breathing. Review of the wound provider documentation dated 3/3/23 had shown Resident #38 had been treated for one non-pressure wound of the right ischium. Documentation further stated an excisional debridement (provider uses a sharp blade to remove dead tissue from the wound margins to a point where living tissue is present for the wound to heal) had been completed on 3/3/23. On 03/08/23 at 3:00 PM wound care treatment had been observed with Resident #38 consent. left buttock has new surface area. The upper right buttock had two new areas. Both the left and right buttock had been cleaned by Staff F, licensed practical nurse (LPN) providing the care. Staff F then proceeded to complete all wound care. The new areas had not been measured or covered. On 3/08/23 at 4:13 PM in an interview with Staff F the information had been given that Staff E an LPN who had been designated as the wound nurse, had called the wound provider and received orders for Mepilex (a dressing cover) to be applied to the three areas of buttocks and the wound provider would assess on 3/10/2023 when at the facility. Review of the Progress notes on 3/9/2023 had shown that on 3/8/2023 at 4:54 PM a progress note had been completed stating there had been new orders from the wound provider to cover open areas on the right and left top buttocks with border gauze. The wound provider would see the resident on 3/10/2023. On 03/09/23 at 07:45 AM In an interview with Staff F the subject of wound covering had been discussed. When asked if the new wound dressing order that had been given on 3/8/2023, by the wound provider had been started then Staff F stated she had worked until 6:00 PM on 3/8/2023 and had not been present when Resident #38 had been laid down on 3/8/2023. When asked about Resident #38 and what the resident had been dressed in when staffs assisted resident to a chair on 3/8/2023 then Staff F had stated on 3/8/23 at 4:30 pm the resident had been dressed and put up in chair, dressed in sweatpants. Resident #38 had fabric material to direct non-pressure skin areas that had been left uncovered creating the fabric to bare skin. When asked about the resident's chair then Staff F had stated a cushion had been set in the chair. Staff F further stated there had been no new orders given when the resident had been transferred to a chair. The interview had continued with asking when the new orders had been initiated. When asked if the nurse who worked from 6:00 PM on 3/8/2023 to 6:00 AM 3/9/2023 had covered the three new wounds then Staff F stated the nurse who relieved her had been an agency nurse and Staff E had put the new order in to begin on 3/9/2023. When asked if skin sheets had been started and the wounds measured then Staff F stated the documentation had not been completed yet and had been left until wound care today 3/9/2023. Staff F had reviewed the resident electronical medication administration record (EMAR) and the treatment administration record (TAR) which concluded there had not been any further documentation about Resident #38 new wounds. There had been no documentation of covering the wounds at bedtime. An interview had been completed on 03/09/23 07:00 AM In an interview with resident he stated the evening nurse did not apply any dressings to buttock when he had been put to bed last PM from his chair, On 3/10/23 the wound provider evaluated Resident #38 for the second time. Documentation included acknowledgement of the resident having a new non-pressure wound to the sacrum that had been present for at least one day with a moderate amount of serous exudate (A clear, amber, thin, and watery clear part of blood that is normal during the inflammatory stage of wound healing, and smaller amounts are considered normal). The wound is identified by the wound provider as site four, non-pressure wound sacrum due to moisture associated skin damage, initial evaluation, full thickness. Wound size documented as 2 centimeters in length, 1 centimeter in width and 0.2 centimeters in depth. Provider ordered a primary dressing of alginate calcium daily with a secondary dressing of a bordered foam. The wound orders had been ordered for a 23-day duration. Based on observation, interview, and record review, the facility failed to thoroughly assess and implement interventions for a worsening non-pressure wound and failed to promptly treat two non-pressure wounds for three of three residents reviewed for non-pressure wounds (Resident #14, Resident #38, Resident #165). The facility reported a census of 64 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #14 dated 2/14/23 revealed the resident scored 12 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated moderately impaired cognition. Per this assessment the resident was at risk for pressure ulcers/injuries, had one or more unhealed pressure ulcers/injuries, and documented one stage two pressure ulcer present on admission, entry, or reentry. The Care Plan dated 2/17/23 documented, Resident has an actual pressure ulcer r/t (related to) diabetes, present upon admit. Stage 2 Location: left inner glut. All interventions per the Care Plan had been dated 2/17/23. One intervention dated 2/17/23 documented the following: Monitor skin during cares. Report any further skin breakdown (sore, tender, red, or broken areas). The admission summary dated [DATE] at 8:10 PM documented, Coccyx has 2.0cm (centimeter) x 1.5cm red non-blanchable area, not open. The Wound/Skin Healing Record documented a date of onset of 2/15/23 for a left inner glut wound. The wound had been documented as a stage two which measured 0.5x1. The assessment documented no depth, no exudate or odor, and granulation tissue (pink-red moist tissue that fills an open wound, when it starts to heal) for the wound bed. The definition of a Stage 2 Pressure Ulcer per the section Stage 2 Pressure Ulcer: Partial-thickness skin loss with exposed dermis in the State Operations Manual documented, in part, Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. This stage should not be used to describe moisture associated skin damage including incontinence associated dermatitis, intertriginous dermatitis (inflammation of the skin folds), medical adhesive related skin injury, or traumatic wounds (skin tears, burns, abrasions). The following had been documented on later assessments of the same wound: a. 2/16 (no year documented): Same measurements as 2/15/23, and documented no exudate or odor, and no pain related to wound. A Physician Order dated 2/16/23 to 3/3/23 Puracol Plus AG+ Collagen Wound Dressing with Silver Apply to lt (left) glut topically every day shift for open area cleanse, apply, cover. b. 2/23 (no year documented): Stage two 7 (Length) x3 (Width) x0.1 (Depth) centimeters, and documented serosanguineous exudate, slight odor, and scant exudate amount, and no pain related to wound. The wound bed documented granulation tissue. The assessment documented the wound had deteriorated. The Health Status Note dated 2/25/23 at 1:39 PM authored by Staff J, Licensed Practical Nurse (LPN)documented, Upon wound treatment to buttock/coccyx resident c/o (complained of) pain. Wound appears to be macerated with sloughing of tissue within the center of the wound. Also, dark areas found within the wound. Wound treatment completed per physician order. Will continue to closely monitor. The Health Status Note dated 2/26/23 at 10:27 AM authored by Staff J, LPN documented, Coccyx wound macerated, open and bleeding with dark purple areas. Wound tx (treatment) completed per physician order. c. 3/2 (no year documented): Stage two 12 (Length) x5 (Width) x0.2 (Depth) centimeters, and documented serosanguineous exudate, slight odor, and scant amount of exudate. The wound bed documented epithelial tissue and slough, and noted pain related to the wound. The assessment documented the wound had deteriorated. The Skin/Wound Note dated 3/2/23 at 3:59 PM documented, in part, the following for Weekly Wound Assessment: a. Type: Abrasion b. Status: Declined c. Location: Coccyx d. Treatment: Prisma/Cover e.Measurement 1x0.3 f. POA (Power of Attorney)/PCP (Primary Care Provider)/Dietary Aware On 3/3/23, a Non-Pressure Skin Condition Report documented the resident had a 13cm x 8cm x 0.2 cm wound with serosanguineous exudate, light amount of exudate, and no odor. The tissue type had been documented as epithelial, progress documented improved, and documented the resident was not experiencing pain related to the wound. Review of the [Name Redacted] Initial Wound Evaluation and Management Summary dated 3/3/23 documented non-pressure wound sacrum full thickness 13.0x8.0x0.2cm (centimeters) with moderate serous exudate with 25% slough (dead tissue). The Initial Wound Evaluation and Management Summary documented the wound had undergone surgical excisional debridement. The indication for procedure section documented the following: Remove necrotic tissue and establish the margins of viable tissue. The Skin/Wound Note late entry note dated 3/3/23 at 12:35 PM Weekly Wound Assessment note documented: a. Type: MASD (moisture associated skin damage) b. Status: Dr. [Name Redacted] First Assessment c. Location: Coccyx d. Treatment: alginate calcium/mepilex e. Measurement: 13x8x0.2 f. Debridement g. POA/PCP/Dietary aware On 3/8/23 at 9:40 AM, Resident #14's wound care was observed with Staff C, Licensed Practical Nurse (LPN). The resident had been sitting on the toilet in the restroom in the resident's room. The nurse explained they were going to clean the resident's wound with soap. Blood had been observed on the gauze after Staff C took the gauze away from the resident. Two areas had been observed to the right side of the resident's buttocks near the area between the left and right buttock. When Staff C had been asked to describe the wound, she said that on the right glut there was a little slough and on the other epithelial. Staff C explained it had been looking a lot better, and when she had first seen it it had all slough and bigger. On 3/8/23 at 9:53AM, Staff C explained the facility now had an in-house wound doctor that came in. Per Staff C, prior they had a wound nurse On 3/8/23 at 9:53 AM, Staff C, Licensed Practical Nurse (LPN), explained the facility now had an in-house wound doctor come in. Per Staff C, before they had a wound nurse do weekly assessments, and now the facility had both on a weekly basis. Staff C explained Staff E was the wound nurse. When queried what would occur if they noticed the wound had been worsening, Staff C explained they would let Staff E know, and Staff E would assess when they came back in. Per Staff C, Staff E did weekly skins on anyone with an area, and Staff C explained they did have skin sheets that would be completed to notify Staff E. Staff C acknowledged the floor nurse would do the treatment, and the floor nurse would not do weekly skin assessments. The form would be initially filled out by whoever found the wound. When queried what would occur if they changed the wound and it had looked different, Staff C explained they would go ahead with the treatment ordered, and would let Staff E know and the resident's primary know there had been a change. When queried where this would be charted, Staff C explained this would be in electronic medical record in the progress notes. When queried who could stage at the facility, Staff C explained they tried to leave it to Staff E. When queried about the resident's wound appeared when the resident first came in, Staff C explained the resident had a little reddened area that had been blanchable that had stayed consistent until Covid. Per Staff C, the resident gotten Covid and had been more sedentary. Staff C acknowledged the area had opened after the resident got Covid. When queried about the progression of the wound over time, Staff C explained she had noticed it had kind of grown a little bigger. Per Staff C, the resident had been started on health shakes as the resident's protein intake had not been that great. Staff C explained the resident had an area on the left side and two on the right side. On 3/08/23 at 1:50 PM, when queried if the resident had come in with open wounds, Staff E, Licensed Practical Nurse (LPN) responded yes, on her bottom. Staff E explained that she would go in to do weekly assessments and it had been open. When queried if this meant it had been open when the resident arrived to the facility, Staff E explained she could not answer that question. Per Staff E, when the resident first got the facility the doctor had ordered Z Guard which had been applied. Per Staff E, if the resident ad an area they would get a skin sheet on admission, otherwise the information was charted in the assessment for admission. Staff E explained she had first seen the resident's wound on 2/16/23. Per Staff E, the staff member who completed the first skin sheet for the resident no longer worked at the facility. When asked about the wound staging, Staff E explained it remained at a two (stage two noted on skin sheets) until the doctor told them otherwise. Staff E also explained they could not move a wound to a non-pressure wound until they talked to the physician, it was the decision of the first nurse for staging, and a lot of times if there was a question they put non-pressure until they saw the doctor. Staff E explained the wound had been changed to MASD (moisture associated skin damage) by the wound doctor. When queried about the assessment on 3/2, Staff E explained she had not known how to change it, she had known the wound doctor had been coming in, and she had been very much questioning it. When queried about the note which mentioned slough on 2/25/23, Staff E acknowledged if the wound had been worse the doctor should have been notified, and there should have been a progress note or a fax. Review of faxes to the doctor present in the resident's paper chart did not reveal a fax pertaining to the note dated 2/25/23. On 3/8/23 at 5:23 PM during an interview with the Corporate Nurse and the Director of Nursing (DON) the Corporate Nurse said that if it had been an agency nurse or someone who had not worked in four days they would not know if it had been a change, and the physician would be notified if the situation had been alarming or immediate. When queried if the wound had slough, the Director of Nursing (DON) explained that it would depend on the treatment ordered, and the order wouldn't be changed because it was still trying to work. On 3/9/23 at 4:15 PM, Staff G, Registered Nurse (RN) had been queried what they would do if a resident had an open wound with purple in it. Staff G responded they would notify the doctor, get orders, and make sure the wound doctor had been aware. On 3/9/23 at 4:23PM when queried what they would do if they already had an order but the purple had been new, Staff G responded they would notify the PCP (Primary Care Provider) when queried as to the process prior to having the wound doctor at the facility. On 3/13/23 at 11:35 AM, Staff J, LPN had been queried about Resident #14's wound. Staff J explained the wound had been along the resident's butt cheeks, not on the coccyx, more on the outside. Staff J had been queried if the wound had odor and said she did not recall an odor. When queried about her documentation of dark areas, Staff J explained getting darker, almost purple color, and not black. Per Staff J, the darkened area had been within where the wound had been. Staff J had not been sure the instance this had happened. When queried if the resident had had the dark areas prior, Staff J responded she did not think it had those purple areas. Staff J explained she had some concern with the wound's maceration and sloughing. When queried what she would about the purple areas, Staff J explained she would fill out a call slip, call the Physician, and update the wound nurse in the facility (Staff E) as sometimes she had suggestions. When queried as to where documentation of notification would be documented, Staff J explained it would be in the electronic medical record under progress notes. Staff J said she knew she had talked to Staff E about them, and further explained Staff measured and followed wounds weekly. On 3/13/23 at 12:38 PM, during an interview with the Corporate Nurse and the Director of Nursing (DON) conducted via telephone, the Corporate Nurse explained they felt the nurse doing the treatment would not be looking at the previous assessment, and if the site was necrotic or something like that then immediate notification would occur and not otherwise. The Corporate Nurse explained otherwise with every treatment staff would go back and do another assessment, and unless there was a significant change they probably would not notify right away if the wound doctor was in the next day. The Facility Policy titled Skin Integrity Program dated 12/1/21 documented the following per the Risk Assessment section: Braden assessment is a standardized, evidence-based assessment tool commonly used in health care to assess and document a patient's risk for developing pressure injuries. Complete weekly for 4 weeks upon admission, quarterly, and with a significant change in status. Identify and implement skin integrity interventions based on the results of the risk assessment. The policy lacked specific steps for staff to follow if they identified changes in appearance of a non-pressure wound.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure fall prevention interventions were being followed for 1 of 3 residents reviewed (Resident #1). Resident #1 fell in her room which resulted in a fractured arm. Staff were unable to verify that the care planned alarm sounded. This resident later passed away. The facility reported a census of 62. Findings include: 1. A Quarterly Minimum Data Set (MDS) dated [DATE], documented diagnoses for Resident #1 included generalized muscle weakness and respiratory failure. This resident's Brief Interview for Mental Status score was 14 out of 15, which indicated intact cognition. This resident required limited assist of 1 for transfers and bed mobility. The MDS documented that she did not ambulate in her room or in a corridor during the observation period for this MDS. This resident required extensive assist of 1 for toileting. This MDS documented Resident #1 had 2 or more falls without injury since the last assessment. 2. A Care Plan documented that an intervention initiated on 7/29/22, directed that a seat alarm was to be on at all times when transferring from bed to wheelchair. 3. An undated investigation, done by the facility, documented that upon interviewing the staff on duty at the time of the fall, the staff were unable to state whether or not her seat alarm was sounding/alarming. This investigation documented that it was care planned as an intervention for her to have a seat alarm in her wheelchair. This investigation documented at the time of this incident the resident had not initiated her call light prior to getting out of her wheelchair. 4. A review of progress notes revealed the following: -On 9/19/22 at 11:30 p.m., documented that the nurse was called into this resident's room by a CNA. Resident was found sitting in the bathroom on the floor resting against the wall. The resident was awake, alert, and answered questions appropriately. She was noted to have a skin tear to her left upper arm. There was no obvious head injury noted. The resident did not remember if she hit her head but stated she probably did. Resident complained of left shoulder pain and refused to move her arm due to pain but was able to grip with her left hand. There was no obvious injury to the left shoulder but it was tender to touch. The Resident was assisted to bed with a Hoyer and assist of 2. The resident tolerated fairly well but still complained of shoulder pain. -On 9/20/2022 at 12:00 a.m., Due to resident's continued complaints of shoulder pain and being unable to move arm and stating that she is sure it is broke, the EMS (Emergency Medical Services) was called to transfer resident to the emergency room (ER). A report was called to the ER staff and family was called and agreed with the plan. - On 9/20/2022 at 5:30 a.m., a call was received from the ER with a report that resident did fracture her left humerus and was this resident was found to have a UTI (urinary tract infection). This resident was to return to facility with an arm immobilizer and was to make a follow up appointment with the doctor. This resident was also started on Cipro (an antibiotic) in the ER for the UTI and one dose was given there. This resident was to continue with her current medications and treatments as ordered previous to fall. This resident was also given one dose of Morphine (narcotic for pain) in the ER which did control pain and this resident did not have pain if arm was not moved. - On 10/13/2022 at 11:53 a.m., this nurse was made aware by CNA that resident was feeling short of breath. This nurse assessed resident to find that resident was short of breath, complained of indigestion, and feeling hot. This nurse took BP (blood pressure) to find it was 96/70, pulse was from low 90's to 130's. This nurse called the PCP (primary care provider) and received a new order to send to ER for evaluation and treatment. This nurse called resident's sister to make aware. This nurse called the ER and gave report. - On 10/14/2022 at 4:12 p.m., this resident's second contact stated Resident #1's heart was functioning at 15 to 20% and Resident #1 may come back from the hospital and go on hospice. - On 10/17/2022 at 2:40 p.m., Resident#1 returned to the facility from the hospital. - On 10/17/2022 at 9:08 p.m., this resident ceased respirations, no apical pulse heard for 60 seconds by this RN, and a LPN at 7:50 p.m. ARNP (advanced registered nurse practitioner) notified and gave order to release this resident's body to the funeral home at 8:05 p.m This ARNP had spoken with [NAME] (medical examiner investigator), and stated they did not need to come in to investigate. Funeral Home was here to pick up body at 8:53 p.m. 5. On 11/9/22 at 4:10 p.m., the Nurse Consultant (NC) and the Provisional Administrator (PA) stated that their care plans needed a lot of work. The Nurse Consultant and the PA stated that the staff that were interviewed after the fall with fracture, stated they did not know if the alarm sounded or if it was even in the chair. The NC and the PA acknowledged that this was an issue, as at the time of the fall with fracture, this resident was care planned to have the alarm on the chair or the bed at all times. 6. On 11/15/22 at 5:00 p.m., the DON acknowledged that there was an issue with the alarm not being on at the time of the fall. 7. On 11/16/22 at 11:30 a.m., Staff A, Registered Nurse (RN), stated the alarm was not sounding when she entered this resident's room. The resident was sitting on the floor. There was one CNA in this resident's room with the resident and the other CNA had come to get this RN to assess the resident after she was found on the floor. This RN stated she was busy so she could not say if the alarm sounded before she went into this resident's room or not. She knew Resident #1 and knew that this resident would transfer by herself a lot. She does not recall if this resident was supposed to have an alarm or not. What Staff A did remember was that this resident kept complaining that her arm hurt, so she sent this resident out to the hospital. 8. On 11/16/22 at 5:00 p.m., Staff B, Certified Nurse Aide (CNA) stated she was working a different hallway the night of Resident #1's fall. She was approaching the central nursing station when Staff C, CNA, told Staff B that she might want to go into Resident #1's room. Staff B yelled at her nurse, Staff A to let her know, and then headed down to Resident #1's room. Staff B stated this resident was pinned between the bottom of the bed, the doorway to the bathroom and her head was propped up on the wall. Staff B stated that this resident more or less landed on her shoulder. Staff B stated the 3 staff had a conversation regarding how to get this resident up safely and they decided to use the Hoyer lift. Staff B stated that this resident never wanted to stay in bed. Staff B stated this resident was supposed to have an alarm on her. Staff B did not remember an alarm sounding. Staff B stated that Resident #1 knew how to turn the alarm off. Staff B added that this resident knew how to remove the alarm from underneath herself. Staff B stated that as far as she understood, the nurses all knew this resident knew how to remove the alarm. Staff B stated the staff were always on the lookout for this resident. Staff B stated she worked that night 6:00 p.m. to 6:00 a.m. She stated the fall happened around midnight or 1 a.m. 9. On 11/17/22 at 11:15 a.m., Staff C, CNA, stated she was doing her rounds, and she heard a noise like a [NAME] and holler. She wasn't sure if it was Resident #1 or not. She went into Resident #1's room and Resident #1 was in the bathroom on the floor. This CNA went and got help. She stated she did not remember if an alarm was sounding, nor did she know if Resident #1 was care planned for an alarm. This CNA stated she knew that Resident #1 had tried to get up and move on her own several different times. This CNA stated she knew she needed to keep an eye on Resident #1 more, because Resident #1 liked to try to take herself to the bathroom and Resident #1 was very forgetful. 10. An Inpatient Clinical Summary faxed on 10/17/22 at 2:05 p.m., documented the following discharge diagnoses: 1. atrial fibrillation (rapid) 2. elevated troponin 3. CHF-congested heart failure 4. COPD-chronic obstructive pulmonary disease 5. DM-diabetes mellitus 6. hypercholesterolemia 7. comfort measures 11. An Order Summary dated 10/17/22, documented that resident was admitted back to the facility on hospice care. 12. A Comprehensive Care Plan policy, revised on 7/18/22, directed the following: Care, treatment and services shall be planned to ensure that they are individualized to the resident's needs. Results of the assessment shall be used to develop, review and revise the resident's comprehensive care plan. The care plan shall describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being as required. The planning for care, treatment and services shall include the following- frequency of care, services and treatment AND team members responsible for care, services and treatment. Care plan, treatment and services should be regularly reviewed and revised The care plan should be individualized to the needs of the resident.