**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident and staff interviews, the facility failed to provide assessment and interventions for the necessary care and services, to maintain the residents' highest practical physical well- being. Clinical record review revealed the Nursing Staff did not complete a thorough assessment and provide treatment according to the Physician's Orders for 1 of 1 residents reviewed (Resident #7) also the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, for 1 of 1 resident reviewed for bruising (Resident #23). Resident #23 noted with multiple bruises which had not been assessed, documented nor were additional interventions put in to place by/at the time of the Survey. Resident #23 had bruises in different stages of healing. The facility reported a census of 38. Finding Include: 1. Resident #7's Minimum Data Set (MDS) Assessment, dated 4/14/22, revealed diagnoses: stroke, coronary artery disease (heart disease), hypertension (high blood pressure) and diabetes. The MDS documented the resident's cognition intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Care Plan dated 4/20/22 revealed directive for staff to give anti-hypertensive medication as ordered. There was no directive for treating of chest pain with Nitroglycerin, and no direction for staff to follow for when to monitor blood pressure or when to call physician. During an interview on 7/5/22 at 2:30 PM, resident #7 stated they facility ran out of the evening blood pressure medication and he experienced chest pain and a headache at the base of his skull. Resident #7 stated it felt like when he had his stroke and described the feeling as the blood pressure was frightening, my head was throbbing and I could hear the whooshing sound. Resident #7 stated the nurse brought the evening medication and the resident noticed the blood pressure pill was not there. Resident #7 stated when he inquired about the medication, the nurse stated they ran out and you're not the only one this happens to. Resident #7 stated his blood pressure was over 200 and he called 911. Physician's Orders revealed Toprol XL 75 milligrams (mg) to be given once a day started on 4/28/22 and Nitroglycerin (Nitro) tablet 0.4 mg ordered on 6/16/22 for chest pain. Progress Notes revealed on 6/9/22, resident #7 experienced stabbing chest pain, Tylenol given, physician not notified. Resident #7 experienced chest pain again on 6/13/22 and 6/15/22 when the physician was sent a fax. The fax was answered on 6/16/22 with the new order for Nitro for chest pain. Resident was monitored on 6/17/22 through 6/20/22 with no reoccurring chest pain. Review of the Medication Administration Record (MAR) dated 6/1/22 - 6/30/22 revealed Toprol was not given on 6/24/22, code 9 indicates medication not available. Progress Notes dated 6/24/22 revealed at 6:58 PM, the medication Toprol for high blood pressure was not available. At 11:00 PM, staff was called to resident #7's room, resident was agitated, reported a headache, feels exactly like when I had my stroke, blood pressure 220/143, heart rate 87. Resident #7 calling police. At 11:10 PM nurse called the Physician Assistant (PA) and received an order to send resident #7 to the hospital. At 11:15 PM the nurse called the Emergency Medical Service (EMS) and they were on the way already. At 11:35 PM EMS arrived to the facility. Progress Notes dated 6/25/22 at 4:05 AM, revealed resident #7 returned to the facility, blood pressure 164/111, resident #7 complained of headache. There are no further cardiac assessments nor follow up completed. On 6/30/22 at 2:27 PM the physician seen resident #7. Review of a document from the local hospital - Ambulance Service Transport Record dated 6/24/22, contained a paragraph titled History of Present Event revealed that resident #7 developed chest pain and headache after 7:30 PM described chest pain as stabbing and reported the facility had trouble adjusting resident's blood pressure medications over the last two months, resident had not received his blood pressure medication that evening resulting in a blood pressure of 230/120. The document listed resident #7's past history of two heart attacks and stroke. The document revealed an electrocardiograph (EKG) results of sinus rhythm and blood pressure at 11:36 PM at 186/96, at 11:42 PM 181/100 and at 11:50 PM 167/102. Resident taken to a local hospital A document from the local hospital's Emergency Department dated 6/24/22 revealed resident #7 was seen for elevated blood pressure. Resident #7 reported his chest pain stopped and was given a pain medication for headache in the Emergency Department (ED). An EKG, Chest X-ray and labs were performed and reviewed. The elevated blood pressure was stabilized and resident #7 was returned to the facility. During phone interview on 7/8/22 at 12:45 PM, Staff B, Licensed Practical Nurse (LPN) stated they have been having problems receiving medications from the pharmacy, not arriving. Staff B stated she worked on 6/25/22 and remembered the situation with resident #7's medication, it was labeled wrong. She stated she found it with that mornings medication, relabeled it and put it with the evening medications. During an interview on 7/9/22 at 2:00 PM, the Director of Nursing (DON) stated the Evening Staff Nurse, Staff C, LPN, called and notified her of Resident #7 transfer and return to the facility. The DON revealed she knew about the missing medication and that it was found in the morning, incorrectly labeled. She stated her expectations of her nurses for chest pain, I would expect them to do a cardiac assessment for symptoms and take blood pressure and pulse then call the doctor to report, probably get a onetime order for blood pressure medication or transfer him to the hospital. 2. A MDS assessment dated [DATE], documented diagnoses for Resident #23 included Cerebrovascular Accident (CVA) and schizophrenia. The Brief Interview for Mental Status revealed a score of 6 out of 15, indicating severely impaired cognition. The resident required assist of 1 with transfers and ambulation. A Care Plan with a focus area initiated on 7/2/22, directed staff that Resident #23 was at risk for falls. Her goal was that she would not experience any injuries related to falls. The Care Plan directed staff on the following: a. To encourage this resident to use her call light for assistance. b. This resident needed a safe environment without clutter. c. To make sure she was wearing appropriate footwear. d. To monitor her for unsteady gait. Nursing Skin Observation forms documented the following weekly assessments: a. On 6/23/22 this resident had no new skin issues b. On 6/29/22 this resident refused a skin assessment. c. On 7/6/22 this resident had no new skin issues. d. On 7/13/22 this resident had no new skin issues. A Hospital Emergency Department Provider Notes document dated 7/6/22, documented that there was a number of bruises mainly on extremities. Pictures revealed that there was more than 20 bruises on this resident's lower extremities and left wrist. Progress Notes included documentation of the following: a. On 6/24/22 at 4:50 AM, Certified Nurse Assistant (CNA) called this nurse that the resident is on the floor. Upon arriving in resident's room, the resident was on the floor and laying on her right side. Resident was in front of the door, behind her wheelchair and next to foot of her bed. Resident laid on her back and head supported with a pillow. Resident was assessed and vitals were taken. No injuries noted, res denied having pain or discomfort. Resident was wearing gripper socks at the time of fall, resident did not utilize call light. b. On 6/24/22 at 11:10 PM, Resident denies pain or injury from recent fall. c. On 6/25/2022 at 9:45 AM, Resident has no injuries noted related to fall. d. On 6/25/2022 at 8:35 PM, Resident denies pain or injury from recent fall. Full Range of Motion (ROM) to all extremities. Resident is alert but forgetful. e. On 6/26/2022 at 9:15 AM, Resident has no injuries noted related to the fall. Resident is alert and oriented x 3 (person, place and time) with noted forgetfulness at times. f. On 6/26/22 at 8:25 PM, Resident forgetful at times but alert. Denies changes pain or injury related to recent fall. g. On 6/27/22 at 12:50 PM, Follow up related to unwitnessed fall. Resident is alert, resting in bed with no complaints of pain or discomfort. No new skin issues or injuries observed. h. On 6/29/2022 at 1:45 AM, fall follow up, denies injury. i. On 7/1/2022 at 4:10 PM, Resident being monitored for unwitnessed fall on 6/30. No injuries noted. Resident Alert and Oriented x 3 with noted forgetfulness. j. On 7/7/2022 at 1:26 AM, CNA reports to his nurse that resident was on the floor. Found resident sitting on the floor by bed side, no injuries noted, vitals and neuros stable. k. On 7/9/2022 at 1:50, Resident complained of chest pain. At 2:30 AM, resident was transported to the hospital. l. On 7/12/2022 at 5:35 PM, Resident noted to have scattered bruising in multiple healing stages. A fax (was sent) to the doctor related this resident was on plavix and aspirin and will have various bruises. m. On 7/13/22 from 3:17 to 3:21 PM, 6 entries were documented each entry had an identified bruise. n. On 7/13/2022 at 3:56 PM, Nurse notified of resident having multiple bruises to extremities. Resident assessed head to toe and bruises noted in various stages to all extremities. Skin evaluations completed. Resident states she bumps them (arms and legs) a lot. Medications reviewed and resident taking plavix and aspirin. Resident has fragile skin and bruises easily. Doctor notified. Call placed to brother and made aware. Thanked nurse for the update. On 7/12/22 at 12:56 PM, Skin Assessments and Evaluations were requested regarding bruises on this resident. The Director of Nursing (DON) was not aware of bruises and stated she would look into it. On 7/14/22 at 10:59 AM, the Director of Nursing (DON) stated she had went down and did a head to toe on Resident #23. She stated this resident did have extremity bruises in various stages and some were faded out yellow. There were one or two that were a darker purple. The DON stated this resident had a couple of falls lately and is also on Plavix and aspirin. The DON stated this resident said she bumped into things. The DON stated this resident is hit or miss on reliability. The DON felt like when she talked to the resident about stuff the resident is reliable. She was not sure why none of the bruises were charted. She stated they should have been charted on the weekly skin checks. When told the weekly skin checks on the 7th and the 13th stated there were no new skin issues, she stated it should have been charted there. When asked if the CNAs report bruises, she said the bruises should have been reported and documented on. She stated that directly after the 3 falls the bruises may not have shown up yet. She stated she called the Nurse Consultant about the bruises after being asked about documentation on them on 7/12/22. The DON stated that she was directed to call the physician, do assessments on the bruises and document it all in the chart. The DON stated she did not start any type of investigation into this. She stated she will need to ask some questions of her staff as to why this was not documented. She repeated it should have been documented on the weekly skin assessments. On 7/14/22 at 12:25 PM, Staff A, CNA, stated Resident #23 is technically an assist of 1, but she is non-compliant and transfers all the time by herself. She stated this resident takes herself to the bathroom and is incontinent and doesn't' always change her brief when it is wet. Staff A stated they check and change this resident. Staff A stated this resident puts her knees on the bed instead of sitting then crawls on to the bed and gets the bruises on her shins a lot. Staff A, reported that she didn't see the bruising so much when working as a Medication Aide, as this resident would have pants on but Staff A saw it a lot more as a CNA. Bruises are pretty typical for this resident. Staff A stated this resident uses her call light when she needs something as well, but has had a couple of falls lately. On 7/14/22 12:36 PM, Staff E, CNA, stated that sometimes Resident #23 has bruises on her legs. Staff E stated that when she first started, she reported the bruising, but she was told it happens and they knew about the bruising. She repeated that they just tell me they know about it. On 7/14/22 at 12:57 PM, Staff F, Licensed Practical Nurse (LPN), stated she just started working again in the last 2 weeks as she was in Nursing School. She stated she had done the weekly skin assessment on 7/13/22 for Resident #23. She stated that none of those bruises were new and that is why she marked no, to the question if there are any new skin areas. When asked if records were kept of bruises, she stated she would assume they would keep those on a record until they were healed or gone. She stated there is an I-Pad thing that they use to take a picture of the new skin areas and measure them. She did not know the paper work piece of it yet. She hadn't heard anything about the bruises through report so she guessed those bruises were from Resident #23 transferring herself and recent falls. Staff F stated that she was still in orientation so not sure how the records are kept. An Accidents and Incidents-Investigating and Reporting Policy revised on 7/2017, directed that all accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. Policy Interpretation and Implementation 1. The Nurse Supervisor/Charge Nurse and/or the Department Director or Supervisor shall promptly initiate and document an investigation of the accident or incident. 2. The following data, as applicable, shall be included on the Report of Incident/Accident form: a. The date and time the accident or incident took place; b. The nature of the injury/illness (e.g., bruise, fall, nausea, etc.); c. The circumstances surrounding the accident or incident; d. Where the accident or incident took place; e. The name(s) of witnesses and their accounts of the accident or incident; f. The injured person's account of the accident or incident; g. The time the injured person's Attending Physician was notified, as well as the time the physician responded and his or her instructions; h. The date/time the injured person's family was notified and by whom; i. The condition of the injured person, including his/her vital signs; j. The disposition of the injured (i.e., transferred to hospital, put to bed, sent home, returned to work, etc.); k. Any corrective action taken; l. Follow-up information; m. Other pertinent data as necessary or required; and n. The signature and title of the person completing the report. 3. This facility is in compliance with current rules and regulations governing accidents and/or incidents involving a medical device. 4. This facility will adhere to the definitions in the Medical Device Reporting Act when filing the Food and Drug Administration MED-WATCH Forms (3500). 5. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the Director of Nursing Services within 24 hours of the incident or accident. 6. The Director of Nursing shall ensure that the Administrator receives a copy of the Report of Incident/ Accident form for each occurrence. 7. Incident/Accident reports will be reviewed by the Safety Committee for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities.