**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, it was determined the facility failed to notify the physician and the resident's responsible party when there was a change in condition for one (1) of sixteen (16) sampled residents, Resident #47. Resident #47 developed a fever, had complaints of pain, fell, and was transferred to the Emergency Room; however, the facility did not notify the physician or responsible party of the incidents. The findings include: Review of the facility's policy, Acute Condition Changes (ACC)-Clinical Protocol, revised October 2010, revealed staff was to call the attending physician or on call physician with an identified ACC, and were to include current symptoms and status of the resident. The staff was to report to the physician possible causes related to the current symptoms or known test results. If lab results were not available, the facility and physician were to determine if an order for diagnostic tests were indicated. Further review revealed an ACC could be managed effectively in the facility with outcomes comparable to those who were hospitalized . The physician, after review of the reported ACC, would determine and authorize the appropriate treatment for the resident. Review of the facility's policy, Charting and Documenting, dated April 2008, revealed staff was to document notification of family, physician, or staff. Review of the facility's policy, Making an Emergency Transfer or Discharge, revised April 2007, revealed when an emergency transfer was initiated, the facility was to notify the resident's physician and notify the resident's representative/responsible party. Review of Resident #47's clinical record revealed the facility readmitted the resident after a hospital stay on 11/30/18, with diagnoses of a Urinary Tract Infection (UTI), Chronic Kidney Disease, and Dementia. Review of Resident #47's Nurses' Note, dated 11/17/18 at 5:42 AM, revealed Licensed Practical Nurse (LPN) #7 documented the resident complained of bladder pain while holding his/her lower abdomen. LPN #7 documented the responsible party was notified; however, did not notify the physician. A urine sample was obtained and the results faxed to the physician. Review of Nurses' Notes, dated 11/20/18 at 11:32 AM, revealed LPN #4 documented the resident complained he/she felt cold and the oral temperature was 101.2 degrees Fahrenheit (F). LPN #4 did not document physician or responsible party notification regarding the elevated temperature. Review of Nurses' Notes, dated 11/21/18 at 4:04 AM, revealed LPN #5 documented the resident complained he/she felt cold and the oral temperature was 100.5 F. There was no documentation the physician or responsible party was notified of the abnormal temperature. At 5:06 AM, the nursing note stated LPN #5 found the resident on the floor and the resident had a fever and felt un-well. LPN #5 did not document she notified the physician. At 4:10 PM, LPN #4 noted the resident was given Acetaminophen (Tylenol-for fever reduction) rectally because the resident's temperature was 102 F. LPN #4 did not document she notified the physician or responsible party about the resident's abnormal temperature. Continued review of Nursing Notations, revealed at 2:35 PM, LPN #6 noted the resident's temperature was 101.7 F, and the family was aware; however, there was no documentation the physician was notified. Review of Nurses' Notes, dated 11/23/18 at 1:22 AM, revealed LPN #7 documented the resident's temperature was 102.6 F, the resident had yelled out I'm hot, I'm cold, and I am so sick, and had dry heaves. The physician was notified of condition and ordered if there was no change in status to send to the emergency room (ER) for evaluation and treatment. There was no documentation the responsible party was notified. Review of Nurses' Notes, dated 11/26/18 at 1:30 AM, revealed LPN #7 found Resident #47 on the floor on his/her back. The resident said he/she was engaged in a conversation with someone in the room, became distracted, and fell. The physician was notified and x-rays were ordered for the pelvic region. Documentation revealed the responsible party was not notified and was to be notified in the morning. At 5:34 AM, LPN #7 sent the resident to the ER related to complaints of increased pain at his/her pelvic region. LPN #7 did not document the order to send the resident to the ER, nor document notification to the physician or responsible party. The facility could not provide an order to transfer Resident #47 to the ER on [DATE]. Interview with LPN #4, on 03/29/18 at 9:31 AM, revealed staff was to call the physician and responsible party immediately when there were changes in a resident's condition. She stated the facility protocol for fevers was utilized when residents presented with a fever and the as needed (PRN) medications were to be administered as ordered, the resident was to be monitored every four (4) hours, and by the end of the day, the physician was called if the fever or condition did not improve. LPN #4 stated she used her judgement as to when to call the physician for fevers, and when a resident presented with a fever of 102 F or 103 F, and the PRN medication for fevers was effective, she would not call the physician. LPN #4 further stated the facility and physician did not identify parameters for temperatures of when to notify the physician or responsible party, and she would not call a family in the middle of the night. The physician was to be called for changes in condition; however, she had not received in report regarding a fever with Resident #47. Per interview, everyone was responsible for the residents' welfare, which included notifications and failure to notify the physician could result in the resident's condition to worsen and become septic (severe infection) due to the fragility of the residents. She stated the facility did not provide in-services on notifications or changes in resident condition. Interview with LPN #3, on 03/29/19 at 10:04 AM, revealed the physician was the Medical Director and the facility phone conferenced with the physician twice a day for updates on residents, and the times were prescheduled in the late morning and afternoon. LPN #3 stated the Unit Manager (UM), Assistant Director of Nursing (ADON), and the Director of Nursing (DON) were to have the phone conference and they learned about resident needs through shift report or when rounds were made. She stated if the information was not passed along in report, then she was unsure how the physician was notified of changes. She stated when the UM, ADON, or DON conference call was completed, the facility was to document in the residents chart of the notification since it's the facility decision to only have two (2) conference calls a day with the physician. According to the LPN, the physician was to be notified of resident changes and if the issue were an emergency, the facility would call immediately; however, she did not consider a 102 F temperature an emergency. She would not call the family at night for a fever and was unsure if the next shift would know to notify the family of the change of condition. Per interview, delayed notification could result in the resident to further decline, and with elderly, it did not take much for decline to occur. She continued and stated she would be very upset if the facility did not call her with a fever or change of condition for her family member. Interview with the UM, on 3/29/19 at 10:24 AM, revealed the person on call was to receive report from the units as to condition changes and resident needs. She stated the Medical Director, who was Resident #47's physician, completed a conference call twice a day to discuss lab results, needs, and illnesses that could wait. After the phone conference, orders were placed on an order sheet and given to staff. She stated she documented in the chart after the phone conference but was unsure about what the others did after the phone conferences. According to the UM, the facility did not have protocols for vital sign parameters and when to call the physician or family as it has not been a previous issue. The UM stated staff was to notify the physician in emergency events or incidents, and notify the family when a resident was sent out of the facility. She stated it was the nurse on duty's responsibility to notify the physician and family as soon as possible, and if not done, it would be very stressful to the resident and family. Interview with LPN #7, on 03/29/19 at 12:08 PM, revealed the physician and family were to be notified with conditions that were out of normal range for a resident. However, she stated physician notification depended on the situation because the Medical Director was notified twice a day, unless it was an emergency. She stated when Resident #47 complained of bladder pain, she obtained and completed a urine dip to see if there was in infection. She stated she faxed the results over to the physician's office but did not see any new orders when she returned the next day. She was assigned to Resident #43 when the resident fell and resulted in the transfer to the ER. She stated Resident #47 refused immediate transfer to the ER and she called the physician and obtained an order for a mobile x-ray of the resident's pelvis region. However, the resident complained of increased hip pain and she used her discretion to send Resident #47 to the ER because of the intensity of the pain. LPN #7 stated she sent the physician a notice of transfer through the electronic system and the physician was not contacted. Per interview, staff was to notify the physician of condition changes as well as the responsible party immediately and delay in notification could allow the resident to become ill and get hurt. Interview with Family #5, on 03/29/19 at 12:43 PM, revealed the facility did not notify her of Resident #47's multiple events in November 2018. She stated she found out Resident #47 was transferred to the ER when the ER called her to see if she was on her way to be with the resident. She stated she was very upset and angry and stated the DON apologized for the failure to notify her; however, it did not fix the issue of continued lack of communication by the facility. Interview with the Medical Director, on 03/29/19 at 2:02 PM, revealed he could not remember if the facility notified him of Resident #47's temperature fluctuations. However, he stated he would have ordered tests for a temperature of 102 F and if orders did not reflect this or documented, then he was not notified. He stated he was not notified of Resident #47's transfer to the ER until later in the day during the scheduled phone conferences he held with the facility. He stated he expected the facility to notify him of changes of conditions with any resident. Interview with the ADON, on 03/29/19 2:20 PM, revealed in the morning, the administrative staff gathered new orders, reviewed nurses' notes, the on-call phone notification, and the nurse who was on call reviewed changes and/or needs of residents with the Medical Director during phone conferences twice a day. She stated the facility's vital sign protocols did not include parameters, and the physician set parameters for notification. The ADON further stated acute changes of condition, and falls were a cause of an immediate notification to the physician and the facility was to notify the responsible party of a change of condition, fall, or transfer to an ER. She stated the responsible party was the voice of the residents who could not make choices or decisions on their own, and it was policy to notify the responsible party of changes in condition. She further stated it could affect the resident physically with a delay of treatment and emotionally if the family was unaware of changes which effected the resident's health. She stated the facility in-services did not include notification or changes of condition assessments and notification. Interview with the DON, on 03/29/19 at 2:46 PM, revealed the nurse was to identify changes of condition and notify the physician and responsible party. She stated immediate notification to the physician included increased confusion and fever. The facility did not have a policy or parameters for when to call the physician for vital signs, only when the physician wrote orders for parameters for notification, which were usually for blood pressure. The DON further stated if a resident's temperature was above 101.5, staff should notify the physician and responsible party. She revealed she instructed LPN #7 to call the responsible party when Resident #47 was transferred to the ER; however, LPN #7 did not complete the notification. When she interviewed LPN #7 with the complaint from the responsible party, LPN #7 said she forgot to notify the responsible party. She further stated the nurses were to notify the physician and responsible party at the time the change in condition, or transfer, occurred as it could affect whether the resident received appropriate and timely treatment. She continued to state she audited staff notification with daily review of the residents' clinical records. Interview with the Administrator, on 03/29/19 at 3:10 PM, revealed the facility identified one or two isolated incidents of failure to notify the physician or responsible party, but not as a facility wide issue. He stated the facility reviewed clinical records every day when there was a reported or written documentation of a fall, change of condition, or resident need to ensure the process was completed correctly. The Administrator further stated he was responsible for the facility and the care the residents received while under the facility's care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, facility policy review, and review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) User's Manual, it was determined the facility failed to develop a care plan for two (2) of sixteen (16) sampled residents, Residents #5 and #47. Resident #47 was diagnosed and treated for a Urinary Tract Infection (UTI) on 11/23/18. The resident was sent to the hospital on [DATE] and re-admitted to the facility on [DATE], with diagnosis of a UTI; however, the facility did not develop a care plan for the UTI when it was first diagnosed at the facility, nor when the resident was re-admitted on [DATE]. In addition, the facility failed to develop a care plan for Resident #5's restraint. The findings included: Review of the facility's policy, Care Plans-Comprehensive, revised October 2010, revealed areas of concern were to be added to the resident's care plan. Based on thorough assessment, the Minimum Data Set (MDS) team was to ensure the resident's focus, goals, and interventions were individualized for the resident with the needs. Identification and development of the care plan was obtained from consideration of the resident's identified problems and conditions. The facility was to have interventions, which addressed the underlying source of the problem, and to focus the intervention on the symptoms or triggers. The Interdisciplinary Team (IDT) was to re-evaluate the resident's care plan after re-admission to ensure new diagnoses or care needs were addressed or added. Review of the facility's policy, Goals and Objectives, Care Plans, revised April 2011, revealed care plans were to include goals and objectives, and were to define desired outcomes for resident problems. Care plan goals and interventions were identified so facility staff were able to have access to the information and were able to report if the desired outcomes were not achieved. The facility goals and interventions were revised after the initial care plan when desired outcomes were not achieved. Review of the facility's policy, Using the Care Plan, revised August 2006, revealed the resident care plans were used to assess, care, and re-evaluate the resident care needs. 1. Review of Resident #47's clinical record revealed the resident was diagnosed with a UTI on 11/23/18, and ordered an antibiotic for treatment. On 11/26/18, the facility transferred the resident to the hospital after a fall and the facility re-admitted the resident on 11/30/18, with diagnoses of UTI, Pneumonia, and Falls. Review of Resident #47's Significant Change MDS, dated [DATE], revealed the resident had a diagnosis of UTI. Review of Resident #47's Nurses' Notes, dated 11/17/18 at 5:42 AM, revealed the resident complained of bladder pain and held his/her area of the lower abdomen. However, review of Resident #47's care plan revealed no evidence the facility developed a care plan with identified concerns, problems or conditions related to the resident's bladder pain. Review of Urinalysis Results, dated 11/22/18 at 9:16 PM, revealed Resident #47 had cloudy urine; specific gravity was marked abnormal with 1.010, abnormal presence of blood and abnormal protein presence in the urine. There was abnormal presence of Leukocytes (cells present with infections), abnormal Urine Red Blood Cells (URBC) and Urine [NAME] Blood Cells (UWBC), and abnormal high presence of bacteria in the urine. The facility faxed the results to the provider on 11/22/18, as noted on the lab result page. However, with this knowledge the facility did not develop a plan of care for Resident #47, related to the identified UTI. Further review of Resident #47's nursing documentation, revealed on 11/23/18 at 1:22 AM, staff reported Resident #47 was unable to walk from the bathroom and the resident stated he/she was hot, was cold, and very sick. Nursing staff assessed the resident to have a temperature of 102.6 with a pulse rate of 123 beats per minute. The resident also had dry heaves. The facility notified the physician of Resident #47's condition, as well of the lab results at this time. Licensed Practical Nurse (LPN) #7 noted the physician ordered antibiotics and if there was no change in status to send to the emergency room (ER) for evaluation and treatment. However, the facility did not develop a plan of care after receiving orders and direction from the physician regarding Resident #47's identified UTI. Review of Resident #47's Urine Culture, dated 11/25/19 at 8:03 AM, revealed Escherichia Coli (E Coli - bacteria found in the intestines) was found in the urine when cultured. After the facility obtained the urine culture test results, continued record review revealed the facility did not develop a plan of care that directed staff in the care of the resident with a UTI. Review of Nurses' Notes, dated 11/26/18 at 1:30 AM, revealed Resident #47 was found on the floor and on his/her back and stated to LPN #7 he/she was engaged in a conversation with someone in the room, became distracted, and fell. The resident was assessed and had a skin tear to the back of the right arm. The physician was notified with orders received for a mobile x-ray. The resident was reeducated to use the call light and not to get up without assistance and staff provided additional fall mats to the bedside. At 5:34 AM, LPN #7 sent the resident to the ER related to the resident's complaint of increased hip pain. Interview with LPN #3, on 03/29/19 at 10:04 AM, revealed staff utilized care plans in order to care for residents correctly. She stated care plans were to be up to date, and should reflect a resident's condition and needs. She stated the nurse administration and MDS team reviewed the care plans. The LPN further stated the care plan was be accurate within at least a week of a resident's re-admission. Interview with the Unit Manager, on 03/29/19 at 10:24 AM, revealed the MDS team developed care plans and updated them quarterly, with change of condition, and as needed. She stated care plans for UTIs, were generated and placed on the care plan, when UTIs were chronic. The Unit Manager stated she did not randomly review care plans, but MDS completed a review during care plan meetings. Interview with the Director of Nursing (DON), on 03/29/19 at 2:46 PM, revealed care plans were reviewed when a significant change occurred, with a new diagnosis or condition, and with quarterly reviews by the MDS team. She stated after a care plan meeting, the resident's care plan was reviewed. She stated Resident #47's UTI was not a chronic condition so therefore, was not identified as a problem. She stated it was everyone's responsibly to ensure resident care plans were accurate and reflected resident needs, which included active and potential issues. Interview with the Administrator, on 03/29/19 at 3:10 PM, revealed the facility reviewed resident care plans during the IDT morning meetings for admissions, readmission, and changes in conditions. He stated the resident care plan would be reviewed by MDS in the IDT meetings and new interventions or problems were added to the care plans. He stated the resident care plans were updated on a constant basis. He further stated the care plan process and reviews were discussed in the Quality Assurance and Performance Improvement (QAPI) meetings and issues were not identified. 2. Review of the CMS RAI User's Manual, dated 10/01/18, Chapter 3, Section P: Restraints and Alarms, revealed the definition of a restraint was any manual, physical, or mechanical device adjacent to the resident's body which the resident could not remove easily, and restricted freedom of movement or normal access to their body. Further review revealed when the facility used a restraint, care plans were to focus on the prevention of adverse effects of the physical restraint. Review of the facility's policy, Restraints, dated 07/01/12, revealed it was the facility's belief residents had the right to be free from physical restraints. However, if a resident developed medical symptoms that placed the resident at risk of harm to self or others, and restraint alternatives had been unsuccessful, the resident's physician and staff would assess whether a restraint would be helpful and the physician would order the least restrictive restraint. The policy further stated the restraint would be discontinued as soon as the resident's condition no longer required the intervention. Review of Resident #5's clinical record revealed the facility admitted the resident on 08/16/18, with diagnoses of Dementia, Ataxia, and Muscle Weakness. Review of Resident #5's Quarterly MDS, dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15) and determined the resident was not interviewable. The facility determined the resident received extensive assistance of two (2) for transfers, walking, toileting, and personal hygiene. The facility used a chair alarm and a wander/elopement alarm on the resident daily. Review of an Occupational Therapy Order, dated 12/13/18, revealed the resident was provided a full lap tray for the wheelchair. Review of Resident #5's Physician Orders, dated 01/06/19, revealed the facility was to provide the resident with a full lap tray for the resident's wheelchair per Occupational Therapy. Review of the facility's Safety Device Assessment, dated 12/17/18, revealed Resident #5 was assessed related to use of a full lap tray when up in the wheelchair, and the facility determined the device restricted the resident's access to his/her body, and restricted the resident's freedom of movement. In addition, the facility determined the resident was cognitively aware of the device, able to remove it on command, and determined the device was not a restraint. However, observations of Resident #5, on 03/26/19 at 3:36 PM, 03/28/19 at 1:32 PM, and 03/29/19 at 9:19 AM, revealed the resident in a wheelchair with a full lap tray in front of the resident, attached to the wheelchair. The resident attempted to remove the lap tray on command and was physically unable to, and did not demonstrate understanding of the way the lap tray attached to the wheelchair. Observation, on 03/28/19 at 4:07 PM, revealed Registered Nurse (RN) #3 was speaking to Resident #5 in the resident's room. The resident was sitting in his/her wheelchair with the lap tray in front of him/her and the RN asked the resident to remove the lap tray. The resident pushed on the lap tray but was unable to remove it from the wheelchair. Review of Resident #5's Care Plan, dated 06/25/18, revealed the resident was at risk for injury related to falls with an intervention for a full lap tray, which was undated. However, a restraint care plan was not developed related to the resident's inability to remove the lap tray from his/her wheelchair. Interview, on 03/28/19 at 4:08 PM, with RN #3 revealed there was no order for checking Resident #5's lap tray every shift to ensure it was safe and was not restricting the resident's movement. The RN further stated the facility intended to be a restraint free facility, and nursing administration was responsible for ensuring the devices the facility used on residents were not restraints. According to the RN, when she asked Resident #5 to remove the lap tray from the wheelchair, the resident was not able to remove the tray on command. The RN stated the resident understood what the RN was asking him/her to do, tried to move the lap tray, but was unable to remove it successfully. Per interview, in the past she had seen Resident #5 shake the tray but had not seen him/her remove the tray, and she further stated, by definition the full lap tray was a restraint because the resident was unable to remove it. Observation, on 03/29/19 at 10:55 AM, revealed Resident #5 in the therapy room and Occupational Therapist (OT) #1 placed a full lap tray on the resident's wheelchair and asked the resident to remove it. When the resident did not attempt to follow the OT's request, the OT instructed the resident to place his/her hands on tray and push. The resident demonstrated he/she had difficulty understanding the OT's request, and was physically unable to remove the lap tray from the wheelchair. Interview with OT #1, on 03/29/19 at 10:59 AM, revealed the facility placed a full lap tray on Resident #5's wheelchair after the resident fell out of the chair and other interventions had been ineffective. She stated the therapy department did not assess devices, including lab trays, for whether or not they were restraints, and it was the responsibility of the nursing department to complete restraint assessments and develop care plans for a device such as a full lap tray. The OT revealed the resident was not able to take the lap tray off the wheelchair, and the lap tray restricted the resident's access to his/her lower extremities. Interview, on 03/28/19 at 4:57 PM and 3/29/19 at 2:40 PM, with the MDS Coordinator revealed she collected information about restraints and used the information when completing the MDS assessments. However, she stated she did not recall receiving information a full lap tray was placed on Resident #5's wheelchair. She stated without the information, she would not have known to list the item under restraints on the upcoming MDS unless she noticed it on the resident and questioned nursing administration about the device. The MDS coordinator reviewed the Safety Device assessment dated [DATE], and stated the facility determined the full lap tray restricted the resident's access to his/her body and therefore, the lap tray was a restraint. The MDS Coordinator stated the facility should have initiated a restraint care plan with interventions including monitoring the resident for safety and increased agitation. The Coordinator revealed Resident #5 used to have a half lap tray, which he/she was able to remove, and it was on the care plan as a previous intervention which was changed to the full lap tray, which was not acceptable. Interview, on 03/29/19 at 4:18 PM, with the DON revealed when lap trays were put in place, ideally, residents should be able to remove them on command. She stated the facility used the Safety Device assessment to determine if a device, such as a lap tray was a restraint. A restraint was a device that the resident was not able to access their body or not able to remove the device. The DON reviewed the Safety Device assessment, dated 12/17/18, which noted the device restricted Resident #5's access his/her body and the DON validated the device was a restraint. She stated the facility should have developed a care plan for Resident #5's restraint for safety, which included checking the device and maintaining the resident's dignity while the restraint was in use. In addition, she stated the care plan should have included continued evaluation for least restrictive devices, and potential elimination of the device. Interview, on 03/29/19 at 5:22 PM, with the Administrator revealed the facility's goal was to have no restraints in the facility; however, he was aware there were some in use. He stated the Interdisciplinary Team was to determine if a device was a restraint and he was not aware of any devices the facility had not identified appropriately as restraints. In addition, he stated the facility should identify when a device became a restraint by observing residents using the devices. The Administrator further stated he relied on nursing staff to complete assessments and the DON should have been doing audits of restraints. In addition, he stated the facility was to develop care plans for restraints.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure timely care and services were provided to a resident to treat a Urinary Tract Infection (UTI) for one (1) of sixteen (16) sampled residents, Resident #47. Record review and interviews revealed on 11/17/18, Resident #47 complained of bladder pain, presented with a fever on multiple days, was noted to have increased confusion, and experienced falls. The resident was not evaluated for a UTI until 11/22/18, which resulted in the UTI to worsen and the resident experienced a fall and required hospitalization due to fractures from the fall. Resident #47 returned to the facility and was totally dependent on staff for care, when prior to the fall, the resident was independent. The findings include: Review of the facility's policy, Urinary Tract Infections/Bacteriuria/Clinical Protocol, revised October 2006, revealed signs and symptoms of a UTI were to be identified as soon as possible to begin treatment. Staff was to notify the Medical Director (MD) of residents who exhibited a fever. A fever was identified as over 100.4 degrees Fahrenheit (F). Continued review revealed in order for the facility and MD to make an empirical diagnosis of a UTI, three (3) symptoms were to be present which included a fever, supra pubic pain, and decreased mental or functional status. Notification to the MD of the presence of a fever with other identified complaints or findings was completed for the MD to interpret the signs and symptoms of a possible UTI and conclude the course and treatment for the resident's behalf. Review of the facility's policy, Acute Condition Changes (ACC) Clinical Protocol, revised date October 2010, revealed staff was to call MD, who attended to the care and services for the resident with the identified ACC, and were to include current symptoms and status. Lab results were to be reported to the MD when available. The MD was to determine and authorize appropriate treatment for the resident with the ACC notification. Further review revealed an ACC could be managed effectively in the facility with outcomes comparable to those who were hospitalized . Review of the facility's McGreer Pathway for Infection Surveillance, undated, revealed for a UTI without a catheter, two (2) criteria were to be present to consider surveillance for a UTI and included fever and supra pubic pain. A UTI was to be diagnosed with localized genitourinary symptoms, absence of a clear alternate source of infection with the presence of fevers, and acute confusion. The facility was to obtain a urine sample with MD order with the presented symptoms as a diagnostic tool. Review of the McGreer definition of fever, dated October 2012, revealed a fever was a temperature greater than 100.4 F and was consistent with the 2008 Infectious Disease of America (IDSA) guideline for the evaluation of fevers and infection with older adults in a Long Term Care facility. Review of the Resident #47's clinical record revealed the facility readmitted the resident on 11/30/18, with the diagnoses of Repeated Falls, UTI, and Dementia. Review of Resident #47's Annual Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with the Brief Interview for Mental Status (BIMS) score of twelve (12) of fifteen (15) and determined the resident interviewable. The facility determined Resident #47 required supervision with set up help for Bed Mobility, Transfers, Walking, Locomotion, Dressing, Eating, Toilet Use, and Personal Hygiene. Resident #47 was always continent of bladder and bowel. Further review revealed Resident #47 did not receive scheduled pain medication management and denied pain. Review of Resident # 47's Medication Administration Record (MAR), dated November 2018, revealed a physician order, dated 04/18/17, to give Acetaminophen (Tylenol) 650 milligram (mg) suppository every four (4) hours as needed (PRN) for a temperature greater than 100.0 F. Documentation revealed a dose was given on 11/20/18 at 11:35 AM and 11/22/18 at 4:10 PM. In addition, the MAR had an order, dated 04/30/18, for Tylenol 325 mg, give two (2) caplets by mouth every four (4) hours PRN for a temperature greater than 101.0 F. Documentation revealed Resident #47 received a dose, on 11/22/18 at 3:02 PM, for a temperature of 101.7 F, and again on 11/24/18 at 4:17 PM for a temperature of 100.2 F. Review of Resident #47's Nurses' Notes, dated 11/17/18 at 5:42 AM, revealed the resident complained of bladder pain and held his/her area of the lower abdomen. The resident reported the symptoms started several days prior to the notification. Nursing staff obtained a urine sample to perform a dipstick test (dipstick test is a basic diagnostic tool used to determine changes in a urine) and results revealed trace leukocytes and positive for nitrites (The dipstick test for nitrites is a rapid screening method for possible asymptomatic infections caused by nitrate-reducing bacteria. Some bacteria species that most commonly cause UTIs like Escherichia coli have enzymes that reduce the nitrate present in urine to nitrite). The results were faxed to the MD's office. Nursing staff noted follow-up was to occur next shift after report to day shift and nursing staff would continue to monitor the resident. Review of MAR Documentation, dated 11/18/19 at 7:58 PM, revealed the resident received two 325 mg caplets of Tylenol for complaints of abdominal pain. However, continued review of nursing note documentation did not reveal nursing staff monitored the resident for potential UTI symptoms, until 11/20/19. Nor did nursing staff follow-up regarding the faxed results sent to the MD's office regarding the urine dipstick results. Review of Nurses' Notes, dated 11/20/18 at 11:32 AM, revealed Resident #47 complained he/she felt cold and had an oral temperature of 101.2 F. Licensed Practical Nurse (LPN) #4 noted she administered medication to reduce the fever and would monitor the resident. Continued review of nursing notes revealed no resident assessment regarding previous reported bladder pain or other UTI signs or symptoms. Continued review revealed LPN #4 noted, at 2:26 PM on 11/20/19, the resident felt better and temperature was 98.3 degrees and nursing staff would continue to monitor, however, no further nursing assessments were documented as conducted on 11/20/19. Review of Nurses' Notes, dated 11/21/18 at 3:34 AM, revealed nursing staff observed the resident shaking and noted the resident's clothing and bed linen were wet with sweat. LPN # 5 noted the resident's clothes and bed linens were changed. LPN #5 documented the resident was afebrile and had previously received medication as ordered. At 4:04 AM, the resident complained he/she felt cold and had an oral temperature of 100.5 F, was shaking and continued to complain he/she felt cold. Continued review of Nurses' Notes for 11/21/18, revealed at 5:06 AM, LPN #5 found the resident on the floor. The resident had a fever and felt un-well and stated he/she was unsure what caused the fall. Vitals signs were assessed with a temperature of 99.5 F, and the pulse rate was 100 beats per minute (normal 60-100). At 4:10 PM, LPN #4 noted the resident was given Acetaminophen rectally because Resident #47's temperature was 102.0 F and previously vomited oral medication. Review of Nurses' Notes, dated 11/22/18 at 2:35 PM, revealed Resident #47's complained of a chill, headache, and stomach and body aches. The resident's temperature was 101.7 F. Staff administered medication for the fever, notified the responsible party, and monitored the resident. At 3:38 PM, the resident was found on the floor and he/she stated he/she attempted to get out of bed and lost his/her balance. The nurse noted the resident was sick and weak. The MD was notified and orders for a Flu test was obtained. Further review revealed the MD was notified at 4:48 PM of a negative Flu test. The MD ordered a Urinalysis (UA) with a Culture and Sensitivity (C&S) and to notify of the results. Review of Resident #47's UA Results, dated 11/22/18 at 9:16 PM, revealed the results were cloudy, specific gravity was marked abnormal with 1.010, abnormal presence of blood, abnormal protein presence in the urine, abnormal presence of Leukocytes (cells present with infections), abnormal Urine Red Blood Cells (URBC) and Urine [NAME] Blood Cells (UWBC), and abnormal high presence of bacteria in the urine. The results were faxed to the provider on 11/22/18, as noted on the lab result page. Review of Resident #47's Nurses' Notes, dated 11/23/18 at 1:22 AM, revealed staff reported to LPN #7 the resident was unable to walk from the bathroom and the resident stated he/she was hot, was cold, and very sick. The resident was assessed and his/her temperature was 102.6 F with a pulse rate of 123 beats per minute. The resident also had dry heaves. The MD was notified of his/her condition as well of the lab results at this time. LPN #7 noted the MD ordered antibiotics and if there was no change in status to send to the emergency room (ER) for evaluation and treatment. Review of Resident #47's Urine Culture, dated 11/25/19 at 8:03 AM, revealed Escherichia Coli (E Coli - bacteria found in the intestines) was found in the urine when cultured. Review of Nurses' Notes, dated 11/26/18 at 1:30 AM, revealed Resident #47 was found on the floor and on his/her back and stated to LPN #7 he/she was engaged in a conversation with someone in the room, became distracted, and fell. The resident was assessed and had a skin tear to the back of the right arm. The MD was notified with orders received for a mobile x-ray. The resident was reeducated to use the call light and not to get up without assistance and staff provided additional fall mats to the bedside. At 5:34 AM, LPN #7 sent the resident to the ER related to the resident's complaint of increased hip pain. Review of Resident #47's Hospital Discharge Summery, dated 11/30/18, revealed the resident was discharged with diagnoses of Pelvic Fracture of the right inferior and superior pubic rami, and a Fracture to the Acetabulum with a mechanical fall as the causative factor for the fractures. Resident #47 was also diagnosed with Left Lower Lobe (LLL) Pneumonia and Hypovolemia with Acute Kidney Injury. The resident was noted to have urine retention with the admission and when the resident was sent to the ER, he/she was under treatment for a UTI. Observations, on 03/27/19 at 11:00 AM and 03/28/19 at 2:30 PM, revealed Resident #47 was in his/her room in a Broda chair faced toward the window with eyes closed, and a position alarm clipped to his/her shoulder. Attempts to arouse the resident were unsuccessful. Interview with Family #5, on 03/29/19 at 12:43 PM, revealed prior to the UTI and fall, Resident #47 was completely independent with the exception of supervision and minimal assistance, was alert, active, and carried a conversation easily with the exception of memory issues. She stated after the late diagnosis of UTI, and with the subsequent fall that caused the fractures, Resident #47 required total assistance with the exception of self-feeding with oversight. Family #5 revealed the resident had multiple days of high fevers and she felt nothing was done to find the source of the fever. She stated the resident was in constant pain because the fractures were not healed and would not heal, and was more confused. Per interview, the resident was not a surgical candidate and therefore unable to walk as he/she was unable to bear weight. Interview with LPN #4, on 03/29/19 at 9:31 AM, revealed staff did not report fluctuations of fevers or previous reports of bladder pain for Resident #47. She stated the delay of notifying the MD of a resident's change in condition could result in the condition to worsen and later cause the resident to become septic due to the fragility of the residents. LPN #4 stated Resident #47 was independent and sociable before the fall, and was now dependent for all care and services, and received scheduled pain medication as the fracture to his/her hip area would not heal. Interview with LPN #3, on 03/29/19 at 10:04 AM, revealed the MD and facility set a daily schedule for phone conferences to discuss resident concerns, usually twice a day. She stated if there was an emergency, then the facility would call the MD immediately, but it had to be a true emergency and a fever was not considered an emergency. However, she was not sure fevers were relayed as a concern to the MD, and Resident #47 was not monitored for UTI symptoms and she was not previously aware of any complaints by the resident of bladder pain. The LPN stated when the facility obtained the UA after the MD was notified was the first time the topic of a UTI was mentioned. She stated Resident #47 was fully independent before he/she got sick, and now the resident was highly confused and fully dependent on staff. She stated the resident was unable to independently go to the bathroom and now used a brief. She stated the facility educated with annual online in-services on assessments of the residents and UTI signs and symptom; however, she was unaware of the McGreer pathway. Interview with LPN #7, on 03/29/19 at 12:08 PM, revealed when Resident #47 complained of bladder pain, she obtained a urine sampled and completed a urine dip to see if there was in infection, and faxed the results over to the MD's office. However, she did not follow-up if the information was reviewed or relayed to the MD. She stated fevers were not an emergency and she would not notify the MD in the middle of the night of a fever when she was able to provide medication to address the issue. She further stated she was unaware Resident #47 continued to exhibit fevers after the initial complaint of bladder pain but was aware the resident did not feel well. She continued to state she was not aware of the order to send the resident to the ER if the resident was not improved after the start of the antibiotic. She stated Resident #47 was ill from the UTI and was clearly weak when he/she presented on 11/23/18 as unable to walk back unaided from the bathroom. She stated the resident now, was either in bed or the chair because the resident could not walk and was fully dependent for all care areas. Interview with the MD, on 03/29/19 at 2:02 PM, revealed he was unsure if the facility notified him of Resident #47's temperature fluctuations or complaints of bladder pain. However, he stated he would have ordered tests for a temperatures above 100.5 F because a fever with an elderly resident usually meant an infection was present, and if the record did not reflect orders or notification, then he was not notified to request lab or treatments. He further stated the facility conducted twice a day phone conferences to discuss residents needs and concerns but he would want to be notified of a high fever after staff initially addressed the change of condition. The MD stated he did not set parameters for notification with vital signs unless it was indicated for medications; however, he stated it was standard care to call for temperatures, especially with multiple excessively high temperatures in an elderly resident. He further stated late treatment of an unknown source of a fever set a resident up to become septic. He stated Resident #47 was fully dependent on the nurses for his/her care needs now, and before the fall, the resident was independent. Interview with the Unit Manager (UM), on 03/29/19 at 10:24 AM, revealed the facility did not have protocols for vital sign parameters and when to call the MD, because it has not been an issue. She stated fevers were not considered an emergency and staff thought Resident #47 had a gastric virus, which was present in the facility and felt he/she was properly monitored. However, she was not aware the resident complained of bladder pain. She stated Resident #47 was independent with all areas and was very social prior to the fall and now the resident was completely dependent for all care needs, was unable to walk, and continued to decline. Interview with the Assistant Director of Nursing (ADON), on 03/29/19 at 2:20 PM, revealed the facility conducted twice a day phone conferences with the MD to discuss resident needs. She stated the facility vital sign protocols did not include parameters, and it was up to the MD to set vital sign parameters for notification. She stated the facility was aware of Resident #47's elevated temperatures but assumed the resident had been exposed to the gastric virus present in the facility. The MD was not notified of the high temperatures the resident experienced and she was unaware the resident presented earlier with complaints of bladder pain. She further stated delayed notification and care/services could affect the resident physically and affect the resident's health. She stated Resident #47 was an active resident and now was fully dependent on staff for all care needs, could not walk, was unable to socialize. Interview with the Director of Nursing (DON), on 03/29/19 at 2:46 PM, revealed the facility assumed Resident #47's fevers were associated with a gastric virus, which caused Resident #47's treatment delay and UTI to worsen. She revealed the facility used the McGreer Pathway for UTI care and services and the facility was responsible to ensure residents received the highest level of care while in the facility. Per interview, Resident #47 previously was up and about and was independent with minor oversight, and now was completely dependent on staff for all care needs, slept most of the time, was unable to walk, and was in constant pain. Interview with the Administrator, on 03/29/19 at 3:10 PM, revealed the facility was to ensure residents received timely care and services to manage symptoms and known diseases. He stated Resident #47 was up and about in the facility prior to the fall and now was totally dependent for all care needs. He stated the facility was responsible to meet all resident care needs and services.