**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility investigation, medical records, interviews with facility staff and other pertinent documentation it was determined that the facility failed to 1) notify the physician when it was discovered on 10/14/19, that the side of the tip of Resident #72's penis was discolored (brownish in color) and had a white milky discharge; 2) to document that an assessment was done during the initial findings, which resulted in a delay in treatment, and 3) provide and implement a revised plan of care to meet the resident needs. This was true of 1 (Resident #72) of 45 residents reviewed as part of the annual survey. Based on the findings, on Thursday, October 31st, 2019 at 10:30 AM an Immediate Jeopardy was called related to the quality of care for Resident #72. The facility submitted a revised plan of action at 5:06 PM on 10/31/19 that was reviewed by the surveyors and the Office of Health Care Quality. The plan was accepted on, 10/31/19 at 5:25 PM, but the immediate jeopardy was not removed until 11/4/19 at 1:05 PM after the plan of correction was implemented. After removal of the immediate jeopardy, the deficient practice remained for 3 days with the potential for more than minimal harm and a scope and severity of a G. The findings include: According to the medical record Resident #72 was admitted to the facility in December 2018, with a diagnosis that included Diabetes Type 2, Diabetes Neuropathy, Sarcoidosis, Hypertension Degenerate Joint Disease, Chronic Bilateral Lower Extremity wounds, Obesity, Failure to thrive and Depression. According to the hospital Discharge summary dated [DATE], the resident was transferred to the facility for management of his/her Chronic Bilateral Lower Extremity wounds and rehabilitation services due to the resident's inability to care for him/herself in the community. Review of the resident medical record on 10/28/19 at 11:30 AM revealed a MOLST (Medical Orders for Life-Sustaining Treatment) dated 12/6/18, which indicated the following: (DNR) DO Not Resituate and (DNI) Do Not Intubate, do not transfer to the hospital, but treat with options available outside of the hospital and Do not perform any medical tests for diagnosis or treatment. On 10/10/19, the resident MOLST form was changed to transfer to the hospital for severe pain or severe symptoms that could not be controlled otherwise and only perform limited medical tests necessary for symptomatic treatment and comfort. On 10/14/19, BLE (Bilateral Lower Edema), Malnutrition/Kwashiorkor and Hallucinations were added to the resident diagnosis by the resident primary physician. Review of Resident #72's medical record on 10/28/19 at 11:30 AM, to investigate complaint MD00146497 revealed a concurrent review dated 10/15/19 at 3:03 AM, which noted the following: Geriatric Nursing Assistant (GNA) #8 reported to the 11 PM - 7 AM nurse, Licensed Practical Nurse (LPN) #9, about a condition on Resident's #72's penis. Both employees entered Resident's #72's room and the area was assessed. During the assessment it was noted that the resident had a brownish milky discharge on the shaft of the penis with browning spots on the top of the penis. According to the medical record, LPN #9 cleansed the area with soap and water and attempted to contact the on-call physician at 12 AM but was unsuccessful. Review of the medical record on 10/30/19 at 3:30 pm revealed the labs were drawn on the 7-3 PM shift on 10/15/19. However, the results were not available to the facility until approximately 5:36 PM that night, after the end of LPN #19's shift. At that time LPN #26, who was the 3-11 PM nurse, notified the physician of the following critical lab values: Potassium (2.68) (CL) critical low reference range is 3.5-5.3 mEq/ L, BUN (113) (CL) reference range is 7-25 mg/dl. An order was obtained to send the resident out to the hospital. The resident was transported on 10/15/19 at approximately 6 PM by Emergency Medical Services for abnormal labs. In the emergency room, while a Foley was being placed by the nurse, the resident was noted to have necrosis at the tip of the penis. During the interview with the Director of Nursing (DON) on 10/29/19 at 11:30 AM, s/he revealed the following: at 3:03 AM on 10/15/19, [GNA #8] reported to [LPN #9] about a condition on the resident's penis. Both employees entered the room and [Resident #72's] penis was assessed. During the assessment, it was reported they observed brownish milky discharge on the shaft of the penis. The area was cleansed secondary to a resident having a bowel movement and was further evaluated with browning spots on the top of the penis and whitish discharge on the shaft. The DON continued the interview by stating that LPN #9 reported she initiated a concurrent review for a change in condition on 10/15/19 at approximately 3 AM. LPN #9 had intended to report the change in condition in the morning at 6 am to the doctor. During the report to LPN #19, who was the 7-3 PM nurse, LPN #9 informed LPN #19 of Resident #72's change in condition to the penis, then LPN #19 informed LPN #9 that the resident's primary care physician was scheduled to visit during the 7 am- 3 PM shift on 10/15/19, and she would inform the doctor. The DON stated she had no knowledge of the resident having necrosis or any wounds on the penis. She stated according to the facility policy the nurse is to fill out a concurrent review form and once the concurrent review is locked in the electronic medical record, the form would automatically generate to her as an incident. However, the concurrent review was never locked in the electronic medical record by the nurse, so she had no knowledge of the incident until questioned by the surveyor. During the interview with Resident #72's primary physician, Physician #18, on 10/29/19 at 12:45 PM, she stated, On 10/14/19 I was in to see the resident due to a change in physician care. The resident appeared malnourished and the following labs were ordered: CMP, CBC with diff, prealbumin, Vit D, Vit B12, folate, and HgA1C. The labs were ordered to be drawn on 10/15/19. Also, a psych consult was ordered due to hallucinations and depression. I was not informed about the penis that was discovered at the facility. During my assessment on 10/14/19, the resident was noted with 3 plus edema from the top of the hip to the lower extremities. I was made aware by the nurse the resident was only consuming soda and sweets. Retracting the foreskin and examining the penis is not a part of my normal assessment unless the resident expresses concerns. During the interview, Resident #72's physician gave the opinion that penile necrosis could develop quickly and worsen in hours depending on the cause of the necrosis. She stated that this resident was also malnourished and had 3+ pitting edema which could have also precipitated the necrosis. The physician reported, this was the one and only time she had seen the resident. After a discussion with Physician #18 regarding the condition of the penis, the physician stated, If I had known, I would have sent the resident out to the hospital. During an interview with GNA #8, at 5:40 AM on 10/30/19, he stated, around 7:30 PM to 8:00 PM on 10/14/19 during PM care of [Resident #72], I noticed the resident had a discoloration on the penis after pulling back the foreskin. I notified the 3-11 PM nurse, [LPN #22] about the area on the penis and she replied: 'I am not familiar with the resident and I'll check it out.' I heard no additional information about this resident during the 3-11 PM shift, and nor did I see [LPN #22] do an assessment. I worked a double on 10/14/19 3-11 PM shift on unit 1 and 11-7 AM on unit 2. When the 11-7 AM nurse [LPN #9] came in for the 11-7 AM shift and asked that I help out with another resident, I then made [LPN #9] aware of [Residents #72's] area on the penis and asked if I could show it to her. I went to another nurse because the previous nurse, [LPN #22], had said she wasn't familiar with that resident and I hadn't heard an outcome on the skin issue yet. [LPN #9] and I both went into the resident's room to assess the penis and the resident was soiled. After assisting the resident, I returned to the other unit where I was scheduled and finished my shift. During an interview with LPN #9, on 10/30/19 at 6:05 AM, the following was said: I came in on the 11-7 AM shift on 10/14/19. I was not notified that there was a problem with [Resident #72's] penis at the change of shift from [LPN #22]. Immediately, Resident in 106 reported that someone was knocking at his/her window. I called unit 2 to ask for assistance from [GNA #8] (for safety). When he was over with me, he asked me if he could show me something. I was confused because he was not working on Unit 1 at that time. I accompanied him to [Resident #72's room]. [GNA # 8] then pulled back the foreskin and showed me the resident's penis. It was horrible. We cleaned the resident up s/he was soiled, and [GNA, #8] went back to the unit. Early in the shift, I attempted to contact the on-call physician who did not respond. This was around 12:00 AM on 10/15/19. Around 2:30 AM, I requested [GNA #8] to accompany me back to the residents' room. We then removed the diaper and I soaked the penis to see if the dark area on the tip of the penis was possibly dried stool. It was noted to have white patches and black skin on the side of the tip. At that time, the resident complained of pain and was medicated with Tylenol. I created a concurrent review of the penis at the time. At 6:00 AM I reported to the oncoming nurse [LPN #19] that I had attempted to notify the physician during the night shift however never received a callback. She stated that the resident physician was due to come in to see the resident and she would notify the physician at that time. I left the concurrent review unlocked so after the physician was notified the time of notification could be entered to that review. When I returned to work on 10/15/19, 11-7 AM shift, I went to see [Resident #72] and noted that s/he was not in the room. I asked the 3-11 PM nurse [LPN# 26] what had happened with the resident, and she stated that his/her labs were critical, and s/he was sent to the hospital. I asked, what about his/her penis? She stated she didn't know anything about it. During an interview with LPN #22 on 10/30/19 at 9 AM, she stated I had a resident that was on hospice that was not doing well on the evening of 10/14/19. I don't remember being told of any issues regarding [Resident #72's] penis by the GNA. When asked by the surveyor, are you saying the GNA did not inform you of an area on the resident penis? The LPN #22 responded, I am not saying I was not told; I am saying I don't remember. During an interview with LPN #19, which took place on 10/30/19 at 2:30 PM, she stated that the 11-7 AM nurse LPN # 9 made her aware of the penis's condition. However, she was so busy trying to get the resident out due to abnormal lab values that she forgot to tell the physician about it. The resident was transferred to the hospital and admitted for critical labs and wound treatment on 10/15/19. The Director of Nursing stated, LPN #22 was terminated due to failure to report a change in condition to the physician when the condition was initially identified on 10/14/19 and due to the omission of documentation in the medical record. Upon further investigation, the decision was made to suspend LPN #19 for failure to report a change in condition to the physician when the condition was reported to her on 10/15/19 and due to the omission of documentation in the medical record. The facility was notified on 10/30/19, by the hospital Social Worker, that the resident would not be returning to the facility. On 10/31/19 the facility submitted an initial plan of action to the surveyors and the Office of Health Care Quality for review at 1:00 PM. This initial plan was not accepted. Revised plans were submitted on 10/31/19 at 2:17 PM, 3:20 PM and 3:30 pm which were not accepted. The facility submitted a revised plan of action at 5:06 PM on 10/31/19 that was reviewed by the surveyors and the Office of Health Care Quality. The plan was accepted on, 10/31/19 at 5:25 PM, but the immediate jeopardy was not removed until 11/4/19 at 1:05 PM after the plan of correction was implemented. The Immediate Jeopardy Abatement Plan included: Identification of Others: Unit manager to complete a facility skin sweep of current residents by use of skin check sheet to identify any skin alterations. Skin alterations that are documented on the audit will be addressed to ensure new orders/treatments as appropriate with care plan updates and documentation in the resident's medical record. All current residents' weekly skin evaluations will be audited weekly to ensure completion and ensure that Utilized Date Assessment (UDA) is completed. All Nursing staff to complete competency of questions (separate competency for Licensed Nurses and for Geriatric Nursing Assistants) on how to perform perineal care for residents, notification of a change in condition by 11/4/19. DON/Unit managers/Supervisors will complete a weekly audit of residents for four weeks to ensure that perineal care is completed and documentation if any skin alteration is noted. DON will complete audit of progress notes for the last 30 days to evaluate for residents with a change in condition to validate that notification of change was communicated to the MD, treatment plan was implemented and plan of care is reviewed and/or revised and documented in the resident's medical record. Education: DON /Unit managers/Staff Development coordinator to educate nursing staff on the policy for providing perineal care for residents. Began 10/22/19-11/4/19 DON /Staff Development Coordinator/Unit managers to educate Licensed Nurses on the process for completion of weekly skin evaluation and documentation. Began 10/22/19-11/4/19 DON/Staff Development Coordinator to educate nursing staff on policy for notification of a change in condition for residents to MD and RP, chain of notification to the physician, documentation in the resident medical record and review and revision of the resident plan of care. Began 10/22/19 -11/4/19 DON/Unit manager to educate Geriatric Nursing Assistant on completing a change in condition alert and providing the alerts of concern to DON/ Unit Manager/Executive Director. Began 10/22/19 -11/4/19 Executive Director to educate facility staff on Integrity and use of Action line: 10/30//19-11/4/19. System Change: When a resident is admitted /readmitted to the facility, the Licensed Nurse will be required to complete an evaluation for skin alteration. (For male residents, an evaluation of the penis will be required. The foreskin of the penis for an uncircumcised resident will be retracted to evaluate for any noted skin alteration.) If an alteration is noted, the Licensed Nurse must notify the physician of the change of condition and complete the documentation in the medical record and care plan implementation or updated as needed. Unit managers and/or Nursing supervisors and/or Wound Nurse will complete a second-day skin evaluation of residents that are admitted /readmitted to assess for skin alteration and notify resident physician, implement a treatment plan, complete appropriate documentation in the medical record and review and revise residents' plan of care if applicable. When a change of condition with a resident is observed by the Geriatric Nursing Assistant, he or she will notify the Licensed Charge Nurse and/or Wound Nurse for change in condition related to skin alteration. The Geriatric Nursing Assistant will complete a Stop and Watch Form for the resident observed with a change in condition and submit to the DON. When a change of condition is identified by facility staff, a concurrent review will be completed by the Licensed Charge Nurse. MD and RP will be notified, and the concurrent review will be locked prior to the end of the shift. Licensed Nurses will be required to document the change in condition in the 24-hour report for appropriate follow-up on every shift. The DON will review and follow-up to ensure the care plan is reviewed and revised daily x 4 weeks, then monthly x 3 months and then on an ongoing basis. If a resident refuses assessment, MD (and RP as appropriate) will be notified. Refusal will be carefully planned with the resident's reason for refusal. Every effort will be made to respect resident privacy during assessment. If resident refuses, resident choice care plan will be initiated. Licensed Nurse will make a second attempt to assess within 24 hours. Refusals will be evaluated by DON/Unit Managers daily x 4 weeks, then monthly x 3 months and then on an ongoing basis. Monitoring: Unit Managers/Nursing supervisor will audit daily x 7 days, and then weekly for 4 weeks and then monthly x 3 months all residents to evaluate for any skin alteration (For male residents, an evaluation of the penis will be required. The foreskin of the penis for an uncircumcised resident will be retracted to evaluate for any noted skin alteration). Audits will be reviewed at QAPI monthly x 3 months. Once it has been determined that enhanced system interventions and monitoring have been made, the frequency of the auditing process will be determined. Quality Assurance Nurse/DON will audit weekly skin evaluations to ensure that they are triggered and completed weekly x 4 weeks and then monthly x 3 months. Audits will be reviewed at QAPI monthly x 3 months. Once it has been determined that enhanced system interventions and monitoring have been made, the frequency of the auditing process will be determined. QA Nurse/DON will audit progress notes for residents' concerns of skin alterations, notification of change to the physician, documentation in the medical record and care plan reviewed and updated, daily x 7 days, then weekly x 4 weeks, then monthly x 3 months. Audits will be reviewed at QAPI monthly x 3 months. Once it has been determined that enhanced system interventions and monitoring have been made, the frequency of the auditing process will be determined. If a resident refuses assessment, MD (and RP as appropriate) will be notified. Refusal will be carefully planned with the resident's reason for refusal. Every effort will be made to respect resident privacy during assessment. If resident refuses, resident choice care plan will be initiated. Licensed Nurse will make a second attempt to assess within 24 hours.