Based on observations, interviews and record review, the facility failed to ensure timely and accurate physician notification of a significant change in a resident's status for one Resident (#24) out of a total sample of 39 residents. Specifically, for Resident #24, the facility failed to provide a covering Nurse Practitioner (NP) with complete and accurate information about a resident with coffee ground emesis and ongoing black stools, including but not limited to the Resident's significant history of bowel obstructions and Gastrointestinal (GI) bleeding, resulting in hospitalization and subsequent death. Findings Include: Review of facility policy titled Change in a Resident's Condition or Status, undated, indicated the following: -Our facility promptly notifies the resident, his or her attending physician and the resident representative of changes in the residents medical/ mental condition and or status. -The nurse will notify the resident's attending physician or physician on call when there has been a(an) significant change in the resident's physical/emotional/mental condition; need to transfer the resident to a hospital/ treatment center. -Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR (situation, background, assessment, recommendation) Communication Form. Resident #24 was admitted to the facility in December 2014 with diagnoses that include partial intestinal obstruction, muscle weakness, gastrointestinal hemorrhage, and iron deficiency anemia. Review of Resident #24's Minimum Data Set (MDS) Assessment, dated 8/19/24, indicated a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating that the Resident has moderate cognitive impairment. The MDS further indicated that the resident has medically complex conditions with a primary diagnosis of partial intestinal obstruction. On 11/4/24 at 8:36 A.M., a surveyor overheard Nurse #3 say thank you to Nurse #4 for sending Resident #24 to the hospital. During an interview on 11/4/24 at 8:42 A.M., Nurse #4 said to the surveyors that Resident #24 started vomiting on her shift, around 1:00 A.M., but at first the Resident did not want to go to the hospital. She said she called the Nurse Practitioner (NP), and she ordered labs and Zofran (a medication to treat nausea). When asked about the Resident's history, Nurse #4 said that he/she does have a history of a bowel obstruction as well as a recent fall on 11/1/24. Nurse #4 said that she did not provide a full report of Resident #24's medical history to the Nurse Practitioner that she spoke to at 1:00 A.M., and only gave report on the current situation, that the Resident was vomiting. During a follow up interview on 11/4/24 at 9:21 A.M., Nurse #4 said Resident #24 started vomiting between 1:00 A.M., and 2:00 A.M. and then again around 6:00 A.M. Nurse #4 said she called the covering practitioner again around 6:00 A.M. and was ordered to send the Resident out to the Emergency Room. Nurse #4 said Resident #24 was not agreeable to go to the hospital earlier in the morning, however said at this time the Resident agreed to be sent out. Nurse #4 said that she called for transport between 6:00 and 7:00 A.M. and was told that it would be about one to two hours before transport could be there. She said that the facility can call 911 for transfers but she felt like the Resident was stable and his/her vitals were stable. During a follow up interview on 11/6/24 at 7:45 A.M., Nurse #4 said that on the night before Resident #24 was sent out it was around 1:00 A.M. that the Resident began vomiting. She said that it was coffee ground. She said that as soon as she could, she called the NP. She said that she told the NP the Resident was vomiting but could not remember if she told her that it was coffee ground. She said she did not tell the NP about the history of obstructions or GI bleeding. She said that the NP ordered labs and Zofran for nausea. Nurse #4 said she called the NP again at 6:00 A.M., and an order was given to send the Resident to the hospital. During an interview on 11/4/24 at 8:45 A.M., Nurse #3 said that she arrived at the facility around 7:20 A.M. and was told in report that the resident had coffee ground emesis (vomiting) during the night. She said she went right into Resident #24's room when she got there, and he/she said they wanted to go to the hospital. At the time of the interview the ambulance company was picking up the Resident for transport to the hospital. Nurse #3 said that the Resident looks bad right now and said he/she looks pale and grey, and that the Resident also looked like that at 7:20 A.M. when she saw him/her. During an interview and observation on 11/4/24 at 8:48 A.M., the surveyor observed Resident #24 with black vomit on him/her. Resident #24 said that he/she knew what was happening was bad and that he/she wanted to go to the hospital and did not refuse to go earlier in the morning when the vomiting started. During a phone interview on 11/6/24 at 8:33 A.M. Certified Nurses Aid (CNA) #7 said that she worked over night on 11/3/24 into 11/4/24. CNA #7 said that Resident #24 was moving his/her bowels and vomiting all night long and that both the vomit and stool was liquid and black. CNA #7 said that she provided incontinence care at least five times over night for liquid black stools and that the vomiting was continuous all night and did not stop. CNA #7 said that she told the nurse. CNA #7 said that after the first time Resident #24 vomited he/she did not want to go to the hospital but that at around 3:00 A.M., Resident #24 said that he/she wanted to go to the hospital and after getting the Resident cleaned and changed again at that time, she told the nurse (Nurse #4) that the Resident wanted to go to the hospital. CNA #7 said that when her shift ended, and she left the facility around 7:15 A.M. and Resident #24 was still at the facility. Review of a progress note written by Nurse #4 on 11/4/24 at 8:52 A.M., indicated, at 1 AM Patient started vomiting, I informed NP [#2], and she gave order to do labs. CBC with diff and BMP. Patient refused to go to the hospital at this point. He/she said I want to wait. Around 6 AM, patient started vomiting again and I notified NP [#3], and she said send patient to hospital. Vital signs were bp [blood pressure] 107/77, pulse 66, O2 [oxygen saturation] 96%, temp [temperature] 98, resp [respirations] 18. HCP (health care proxy) was called and left a message. Further review of the nursing progress note written on 11/4/24 failed to indicate a comprehensive GI (gastrointestinal) assessment or abdominal assessment. Review of the Patient Care Report for Resident #24 from the Ambulance service dated 11/4/24 indicated that dispatched received the call from the facility for transfer to the hospital at 8:01 A.M. on 11/4/24. The Patient Care Report indicated that the chief complaint was general illness- GI bleed for 7 hours with a primary symptom of abdominal distension. The Patient care report further indicated that the ambulance was dispatched to the facility for a patient with incontractible vomiting. (sic) The BLS (basic life support) crew arrived at the patient at 8:39 A.M. and patient found lying supine in assigned bed with head elevated and several towels draped over him/her, coffee ground emesis noted on towel .Skin is pale, warm and dry. Significant distension noted on initial impression. The report further indicated, Nursing staff reported coffee ground emesis began at 1:00 A.M. that morning with 3 episodes . No vitals or assessments taken to provide EMS (emergency medical service) staff. Vital signs revealed hypotension with a blood pressure of 80/60 and weakened radial pulses. BLS crew called dispatch at 8:44 A.M. for ALS (advanced life support) secondary to hypotension and likely GI (gastrointestinal) bleed. In route to the hospital at 8:55 A.M. vital signs included a blood pressure of 70 systolically and a weak pulse of 180 beats per minute. During a follow up interview on 11/4/24 at 9:24 A.M., Nurse #3 said she did not call for the transport of Resident #24 to the hospital for evaluation but if she knew it was going to be one to two hours for the transport, she would have called 911 for a more emergent transfer. During a phone interview on 11/6/24 at 9:00 A.M., the surveyor spoke to Nurse Practitioner (NP) #1 who returned a phone call to the surveyor regarding when phone calls were placed into the call service to report the change in condition on Resident #24. NP #1 said that she was not the one who responded to the call, but the service got one call at 1:13 A.M. with a message stating the Resident was vomiting a lot. She said this is the only call that came into the service on the 11:00 P.M. to 7:00 A.M. shift. During an interview on 11/6/24 at 9:42 A.M., Nurse Practitioner (NP)#2 said she was the covering NP for the night of 11/3/24 into 11/4/24 and the only page she got from the facility for this Resident was at 1:13 A.M. and said she called the facility right away. NP #2 said the report she was given was that the Resident's vitals were stable, and the Resident had a lot of vomiting. The NP said it was never reported to her that he/she had coffee ground emesis or multiple loose dark stools. The NP said she was never given a report of the Resident's history or that the Resident had a recent unwitnessed fall. The NP said she would have sent him/her out right away if she was given an accurate report of Resident #24's status and his/her history. During an interview on 11/4/24 at 9:40 A.M., Nurse Practitioner (NP) #3 said that she was paged to call the facility around 7:56 A.M. and said that she called back right around 8:00 A.M. NP #3 said that with Resident #24's history she would have sent him out overnight but was not sure what the initial report was that was given to the covering NP. NP #3 said that if the nurse was given an estimated time of arrival of one to two hours, then 911 should have been called as this was a change in condition. Review of Resident #24's discharge summary from the hospital, dated 11/4/24 at 4:39 P.M., indicated a diagnosis of bowel obstruction and a reason for admission of Abdominal pain, with bowel obstruction and 1600-2000 milliliters (ml) of fecal material suctioned from NGT (nasogastric tube, a thin flexible tube that is passed through the nose and down through the esophagus into the stomach. It can be used to either remove substances from or add them to the stomach.) The discharge summary further indicated that Resident #24 had prior admissions for bowel obstructions including in May 2023, February 2024, May 2024, June 2024 and November 2024. Further, the report indicated that Resident #24 presented to the emergency department from his extended care facility with coffee ground emesis x3 and a report of some dark bowel movements. Resident #24's main complaint was abdominal discomfort, and his/her blood pressure was in the 70's according to the prehospital personnel. The discharge summary also indicated Patient underwent central line insertion for severe hypotension with Afib (atrial fibrillation- an irregular and often very rapid heart rhythm) with RVR (rapid ventricular rate) and on dilt drip (Diltiazem - a medicated intravenous solution used in adults to treat certain heart rhythm disorders such as atrial fibrillation or dangerously rapid heartbeats) with still uncontrolled heart rate and hypotension status post several liters of IV [intravenous] fluid resuscitation, in the setting of AKI (acute kidney injury) with possible pulmonary edema as well. He/she had a nasogastric tube inserted with approximately 2 liters of feculent material suctioned out immediately. CT (cat scan) of the abdomen and pelvis shows markedly distended stomach and proximal duodenum with markedly dilated loops of bowel and air-fluid levels, markedly dilated rectosigmoid. Review of Physical exam indicates an abdominal assessment with hypoactive/ absent bowel sounds, markedly distended abdomen, tenderness to palpation. Review of Nursing progress notes indicated the following: - A progress note dated 11/5/24 at 1:27 A.M., indicating, Patient came back from hospital on a 3-11p shift, earlier this nurse took report from the ED [emergency department] nurse stating that,' Patient had a bowel obstruction', this nurse asked the ED Nurse if patient had any surgeries to correct the obstruction, she said No, patient is coming back to the facility for comfort care admitted to Hospice. however, it is not stated in the Hospital visit, paperwork. Will F/u [follow up] with facility MD. Review of the nursing progress note dated 11/5/24 at 12:03 P.M., indicated the following: - At approximately 8:28 A.M., the resident was noted to be unresponsive. Resident did not respond to verbal or physical stimuli. There was no palpable pulse or visual chest rise/fall and no audible breath sounds. Time of death 8:29 A.M. Health care proxy notified, and body released to funeral home at 10:30 A.M. During an interview on 11/6/24 at 1:13 P.M., Physician #2 said that Resident #24 has a significant history of bowel obstructions and in the past has declined surgical interventions. Physician #2 said that there is a process issue in the facility in terms of communication with covering providers and ensuring that a full and accurate report is provided to the NP or covering providers on call. During an interview on 11/6/24 at 1:30 P.M. the Director of Nursing (DON) said that she didn't think it was necessary to provide a history about Resident #24's previous bowel obstructions because the Resident having coffee ground emesis was not an emergent situation. She said she would not have called the covering again at any point during the shift and wouldn't call again until the Resident was ready to go to the hospital. She said one policy regarding change in condition or transfers does not fit all, if it was something critical, she would have called again, but she said she did not take this as a critical situation. The DON said she talked to Nurse #4 who worked over night and that the Resident had only vomited 3 times. The DON said however, she had not spoken to CNA #7, who reported to the surveyor ongoing black vomiting and black stooling throughout the night.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to protect two Residents (#24 and #323), from neglect, out of a total sample of 39 residents. Specifically, 1. For Resident #24, the facility neglected to monitor, assess and notify the physician timely for the Resident who was found to be vomiting coffee ground emesis and exhibiting continuous stooling of black liquid. 2. For Resident #323, the facility neglected to a) review and intervene on abnormal laboratory tests, resulting in a delay in treatment, and subsequent hospitalization and death; b) implement treatments timely for a newly acquired pressure injury, resulting in an untreated wound for 6 days and; c) address a significant, 11%, weight loss. Findings include: Neglect, as defined at §483.5, means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The American Nurses Association (ANA), Scope of Nursing Practice, Third Edition, indicated Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, facilitation of healing, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, groups, communities, and populations. Review of the facility policy titled, Abuse, Neglect, Exploitation and Misapporpriation Prevention Program, revised April 2021, indicated the following: - Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. - Develop and implement policies and protocols that prevent and identify abuse or mistreatment of residents; neglect of residents; and/or theft, exploitation or misappropriation of resident property. 1. Resident #24 was admitted to the facility in December 2014 with diagnoses that include partial intestinal obstruction, muscle weakness, gastrointestinal hemorrhage, and iron deficiency anemia. Review of Resident #24's Minimum Data Set (MDS) Assessment, dated 8/19/24, indicated a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating that the Resident has moderate cognitive impairment. The MDS further indicated that the resident has medically complex conditions with a primary diagnosis of partial intestinal obstruction. On 11/4/24 at 8:36 A.M., a surveyor overheard Nurse #3 say thank you to Nurse #4 for sending out Resident #24. During an interview on 11/4/24 at 8:38 A.M., Nurse #4 said she is sending Resident #24 to the hospital as he/she was vomiting a lot over night that was coffee ground in color and has a history of bowel obstructions. Nurse #4 said the Resident started vomiting around 1:00 A.M. Nurse #4 said she called the on-call service Nurse Practitioner (NP) and the NP ordered labs because the Resident did not want to go to the hospital. Nurse #4 said the Resident only vomited a few times around 1:00 A.M. but then the Resident was okay and was asleep until 6:00 A.M. Nurse #4 said she then called the on-call service around 6:00 A.M. as the Resident again vomited dark coffee ground substances and wanted to go to the hospital at that time. During a follow up interview on 11/4/24 at 8:42 A.M., Nurse #4 said to the surveyors that Resident #24 started vomiting on her shift, around 1:00 A.M., but at first the Resident did not want to go to the hospital. She said she called the Nurse Practitioner (NP), and she ordered labs and Zofran (a medication to treat nausea). When asked about the Resident's history Nurse #4 told the surveyors that he/she does have a history of a bowel obstruction as well as a recent fall on 11/1/24. Nurse #4 said that she did not provide a full report of Resident #24's medical history to the Nurse Practitioner that she spoke to at 1:00 A.M., and only gave report on the current situation; that the Resident was vomiting. During an interview on 11/4/24 at 8:45 A.M., Nurse #3 said that she arrived to the facility around 7:20 A.M. and was told in report that the Resident had coffee ground emesis (vomiting) during the night. She said when she got there Resident #24 said he/she wanted to go to the hospital. Nurse #3 said that the Resident looks bad right now and said he/she looks pale and grey, and that the Resident also looked like that at 7:20 A.M. when she saw him/her. During an interview and observation on 11/4/24 at 8:48 A.M., the surveyor observed Resident #24 with black vomit on him/her. Resident #24 said that he/she knew what was happening was bad and that he/she wanted to go to the hospital and did not refuse to go. Review of Resident #24's nursing progress note, dated 11/4/24 at 8:52 A.M., indicated, at 1 AM Patient started vomiting, I informed NP [#2], and she gave order to do lab. CBC with diff and BMP. Patient refused to go to the hospital at this point. He/she said I want to wait. Around 6 AM, patient started vomiting again and I notified NP [#3], and she said send patient to hospital. Vital signs were bp [blood pressure] 107/77, pulse 66, O2 [oxygen saturation] 96%, temp [temperature] 98, resp [respirations] 18. HCP [health care proxy] was called and left a message. Review of the Electronic Medical Record (EMR) for Resident #24 indicated special instructions as follows: -Please document on every shift on GI (Gastrointestinal) status- appearance: distended, tenderness, flatus, BMs (bowel movements) and size, N/V (nausea and vomiting), GS/ bloating; anything clinically pertinent; behaviors- refusal of care; GU (genitourinary)- signs or symptoms of UTIs (urinary tract infections); always add effects of any PRN (as needed) medications administered during shift. Review of Resident #24's medical record failed to indicate that any assessments or other vitals were taken on 11/4/24. During a follow up interview on 11/4/24 at 9:21 A.M., Nurse #4 said the vomiting started between 1:00 and 2:00 A.M. and then again around 6:00 A.M. Nurse #4 said that she called the covering practitioner again around 6:00 A.M. and was ordered to send the Resident out to the Emergency Room. She said at this time the Resident agreed to be sent out. Nurse #4 said that she called for transport, not 911 emergency services, between 6:00 and 7:00 A.M. and was told that it would be one to two hours before transport could be there. She said that the facility can call 911 for transfers but she felt like the Resident was stable and his/her vitals were stable. During a follow up interview on 11/4/24 at 9:24 A.M., Nurse #3 said she did not call for the transport of Resident #24 to the hospital for evaluation but if she knew it was going to be one to two hours for the transport, she would have called 911 for a more emergent transfer. During an interview on 11/4/24 at 9:40 A.M., Nurse Practitioner (NP) #3 said that she was paged to call the facility around 7:56 A.M. and said that she called back right around 8:00 A.M. NP #3 said she was told he vomited around 1:00 A.M. and then again prior to the page at 7:56 A.M. NP #3 said that with Resident #24's history she would have sent him out overnight but was not sure what the initial report was that was given to the covering NP. NP #3 said that if the nurse was given an estimated time of arrival of one to two hours, then 911 should have been called as this was a change in condition. During an interview on 11/6/24 at 8:33 A.M. Certified Nurses Aid (CNA) #7 said that she worked over night on 11/3/24 into 11/4/24. CNA #7 said that Resident #24 was moving his/her bowels and vomiting all night long. She said that both the vomit and stool was liquid and black. She said that she provided incontinence care at least five times overnight for liquid black stools and that the vomiting was continuous all night and did not stop. CNA #7 said that she told the nurse. She said that after the first time Resident #24 vomited he/she did not want to go to the hospital but that at around 3:00 A.M., Resident #24 said that he/she wanted to go to the hospital, and she told the nurse (Nurse #4) that he/she wanted to go to the hospital. CNA #7 said that her shift ended, and she left the facility around 7:15 A.M., and Resident #24 was still at the facility. During an interview on 11/6/24 at 9:42 A.M., NP #2 said the only page she got from the facility for Resident #24 was at 1:13 A.M. and said she called the facility right away. NP #2 said the report she was given was that the Resident's vitals were stable, and the Resident had a lot of vomiting. The NP said it was never reported to her that he/she had coffee ground emesis or multiple loose dark stools. The NP said she was never given a report of the Resident's history or that the Resident had a recent unwitnessed fall. The NP said she would have sent him/her out right away if she was given an accurate report of Resident #24's status and his/her history. During an interview on 11/6/24 at 1:13 P.M., Physician #2 said that Resident #24 has a significant history of bowel obstructions and in the past has declined surgical interventions. Physician #2 said that there is a process issue in the facility in terms of communication with covering providers and ensuring that a full and accurate report is provided to the NP or covering providers on call. During an interview on 11/6/24 at 1:30 P.M. the Director of Nursing (DON) said that she didn't think it was necessary to provide a history about Resident #24's previous bowel obstructions because the Resident having coffee ground emesis was not an emergent situation. When asked if she was aware that the CNA #7 said that Resident #24 said he/she wanted to go to the hospital at 3:00 A.M., the DON said that after CNA #7 notified Nurse #4, Nurse #4 went into the room and the Resident said he/she didn't want to go. She said she would not have called the covering again at that point and wouldn't call again until the Resident was ready to go to the hospital. She said one policy regarding change in condition or transfers does not fit all, if it was something critical she would have called again, but she said she did not take this as a critical situation. The DON said she talked to Nurse #4 who worked over night and that the Resident had only vomited 3 times and denied the Resident was having coffee ground emesis. The DON said she had not spoken to CNA #7 who reported to the surveyor the Resident had ongoing black vomiting and black stooling throughout the night. Review of Resident #24's Ambulance Patient Care Report, dated 11/4/24, indicated dispatched at 8:01 A.M. to the facility for chief complaint of incontractable [sic] vomiting. Pt (patient) found lying supine in assigned bed with head elevated and several towels draped over him/her, coffee ground emesis noted on towel. Skin is pale, warm and dry. Significant distension noted on initial impression. Nursing staff reported coffee ground emesis began at 0100 (1:00 A.M.) that morning with 3 episodes. No vitals or assessments taken to provide EMS (emergency medical services) staff. Vitals revealed hypotension (80/60) and weakened radial pulses. Regrouped in patient room and called dispatch at 8:44 A.M. for ALS (advanced life support) secondary to hypotension and likely GI bleed. In route to the hospital at 8:55 A.M. vital signs included a blood pressure of 70 systolically and a weak pulse of 180 beats per minute. Review of Resident #24's discharge summary from the hospital, dated 11/4/24 at 4:39 P.M., indicated a diagnosis of bowel obstruction and a reason for admission of Abdominal pain, with bowel obstruction and 1600-2000 milliliters (ml) of fecal material suctioned from NGT (nasogastric tube, a thin flexible tube that is passed through the nose and down through the esophagus into the stomach. It can be used to either remove substances from or add them to the stomach.) The discharge summary further indicated that Resident #24 had prior admissions for bowel obstructions including in May 2023, February 2024, May 2024, June 2024 and November 2024. The discharge summary indicated that Resident #24 presented to the emergency department from his/her extended care facility with coffee ground emesis times three and a report of some dark bowel movements. Resident #24's main complaint was abdominal discomfort, and his/her blood pressure was in the 70's according to the prehospital personnel. Further the discharge summary indicated Patient underwent central line insertion for severe hypotension with Afib (atrial fibrillation- an irregular and often very rapid heart rhythm) with RVR (rapid ventricular rate) and on dilt drip (Diltiazem - a medicated intravenous solution used in adults to treat certain heart rhythm disorders such as atrial fibrillation or dangerously rapid heartbeats) with still uncontrolled heart rate and hypotension status post several liters of IV [intravenous] fluid resuscitation, in the setting of AKI (acute kidney injury) with possible pulmonary edema as well. He/she had a nasogastric tube inserted with approximately 2 liters of feculent material suctioned out immediately. CT (cat scan) of the abdomen and pelvis shows markedly distended stomach and proximal duodenum with markedly dilated loops of bowel and air-fluid levels, markedly dilated rectosigmoid. After lengthy conversation with patient and nursing at the bedside patient seems for comfort measures at end of life. He/she was requesting narcotics for abdominal discomfort . Patient was cognizant and fully intact to make this decision. Review of Physical exam indicates an abdominal assessment with hypoactive/ absent bowel sounds, markedly distended abdomen, tenderness to palpation. Review of Resident #24's medical record indicated the Resident returned to the facility on [DATE] on the 3:00 P.M. to 11:00 P.M. shift and was readmitted on care and comfort measures. Further review of the medical record indicated that Resident #24 died at the facility on 11/5/24 at approximately 8:28 A.M. 2. For Resident #323, the facility neglected to: a) review and intervene on abnormal laboratory tests, resulting in a delay in treatment, and subsequent hospitalization and death; b) implement treatments timely for a newly acquired pressure injury, resulting in an untreated wound for 6 days and; c) address a significant, 11%, weight loss. Resident #323 was admitted to the facility in June 2024 with diagnoses including dementia and chronic kidney disease. Review of the Minimum Data Set (MDS) assessment, dated 7/1/24, indicated Resident #323 could not participate in the Brief Interview for Mental Status (BIMS) due to severe cognitive impairment. The MDS further indicated Resident #323 required supervision to assistance with meals, supervision with touching assistance for standing and walking. Review of the record indicated that effective 7/26/24 Resident #323 had an activated Health Care Proxy (deemed incapable of making medical decisions for self). The Health Care Proxy was Resident #323's daughter. During an interview on 11/4/24 at 1:32 P.M., Resident #323's daughter said she felt the facility did not listen to any of her concerns. Resident #323's daughter said her parent died and she believed it was the direct result of the facility's mistreatment and neglect. Resident #323's daughter said at the time of the Resident's death, he/she had significant wounds on his/her feet and had lost a significant amount of weight. Resident #323's daughter said she believes Resident #323 was overmedicated and said she was never made aware of medication changes and was never asked to sign consents for changes to Resident #323's medications. She said prior to passing Resident #323 could not get out of bed like he/she used to due to being overmedicated and was left in bed a lot of the day, creating wounds on the Resident's heels. Resident #323's daughter said that when the wounds were discovered on his/her heels that she was horrified. She said that the condition of Resident #323's heels were due to severe neglect by the facility. The Resident's daughter also said the Resident required assistance with chewing and swallowing and his/her meals were often left by the bed side, which likely contributed to the Resident's weight loss. The daughter said she believes that the Resident's death could have been prevented. 2 a. Review of the facility policy titled Lab and Diagnostic Test Results- Clinical Protocol, revised November 2018, indicates the following: - High or toxic serum medication levels. If a test was obtained to monitor the blood level of a medication and the level is reported as high (above therapeutic range) or toxic, the nurse will notify the physician promptly and will not give the next dose until the situation has been reviewed with the physician. - Time frames. A physician will respond within an appropriate time frame, based on the request from nursing staff and the clinical significance of the information. o A physician should respond within one hour regarding a lab test result requiring immediate notification, and by the end of the next office day to a non-emergency message regarding non-immediate lab test notification with a request for response. o If the attending or covering physician does not respond to immediate notification within an hour, the nursing staff should contact the medical director for assistance. Review of the hospital admission paperwork, prior to admission, for Resident #323, dated 6/7/24, indicated Resident #323 was admitted to the hospital with a Covid infection and the family's inability to care for him/her at home. Review of the lab results on the hospital admission paperwork, dated 6/7/24, indicated Resident #323 had the following lab results: - BUN: 31 - Creatinine: 1.87 - Glomerular Filtration Rate: 37 (Blood urea nitrogen is a measure of nitrogen in the blood and is a measure of kidney function. The normal ranges for BUN are 6-24 milligrams per deciliter. Creatinine is a lab used to measure kidney function. The normal ranges for creatinine is 0.7-1.3 milligrams per deciliter. GFR is a lab used to measure the filtration rate of the kidneys. The normal range for GFR is 90-120 milliliters per minute.) Review of multiple nursing progress notes since admission indicated Resident #323 had been experiencing agitation, intrusiveness, and yelling out. On 8/14/24, a urine culture was obtained. Review of the medical record failed to indicate why a urine culture was obtained for Resident #323. Review of the laboratory results, dated 8/14/24, indicated the following: - Culture 10,000-50,000 CFU/mL (colony forming units per milliliter) mixed urogenital flora, probable contamination (mixed bacteria in the urine with possible contamination) Review of the record failed to indicate if a urine sample or lab was ever obtained after 8/14/24. Review of the record failed to indicate any follow up documentation from the Nurse Practitioner or Physician or if the laboratory results were ever reported to the physician or nurse practitioner from 8/14/24-8/16/24. Review of the nursing progress note, dated 8/16/24, indicated that the facility attempted to obtain a urine sample via a straight catheter (a device used to obtain a urine sample), but Resident #323 refused and yelled get out, get out!. Review of the medical record failed to indicate any follow up documentation from the Nurse Practitioner or Physician following the 8/16/24 progress note or if a urine sample was obtained after 8/16/24. Review of the nursing progress note, dated 8/24/24, indicated Resident #323 had a Basic Metabolic Panel (BMP) lab completed and resulted in abnormal lab values. Specifically, a blood urea nitrogen (BUN) of 80, creatinine of 2.70, and a glomerular filtration rate (GFR) of 23, which are considered abnormally high. The nursing progress note indicated that the Director of Nursing was made aware, and the Nurse Practitioner was contacted. Review of the Nurse Practitioner monthly progress note, dated 8/25/24, indicated the following: - No acute concerns from nursing. - Labs and image results: All labs reviewed and found to be negative. - #CKD: Encourage po fluids, monitor renal, monitor retention Review the medical record failed to indicate that any further review or action of the abnormal labs from 8/24/24 through 9/19/24 a total of 27 days. Review of the labs draw on 9/19/24 indicated the following: - BUN 172 - Creatinine 5.6 - GFR 10 Review of the progress note, dated 9/20/24, indicated Resident #323 was transferred to the hospital with critically high labs with a diagnosis of shock, acute kidney failure, and hyperkalemia (high potassium levels). Review of the hospital Discharge summary, dated [DATE], indicated the following: - He/she was found to be acidotic with PH of 7.19. He/she has hypernatremia (high sodium), hyperkalemia (high potassium), acute kidney injury, acute NSTEMI (mild heart attack), sepsis (blood infection) likely due to acute cystitis (infection of the bladder from bacteria). Resident #323 expired shortly after arrival to the hospital. During an interview on 11/5/24 at 8:30 A.M., the Nurse Practitioner said that she doesn't remember the resident, but if there are abnormal labs drawn that are different from the resident's baseline, then he/she should have been sent to the hospital. The Nurse Practitioner said she would have expected to be notified if the facility could not obtain a urine sample via a straight catheter. The Nurse Practitioner said that if a family member refuses any treatment then that should be documented. Review of the medical record failed to indicate the healthcare proxy was made aware or refused any treatment. During an interview on 11/5/24 at 8:37 A.M., Physician #1 said that if a resident has a suspected urinary tract infection (UTI) then the resident should be treated with antibiotics as a precaution. Physician #1 said if labs come back abnormal, most of the time the Nurse Practitioner will address the labs and make the decision with what to do with the Resident. Physician #1 said if he was notified of the labs, he would have sent the Resident to the hospital or hydrated him/her with intravenous fluids because the labs reflected dehydration. During an interview on 11/5/24 at 10:47 A.M., the Director of Nursing said she doesn't remember that far back, but that the urine was done because of the daughter's request. The Director of Nursing said the urine came back inconclusive and the facility attempted to straight cath (use a straight catheter to obtain a urine sample) but were unsuccessful and notified the Nurse Practitioner. The Director of Nursing could not remember why the additional BMP (basal metabolic panel) labs were done, but if labs are abnormal then staff should notify the Nurse Practitioner. During an interview on 11/7/24 at 9:47 A.M., the Physician said that most of the time the Nurse Practitioner makes the decision on what to do with abnormal labs. He said the Nurse Practitioner has been here for 7 years and is usually on top of these things. He said he was upset when they told him about Resident #323 and that this was a big concern. 2 b. Review of Resident #323's care plan for skin indicated the following: - Focus: I have the potential for skin breakdown r/t (related to) impaired mobility (initiated 7/5/24) - Interventions: o Apply barrier cream after incontinence care (initiated 7/5/24) o Document skin checks weekly and PRN (as needed). Notify physician and resident/RP (representative) of new areas if observed. Follow up as indicated (initiated 7/5/24). Review of the weekly skin check, dated 6/25/24, indicated Resident #323 had no open areas. Review of the medical record failed to indicate weekly skin checks were being completed per the Reisdent's care plan from 7/5/24 until 7/25/24. The weekly skin check, dated 7/25/24, indicated Resident #323 had a new open area on his/her right heel and his/her left heel due to pressure. The skin check failed to indicate any measurements for the wounds. Review of the Nurse Practitioner's progress note, dated 7/29/24, four days after the weekly skin check was completed, indicated the following: -Skin: no lesions or rashes noted in b/l (bilateral) UE (upper extremity) or LE (lower extremity). Review of the medical record failed to indicate if the Nurse Practitioner or Physician were notified of the new open pressure wounds. Review of the physician's orders indicated that a treatment order was implemented on 8/2/24, 8 days after the initial wound was identified and 4 days since he/she was last seen by the Nurse Practitioner, for both heels to cleanse with normal saline, apply Xerofoam gauze, to wound perimeter cover with ABD pad, wrap with kerlix. Review of the Initial Wound Evaluation and Management Summary, dated 8/6/24, 15 days after the wound was initially identified, indicated Resident #323 had the following: - an unstageable wound (due to necrosis) of the left heel, approximately greater than 14 days in duration, that was 4x3.8 centimeters. - An unstageable wound (due to necrosis) of the left heel, approximately greater than 14 days in duration, that was 4x3.8 centimeters. During an interview on 11/5/24 at 9:37 A.M., the Wound Physician said when she met with Resident #323, he/she had bad DTI's (deep tissue injuries) and that the treatment for a DTI is to offload the wound. The wound doctor said that in her assessment note she documents duration of the wound. She said the duration is her professional opinion of how long the wounds existed prior to her evaluation. For Resident #323 she said that she believes the wounds were due to pressure, indicating the heels were not offloaded. Review of the medical record failed to indicate any intervention to offload Resident #323's heels after the wounds were first identified. During an interview on 11/5/24 at 10:47 A.M., the Director of Nursing said if a wound is identified then she would have expected the skin prep (a liquid applied to the skin to provide a barrier) to go in earlier, but depends on what the doctor says. 2 c. Review of Resident #323's nutrition care plan indicated the following: Focus: I have a nutritional problem or potential nutritional problem related to significant weight changes, suspected malnutrition, past medical history significant for dementia, anemia pressure ulcers, and GERD (Gastroesophageal reflux disease). Review of the weight report for Resident #323 indicated the following weights: 7/5/24: 158.2 lbs (pounds) 8/5/24: 135 lbs 9/7/24: 120 lbs Review of the nutrition risk assessment, dated 7/10/24, indicated Resident #323 had an ideal body weight of 153 lbs. Review of the weights indicated Resident #323 lost 23.2 lbs in one month from July 2024 to August 2024, which is a 14.6% significant weight loss. Review of the progress note, dated 8/6/24, indicated the following: RD (registered dietitian) suspects pt (patient) meets criteria for protein calorie malnutrition. Malnutrition in the context of chronic illness r/t (related to) dementia AEB (as evidenced by) significant weight loss with NFPE (nutrition focused physical exam) finding indicating fat and muscle loss. Review of the weight warning note, dated 8/6/24, indicated the dietitian recommended a re-weight and to start weekly weights, as well as, a nutritional drink BID (twice per day) and fortified foods. Review of the medical record failed to indicate that weekly weights were implemented as recommended. Review of the weights indicated Resident #323 lost an additional 15 lbs from August 2024 to September 2024, which is an 11% significant weight loss in one month. Review of the clinical record failed to indicate that the significant weight loss was addressed, the care plan was reviewed, or any new interventions were implemented. During an interview on 11/5/24 at 9:00 A.M., the Dietitian said that after the initial significant weight loss, she recommended weekly weights, but said they were not being done. The dietitian said she was not notified of the weight loss that occurred on 9/7/24 and would have expected to be notified so that she could address the weight loss.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure physician and/or delegate supervision after a change in medical status for one Resident (#323) of a total sample of 39 residents. Specifically, the facility failed to follow up on abnormal labs that were drawn, for a Resident with a known history of Chronic Kidney Disease, resulting in critically high labs, which required emergency hospitalization and death. Findings include: Review of the facility policy titled Lab and Diagnostic Test Results- Clinical Protocol, revised November 2018, indicates the following: - A physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. - The laboratory, diagnostic radiology provider, or other testing source will report test results to the facility. - When test results are reported to the facility, a nurse will first review the results. - If staff who receive or review lab and diagnostic test results cannot follow the remainder of the procedure for reporting and documenting the results and their implications, another nurse in the facility (supervisor, charge nurse, etc.) should follow or coordinate the procedure. - A nurse will identify the urgency of communicating with the attending physician based on physician request, the seriousness of any abnormality, and the individual's current condition. - Nursing will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results: * Whether the physician has requested to be notified soon as a result is received. * Whether the result should be conveyed to a physician regardless of other circumstances (that is, the abnormal result is problematic regardless of any other factors) * Whether the resident/patient's clinical status is unclear or he/she has signs and symptoms of acute illness or condition change and is not stable or improving, or there are no previous results for comparison. - High or toxic serum medication levels. If a test was obtained to monitor the blood level of a medication and the level is reported as high (above therapeutic range) or toxic, the nurse will notify the physician promptly and will not give the next dose until the situation has been reviewed with the physician. - Time frames. A physician will respond within an appropriate time frame, based on the request from nursing staff and the clinical significance of the information. * A physician should respond within one hour regarding a lab test result requiring immediate notification, and by the end of the next office day to a non-emergency message regarding non-immediate lab test notification with a request for response. * If the attending or covering physician does not respond to immediate notification within an hour, the nursing staff should contact the medical director for assistance. Resident #323 was admitted in June 2024 with diagnoses including dementia and chronic kidney disease. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #323 could not participate in the Brief Interview for Mental Status (BIMS) due to severe cognitive impairment. Review of the MDS indicates Resident #323 required supervision to assistance with meals, supervision with touching assistance for standing, and supervision with touching assistance with walking. Review of Resident #323's care plan indicated Resident #323 was not capable of making his/her informed consent regarding his/her health care decisions. Review of the hospital admission paperwork for Resident #323, dated 6/7/24, indicated Resident #323 was admitted to the hospital with a Covid infection and family inability to care for at home. Review of the lab results on the hospital admission paperwork, dated 6/7/24, indicated Resident #323 had the following lab results: - BUN: 31 - Creatinine: 1.87 - Glomerular Filtration Rate: 37 (Blood urea nitrogen is a measure of nitrogen in the blood and is a measure of kidney function. The normal ranges for BUN are 6-24 milligrams per deciliter. Creatinine is a lab used to measure kidney function. The normal ranges for creatinine is 0.7-1.3 milligrams per deciliter. GFR is a lab used to measure the filtration rate of the kidneys. The normal range for GFR is 90-120 milliliters per minute.) Review of the progress notes indicated Resident #323 had been experiencing agitation, intrusiveness, and yelling out. On 8/14/24, a urine culture was obtained. Review of the record failed to indicate why a urine culture was obtained for Resident #323. Review of the lab results, dated 8/14/24, indicated the following: -Culture 10,000-50,000 CFU/mL (colony forming units per milliliter) mixed urogenital flora, probable contamination (mixed bacteria in the urine with possible contamination) Review of the progress note, dated 8/16/24, indicated that the facility attempted to obtain a urine sample via a straight catheter (a device used to obtain a urine sample), but Resident #323 refused and yelled get out, get out!. Review of the record failed to indicate if a urine sample or lab was ever obtained after 8/14/24. Review of the record failed to indicate any follow up documentation from the Nurse Practitioner or Physician. Review of the progress note, dated 8/24/24, indicated Resident #323 had a Basic Metabolic Panel (BMP) lab completed and resulted in abnormal lab values, specifically, a blood urea nitrogen (BUN) of 80, creatinine of 2.70, and a glomerular filtration rate (GFR) of 23. The note indicated that the Director of Nursing was made aware and the Nurse Practitioner was contacted. Review of the Nurse Practitioner monthly progress note, dated 8/25/24, indicated the following: - No acute concerns from nursing. - Labs and image results: All labs reviewed and found to be negative. - #CKD: Encourage po fluids, monitor renal, monitor retention Review the record failed to indicate that any further review or action of the abnormal labs took place. Review of the progress note, dated 9/20/24, indicated Resident #323 was transferred to the hospital with critically high labs with a diagnosis of shock, acute kidney failure, and hyperkalemia (high potassium levels). Review of the hospital summary, dated 9/19/24, indicated the following: - He/she was found to be acidotic with PH of 7.19. He/she has hypernatremia (high sodium), hyperkalemia (high potassium), acute kidney injury, acute NSTEMI (mild heart attack), sepsis (blood infection) likely due to acute cystitis (infection of the bladder from bacteria). During an interview on 11/5/24 at 8:30 A.M., the Nurse Practitioner said that she doesn't remember the resident, but if there are abnormal labs drawn that are different from the resident's baseline, then he/she should have been sent to the hospital. The Nurse Practitioner said she would have expected to be notified if the facility could not obtain a urine sample via a straight catheter. The Nurse Practitioner said that if a family member refuses any treatment then that should be documented. Review of the record failed to indicate the healthcare proxy was made aware or refused any treatment. During an interview on 11/5/24 at 8:37 A.M., Physician #1 said that if a resident has a suspected urinary tract infection (UTI) then the resident should be treated with antibiotics as a precaution. Physician #1 said if labs come back abnormal, most of the time the Nurse Practitioner will address the labs and make the decision with what to do with the Resident. Physician #1 said if he was notified of the labs, he would have sent the Resident to the hospital or hydrated with intravenous fluids because his/her labs reflected dehydration. During an interview on 11/5/24 at 10:47 A.M., the Director of Nursing said she doesn't remember that far back, but that the urine was done because of the daughter's request. The Director of Nursing said the urine came back inconclusive and the facility attempted to straight cath (use a straight catheter to obtain a urine sample), but were unsuccessful and notified the Nurse Practitioner. The Director of Nursing could not remember why additional BMP (basal metabolic panel) labs were done, but if labs are abnormal then staff should notify the Nurse Practitioner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of facility policy titled Change in a Resident's Condition or Status, undated, indicated the following: - Our facility promptly notifies the resident, his or her attending physician and the resident representative of changes in the resident's medical/ mental condition and or status (e.g. changes in level of care, billing/ payments, resident rights etc.) - 3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the SBAR (situation, background, assessment, recommendation) Communication Form. - 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/ mental condition or status. Resident #24 was admitted to the facility in December 2014 with diagnoses that include partial intestinal obstruction, muscle weakness, gastrointestinal hemorrhage, and iron deficiency anemia. Review of Resident #24's Minimum Data Set (MDS) assessment, dated 8/19/24, indicated a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating that the Resident has moderate cognitive impairment. The MDS further indicated that the resident has medically complex conditions with a primary diagnosis of partial intestinal obstruction. On 11/4/24 at 8:36 A.M., a surveyor overheard Nurse #3 say thank you to Nurse #4 for sending out Resident #24. During an interview on 11/4/24 at 8:45 A.M., Nurse #3 said that she arrived at the facility around 7:20 A.M. and was told in report that the Resident had coffee ground emesis (vomiting) during the night. She said she went right into the Resident when she got there, and he/she said they wanted to go to the hospital. At this time the ambulance company was picking up the Resident for transport to the hospital. Nurse #3 said that the Resident looks bad right now and said he/she looks pale and grey, and that the Resident also looked like that at 7:20 A.M., when she saw him/her. During an interview and observation on 11/4/24 at 8:48 A.M., a surveyor observed Resident #24 with black vomit on him/her. Resident #24 said that he/she knew what was happening was bad and that he/she wanted to go to the hospital and did not refuse to go. Review of a progress note written 11/4/24 at 8:52 A.M., indicated, at 1 AM Patient started vomiting, I informed NP [#2], and she gave order to do lab. CBC with diff and BMP. Patient refused to go to the hospital at this point. He/she said I want to wait. Around 6 AM, patient started vomiting again and I notified NP [#3], and she said send patient to hospital. Vital signs were bp [blood pressure] 107/77, pulse 66, O2 [oxygen saturation] 96%, temp [temperature] 98, resp [respirations] 18. HCP (health care proxy) was called and left a message. Review of the Patient Care Report for Resident #24 from the Ambulance service dated 11/4/24 indicated that dispatched received the call from the facility for transfer to the hospital at 8:01 A.M. on 11/4/24. The Patient Care Report indicated that the chief complaint was general illness- GI bleed for 7 hours with a primary symptom of abdominal distension. The Patient care report further indicated that the ambulance was dispatched to the facility for a patient with incontractible vomiting. (sic) The BLS (basic life support) crew arrived at the patient at 8:39 A.M. and patient found lying supine in assigned bed with head elevated and several towels draped over him/her, coffee ground emesis noted on towel .Skin is pale, warm and dry. Significant distension noted on initial impression. The report further indicated, Nursing staff reported coffee ground emesis began at 1:00 A.M. that morning with 3 episodes . No vitals or assessments taken to provide EMS (emergency medical service) staff. Vital signs revealed hypotension with a blood pressure of 80/60 and weakened radial pulses. BLS crew called dispatch at 8:44 A.M. for ALS (advanced life support) secondary to hypotension and likely GI (gastrointestinal) bleed. In route to the hospital at 8:55 A.M. vital signs included a blood pressure of 70 systolically and a weak pulse of 180 beats per minute. Review of Resident #24's active risk for constipation care plan, dated 12/8/2014 indicated the following interventions: - Monitor/ document/ report to MD (Medical Doctor) PRN (as needed) s/sx (signs and symptoms) of complications related to constipation: Change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation, bradycardia (slow, low pulse) abdominal distension, vomiting, small loose stools, fecal smearing, bowel sounds, diaphoresis, abdomen: tenderness, guarding, rigidity, fecal compaction. - I have constipation related to decreased mobility, Hx (history) of bowel obstruction, dated 2/26/24. Further review of the nursing progress note written on 11/4/24 failed to indicate a comprehensive GI (gastrointestinal) assessment or abdominal assessment. Review of the Electronic Medical Record (EMR) for Resident #24 indicated special instructions as follows: -Please document on every shift on GI (Gastrointestinal) status- appearance: distended, tenderness, flatus, BMs (bowel movements) and size, N/V (nausea and vomiting), GS/ bloating; anything clinically pertinent; behaviors- refusal of care; GU (genitourinary)- signs or symptoms of UTIs (urinary tract infections); always add effects of any PRN (as needed) medications administered during shift. Review of the medical record failed to indicate documentation regarding the resident's GI status over the last month. Review of Resident #24's progress notes indicated a note dated 11/3/24 at 4:56 P.M. which indicated that the Resident was awake and alert, able to make needs know. During an interview on 11/5/24 at 12:08 P.M., CNA #9 said that on 11/3/24 she worked the 3:00 P.M. to 11:00 P.M. shift and took care of Resident #24. She said that he/she was their usual self, ate dinner, and had no issues. She said he/she had no vomiting on her shift. During an interview on 11/4/24 at 8:42 A.M., Nurse #4 said to the surveyors that Resident #24 started vomiting on her shift, around 1:00 A.M., but at first the Resident did not want to go to the hospital. She said she called the Nurse Practitioner (NP), and she ordered labs and Zofran (a medication to treat nausea). When asked about the Resident's history, Nurse #4 said that he/she does have a history of a bowel obstruction as well as a recent fall on 11/1/24. Nurse #4 said that she did not provide a full report of Resident #24's medical history to the Nurse Practitioner that she spoke to at 1:00 A.M., and only gave report on the current situation, that the Resident was vomiting. During a follow up interview on 11/4/24 at 9:21 A.M., Nurse #4 said Resident #24 started vomiting between 1:00 A.M., and 2:00 A.M. and then again around 6:00 A.M. Nurse #4 said she called the covering practitioner again around 6:00 A.M. and was ordered to send the Resident out to the Emergency Room. Nurse #4 said Resident #24 was not agreeable to go to the hospital earlier in the morning, however said at this time the Resident agreed to be sent out. Nurse #4 said that she called for transport between 6:00 and 7:00 A.M. and was told that it would be about one to two hours before transport could be there. She said that the facility can call 911 for transfers but she felt like the Resident was stable and his/her vitals were stable. During a follow up interview on 11/4/24 at 9:24 A.M., Nurse #3 said she did not call for the transport of Resident #24 to the hospital for evaluation but if she knew it was going to be one to two hours for the transport, she would have called 911 for a more emergent transfer. During a phone interview on 11/6/24 at 9:00 A.M. the surveyor spoke to Nurse Practitioner (NP) #1 who returned a phone call regarding when phone calls were placed into the call service to report the change in condition on Resident #24. NP #1 said that she was not the one that responded to the call, but the service got one call at 1:13 A.M. with a message stating the Resident was vomiting a lot. She said this is the only call that came into the service on the 11:00 P.M. to 7:00 A.M. shift. During an interview on 11/6/24 at 9:42 A.M., Nurse Practitioner (NP)#2 said she was the covering NP for the night of 11/3/24 into 11/4/24 and the only page she got from the facility for this Resident was at 1:13 A.M. and said she called the facility right away. NP #2 said the report she was given was that the Resident's vitals were stable, and the Resident had a lot of vomiting. The NP said it was never reported to her that he/she had coffee ground emesis or multiple loose dark stools. The NP said she was never given a report of the Resident's history or that the Resident had a recent unwitnessed fall. The NP said she would have sent him/her out right away if she was given an accurate report of Resident #24's status and his/her history. During an interview on 11/4/24 at 9:40 A.M., Nurse Practitioner (NP) #3 said that she was paged to call the facility around 7:56 A.M. and said that she called back right around 8:00 A.M. NP #3 said that with Resident #24's history she would have sent him out overnight but was not sure what the initial report was that was given to the covering NP. NP #3 said that if the nurse was given an estimated time of arrival of one to two hours, then 911 should have been called as this was a change in condition. During a follow up interview on 11/6/24 at 7:45 A.M., Nurse #4 said that on the night before Resident #24 was sent out it was around 1:00 A.M. that the Resident began vomiting. She said that it was coffee ground. She said that as soon as she could, she called the NP. She said that she told the NP the Resident was vomiting but could not remember if she told her that it was coffee ground. She said she did not tell the NP about the history of obstructions or GI bleeding. Nurse #4 said she only discussed the current situation. She said that the NP ordered labs and Zofran for nausea. Nurse #4 said that she gave the Resident a dose of Zofran and that he/she slept until vomiting began again around 6:00 A.M. Nurse #4 said she called the NP again at this time and an order was given to send the Resident to the hospital. Nurse #4 said the Resident agreed to go to the hospital. Nurse #4 said that she called the ambulance company and was told it would be a one to two hour wait for the transport. Nurse #4 said the Resident's vital signs were stable, so she was ok with the one to two hours wait. Nurse #4 said nurses can use their judgement and call 911 for an emergent transfer but she did not think it was necessary and said the Resident was stable. Nurse #4 said that coffee ground emesis is a change in condition and could indicate GI bleeding. During a phone interview on 11/6/24 at 8:33 A.M. Certified Nurses Aid (CNA) #7 said that she worked over night on 11/3/24 into 11/4/24. CNA #7 said that Resident #24 was moving his/her bowels and vomiting all night long and that both the vomit and stool was liquid and black. CNA #7 said that she provided incontinence care at least five times over night for liquid black stools and that the vomiting was continuous all night and did not stop. CNA #7 said she told the nurse. CNA #7 said that after the first time Resident #24 vomited he/she did not want to go to the hospital but that at around 3:00 A.M., Resident #24 said that he/she wanted to go to the hospital and after getting the Resident cleaned and changed again at that time, she told the nurse (Nurse #4) that the Resident wanted to go to the hospital. CNA #7 said that when her shift ended, and she left the facility around 7:15 A.M. and Resident #24 was still at the facility. During an interview on 11/6/24 at 1:13 P.M., Physician #2 said that Resident #24 has a significant history of bowel obstructions and in the past has declined surgical interventions. Physician #2 said that there is a process issue in the facility in terms of communication with covering providers and ensuring that a full and accurate report is provided to the NP or covering providers on call. During an interview on 11/6/24 at 1:30 P.M. the Director of Nursing (DON) said that she didn't think it was necessary to provide a history about Resident #24's previous bowel obstructions because the Resident having coffee ground emesis was not an emergent situation. She said she would not have called the covering again at any point during the shift and wouldn't call again until the Resident was ready to go to the hospital. She said one policy regarding change in condition or transfers does not fit all, if it was something critical, she would have called again, but she said she did not take this as a critical situation. She said she talked to Nurse #4 who worked over night and that the Resident had only vomited 3 times. She said however, she had not spoken to CNA #7, who reported to the surveyor ongoing black vomiting and black stooling throughout the night. Review of Resident #24's discharge summary from the hospital, dated 11/4/24 at 4:39 P.M., indicated a diagnosis of bowel obstruction and a reason for admission of Abdominal pain, with bowel obstruction and 1600-2000 milliliters (ml) of fecal material suctioned from NGT (nasogastric tube, a thin flexible tube that is passed through the nose and down through the esophagus into the stomach. It can be used to either remove substances from or add them to the stomach.) The discharge summary further indicated that Resident #24 had prior admissions for bowel obstructions including in May 2023, February 2024, May 2024, June 2024 and November 2024. Further, the report indicated that Resident #24 presented to the emergency department from his extended care facility with coffee ground emesis x3 and a report of some dark bowel movements. Resident #24's main complaint was abdominal discomfort, and his/her blood pressure was in the 70's according to the prehospital personnel. The discharge summary also indicated Patient underwent central line insertion for severe hypotension with Afib (atrial fibrillation- an irregular and often very rapid heart rhythm) with RVR (rapid ventricular rate) and on dilt drip (Diltiazem - a medicated intravenous solution used in adults to treat certain heart rhythm disorders such as atrial fibrillation or dangerously rapid heartbeats) with still uncontrolled heart rate and hypotension status post several liters of IV [intravenous] fluid resuscitation, in the setting of AKI (acute kidney injury) with possible pulmonary edema as well. He/she had a nasogastric tube inserted with approximately 2 liters of feculent material suctioned out immediately. CT (cat scan) of the abdomen and pelvis shows markedly distended stomach and proximal duodenum with markedly dilated loops of bowel and air-fluid levels, markedly dilated rectosigmoid. After lengthy conversation with patient and nursing at the bedside patient seems for comfort measures at end of life. He/she was requesting narcotics for abdominal discomfort . Patient was cognizant and fully intact to make this decision. Review of Physical exam indicates an abdominal assessment with hypoactive/ absent bowel sounds, markedly distended abdomen, tenderness to palpation. Review of Nursing progress notes indicated the following: - A progress note dated 11/5/24 at 1:27 A.M., indicating, Patient came back from hospital on a 3-11p shift, earlier this nurse took report from the ED [emergency department] nurse stating that,' Patient had a bowel obstruction', this nurse asked the ED Nurse if patient had any surgeries to correct the obstruction, she said No, patient is coming back to the facility for comfort care admitted to Hospice. however, it is not stated in the Hospital visit, paperwork. Will F/u [follow up] with facility MD. Review of the medical record failed to indicate a comprehensive assessment was completed on Resident #24 when he/she arrived back at the facility with a diagnosis of bowel obstruction. Review of the nursing progress note dated 11/5/24 at 12:03 P.M., indicated the following: - At approximately 8:28 A.M., the resident was noted to be unresponsive. Resident did not respond to verbal or physical stimuli. There was no palpable pulse or visual chest rise/fall and no audible breath sounds. Time of death 8:29 A.M. Health care proxy notified, and body released to funeral home at 10:30 A.M. 3. Review of the facility policy titled Wound Care, dated as revised October 2010 indicated the following: -The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. -1. Verify that there is a physician's order for this procedure. #70 was admitted to the facility in August 2021 with diagnoses that include type 2 diabetes mellitus with diabetic neuropathy and acquired absence of other left toe(s) Review of Resident #70's most recent Minimum Data Set (MDS) Assessment, dated 8/21/24, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating that Resident #70 is cognitively intact. The MDS further indicated intact skin. During the survey the surveyor made the following observations: -On 11/3/24 at 7:39 A.M. and 11:45 A.M., Resident #70 was observed in bed, an undated dressing was observed over the left foot with staining on the dressing. At 11:45 A.M., the Resident said that she had asked for the dressing to be placed about a week ago to cover an open skin area and it has not been changed since. -On 11/4/24 at 7:58 A.M. and 11:09 A.M., Resident #70 was observed in bed with the same undated and stained dressing covering his/her left foot. -On 11/5/24 at 7:10 A.M. and 12:12 P.M. Resident #70 was observed in bed with the same undated and stained dressing covering his/her left foot. Review of Resident #70's physician's orders failed to indicate an order for a dressing change to the left foot. Review of Resident #70's most recent weekly skin check which was completed 10/4/24 indicated no skin issues noted. Review of Resident #70's progress notes failed to indicate when the dressing was applied to the left foot and why. Review of Resident #70's physician's orders indicated the following orders: -Skin Checks weekly on Monday 3-11 one time a day every Mon, 8/9/2021. -Skin Checks weekly on Tuesday 3-11 every evening shift every Tue, 4/30/2024. During an interview on 11/4/24 at 11:19 A.M., Nurse #3 said that there should be a physician's order to put a dressing on a resident. During a follow up interview and observation on 11/5/24 at 12:46 P.M., the surveyor and Nurse #3 observed Resident #70's foot and dressing. Nurse #3 said she did not know there was a dressing on Resident #70's foot. Nurse #3 said there was no order for this dressing in the medical record. Nurse #3 removed the dressing and Resident #70 said the dry scabbed area was much bigger than it was when the dressing was placed. Nurse #3 said there should have been a physician's order to apply the dressing initially and monitor the area but there was not. During an interview on 11/6/24 at 9:31 A.M., the Director of Nurses said that there should be a physician's order to apply and monitor a dressing on a resident.Based on observation, record review, and interview, the facility failed to ensure treatment and care in accordance with professional standards for 4 Residents (#323, #24, #70, and #2) out of a total sample of 39 residents. Specifically; 1. For Resident #323, the facility failed to follow up on abnormal labs that were drawn for a Resident with a known history of Chronic Kidney Disease, resulting in a subsequent panel of critically high labs, which required emergency hospitalization and resulted in death. 2. For Resident #24, the facility failed to ensure that a significant change in condition was monitored, assessed and reported timely to the physician for one resident who exhibited coffee ground emesis and continuous stooling of black liquid feces. 3. For Resident #70, the facility failed to obtain a physician's order for a wound dressing that was in place. 4. For Resident #2, the facility failed to implement orders for a known rash and failed to monitor his/her skin for further condition change, resulting in unidentified red, scaly, open wound on his/her left lower leg, requiring treatment for cellulitis and wound dressing two times a day. Findings include: 1. Review of the facility policy titled Lab and Diagnostic Test Results- Clinical Protocol, revised November 2018, indicates the following: - A physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. - The laboratory, diagnostic radiology provider, or other testing source will report test results to the facility. - When test results are reported to the facility, a nurse will first review the results. - If staff who receive or review lab and diagnostic test results cannot follow the remainder of the procedure for reporting and documenting the results and their implications, another nurse in the facility (supervisor, charge nurse, etc.) should follow or coordinate the procedure. - A nurse will identify the urgency of communicating with the attending physician based on physician request, the seriousness of any abnormality, and the individual's current condition. - Nursing will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results: * Whether the physician has requested to be notified soon as a result is received. * Whether the result should be conveyed to a physician regardless of other circumstances (that is, the abnormal result is problematic regardless of any other factors) * Whether the resident/patient's clinical status is unclear or he/she has signs and symptoms of acute illness or condition change and is not stable or improving, or there are no previous results for comparison. - High or toxic serum medication levels. If a test was obtained to monitor the blood level of a medication and the level is reported as high (above therapeutic range) or toxic, the nurse will notify the physician promptly and will not give the next dose until the situation has been reviewed with the physician. - Time frames. A physician will respond within an appropriate time frame, based on the request from nursing staff and the clinical significance of the information. * A physician should respond within one hour regarding a lab test result requiring immediate notification, and by the end of the next office day to a non-emergency message regarding non-immediate lab test notification with a request for response. * If the attending or covering physician does not respond to immediate notification within an hour, the nursing staff should contact the medical director for assistance. Resident #323 was admitted in June 2024 with diagnoses including dementia and chronic kidney disease. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #323 could not participate in the Brief Interview for Mental Status (BIMS) due to severe cognitive impairment. The MDS also indicated Resident #323 required supervision to assistance with meals, supervision with touching assistance for standing, and supervision with touching assistance with walking. Review of Resident #323's advanced directive care plan indicated Resident #323 was not capable of making his/her informed consent regarding his/her health care decisions. Review of the hospital admission paperwork for Resident #323, dated 6/7/24, indicated Resident #323 was admitted to the hospital with a Covid infection and family inability to care for him/her at home. Review of the lab results on the hospital admission paperwork, dated 6/7/24, indicated Resident #323 had the following lab results: -BUN: 31 -Creatinine: 1.87 -Glomerular Filtration Rate: 37 (Blood urea nitrogen is a measure of nitrogen in the blood and is a measure of kidney function. The normal ranges for BUN are 6-24 milligrams per deciliter. Creatinine is a lab used to measure kidney function. The normal ranges for creatinine is 0.7-1.3 milligrams per deciliter. GFR is a lab used to measure the filtration rate of the kidneys. The normal range for GFR is 90-120 milliliters per minute.) Review of the progress notes, since admission, indicated Resident #323 had been experiencing agitation, intrusiveness, and yelling out. On 8/14/24, a urine culture was obtained. Review of the medical record failed to indicate why a urine culture was obtained for Resident #323. Review of the lab results, dated 8/14/24, indicated the following: - Culture 10,000-50,000 CFU/mL (colony forming units per milliliter) mixed urogenital flora, probable contamination (mixed bacteria in the urine with possible contamination) Review of the progress note, dated 8/16/24, indicated the facility attempted to obtain a urine sample via a straight catheter (a device used to obtain a urine sample), but Resident #323 refused and yelled get out, get out!. Review of the record failed to indicate if a urine sample or lab was ever obtained after 8/14/24 or any follow up documentation from the Nurse Practitioner or Physician. Review of the progress note, dated 8/24/24, indicated Resident #323 had a Basic Metabolic Panel (BMP) lab completed and resulted in abnormal lab values, specifically, a blood urea nitrogen (BUN) of 80, creatinine of 2.70, and a glomerular filtration rate (GFR) of 23. The note indicated that the Director of Nursing was made aware, and the Nurse Practitioner was contacted. Review of the Nurse Practitioner monthly progress note, dated 8/25/24, the day after the abnormal labs were obtained, indicated the following: - No acute concerns from nursing. - Labs and image results: All labs reviewed and found to be negative. - #CKD (chronic kidney disease): Encourage po fluids, monitor renal, monitor retention Review the record failed to indicate that any further review or action of the abnormal labs took place. Review of the progress note, dated 9/20/24, indicated Resident #323 was transferred to the hospital with critically high labs with a diagnosis of shock, acute kidney failure, and hyperkalemia (high potassium levels). Review of the hospital summary, dated 9/19/24, indicated the following: - He/she was found to be acidotic with PH of 7.19. He/she has hypernatremia (high sodium), hyperkalemia (high potassium), acute kidney injury, acute NSTEMI (mild heart attack), sepsis (blood infection) likely due to acute cystitis (infection of the bladder from bacteria). During an interview on 11/5/24 at 8:30 A.M., the Nurse Practitioner said she doesn't remember the Resident, but if there are abnormal labs drawn that are different from the resident's baseline, then he/she should have been sent to the hospital. The Nurse Practitioner said she would have expected to be notified if the facility could not obtain a urine sample via a straight catheter. The Nurse Practitioner could not recall if she had been notified. The Nurse Practitioner said that if a family member refuses any treatment, then that should be documented. Review of the record failed to indicate the healthcare proxy was made aware or refused any treatment. During an interview on 11/5/24 at 8:37 A.M., Physician #1 said that if a resident has a suspected urinary tract infection (UTI) then the resident should be treated with antibiotics as a precaution. Physician #1 said if labs come back abnormal, most of the time the Nurse Practitioner will address the labs and make the decision with what to do with the Resident. Physician #1 said if he was notified of the labs, he would have sent the Resident to the hospital or hydrated with intravenous fluids because his/her labs reflected dehydration. During an interview on 11/5/24 at 10:47 A.M., the Director of Nursing said she doesn't remember that far back, but that the facility obtained Resident #323's urine for testing because of the daughter's request. The Director of Nursing said the urine came back inconclusive and the facility attempted to straight cath (use a straight catheter to obtain a urine sample) but were unsuccessful and notified the Nurse Practitioner. The Director of Nursing could not remember why additional BMP (basal metabolic panel) labs were done, but if labs are abnormal then staff should notify the Nurse Practitioner. During an interview on 11/4/24 at 1:32 P.M., Resident #323's health care proxy said the family did not feel heard by the facility and feel that Resident #323's death could have been prevented. The health care proxy said that his/her death certificate said the cause of death was sepsis, but also felt the facility was overmedicating Resident #323. The healthcare proxy said she notified the facility to be careful with medication because of the Resident's Chronic Kidney Disease. The healthcare proxy said she felt the Resident was severely neglected.4. For Resident #2, the facility failed to implement orders for a known rash and failed to monitor his/her skin for further condition change, resulting in unidentified red, scaly, open wound on his/her left lower leg, requiring treatment for cellulitis and wound dressing two times a day. Resident #2 was admitted to the facility in May 2024 and has diagnoses that include chronic obstructive pulmonary disease, weakness, ventricular fibrillation, peripheral vascular disease and unspecified dementia. Review of the Minimum Data Set (MDS) assessment, dated 8/21/24, indicated Resident #2 scored a 6 out of 15 on the Brief Interview for Mental Status exam indicating he/she as having severe cognitive impairment. The MDS further indicated that the Resident requires partial to moderate assistance from staff for toileting, and bathing. During an observation and interview on 11/3/24 at 8:00 A.M., Resident #2's right forearm had multiple scabbed areas the size of pencil erasers and smaller reddened areas. Resident #2 said his/her feet looked worse and proceeded to take off his/her left sock revealing a scaly, red, discolored left lower extremity from the calf down. Review of Resident #2's care plans indicated the following: A care plan focus: I have potential for impaired skin integrity r/t (related to) . was blank, dated 5/22/24. Interventions included, Administer treatments as ordered and monitor effectiveness, Monitor for new or worsening s/sx (signs and symptoms) of complications and infection: necrosis, erythema, warmth, edema, exudate, foul odor, maceration, pain/tenderness fever, chills, etc. Report to physician if noted and follow-up as indicated, date initiated 5/22/24. Review of Resident #2's physician's order failed to indicate any treatment or monitoring of the Resident's lower extremity for possible worsening conditions. Review of Resident #2's medical record indicated the following: -A health status progress note dated 10/29/24 entered by nursing, Note text: Resident noted with rash, bilateral arms, feet, groin, new order to wash areas with soap and water, dry and apply antifungal cream twice daily. -A weekly skin check dated 10/30/24, are there any skin impairments noted? yes, type of skin impairment rash site 1d. groin, 2d. other specify feet, and 3d. other both hands. The weekly skin check did not indicate any areas on Resident #2's lower left leg. -The skin check dated 11/6/24 was incomplete and not signed off on the Treatment Administration Record. Review of the Treatment Administration Record (TAR) and Medication Administration Record (MAR) dated 10/29/24 through 10/31/24 failed to indicate that the treatment order to wash areas with soap and water, dry and apply antifungal cream twice daily for Resident #2 were implemented. Review of the Treatment Administration Record (TAR) and Medication Administrat[TRUNCATED]