Based on record review and interviews for one resident (Resident #199) out of a total sample of 12 residents, the facility failed to notify the Attending Physician of a significant change in the Resident's medical status. Specifically, for Resident #199 the facility staff failed to contact the Physician when the Resident began to first exhibit signs and symptoms of a significant decline, resulting in a delayed transfer to the hospital. The Resident was diagnosed with sepsis and admitted to the Critical Care Unit when finally transferred to the hospital. Findings include: Resident #199 was admitted to the facility in June 2023 with the following diagnoses: surgical aftercare following surgery of the nervous system, and history of urinary retention (a condition where a person is unable to fully empty the contents of the bladder that may lead to other health problems such as Urinary Tract Infection [UTI] and kidney failure). Review of the facility's policy titled Physician Notification, reviewed 8/15/22, included but was not limited to: -Upon the identification of a resident who has demonstrated clinical changes, changes in condition and/or changes in diagnostic testing, the licensed nurse will perform the appropriate clinical assessments, data collection and update the physician. -Urgent notification will occur by the licensed nurse calling the physician, nurse practitioner or covering physician by phone if: clinical status and findings indicate need to transfer to the hospital, a significant change in the resident's physical, mental or psychosocial status and abnormal diagnostic results. Review of the Resident's June 2023 Vitals and Weights Summary indicated the following: -Blood Pressure (BP) ranged from a low of 106/85 to a high of 140/76. -Temperature ranged from a low of 97.5 degrees to a high of 98.2 degrees. -Pulse ranged from a low of 68 beats per minute (bpm) to a high of 82 beats per minute. -Oxygen saturation (the amount of oxygen circulating in the bloodstream) from a low of 91 percent (%) to a high of 96%. Review of a Nursing a Progress Note dated 7/11/23 at 7:26 A.M. indicated the following: -The Resident was calling out and moaning which was atypical behavior. -The Resident had dry lips, teeth and mouth, was confused and exhibited body twitching which was not previously noted. -The note further indicated that his/her temperature was 90.5 degrees (normal is approximately 98.6 degrees), BP was 84/40 (normal is between 90/60 and 120/80) and his/her oxygen saturation was 90% (normal is between 95-100%). Further review of the Nursing Progress Notes did not indicate any evidence that the Attending Physician had been notified of the abnormal assessment. Review of the SBAR (situation, background, assessment, recommendations) Communication Form (a technique that provides framework for communication between members of the health care team about a patient's condition) dated 7/11/23, indicated the Attending Physician was notified of the Resident's condition at 11:15 A.M., and his recommendation was to transfer the Resident to the ER for evaluation. Review of the Emergency Department Note dated 7/11/23, indicated the Resident was initially seen by the Emergency Department Physician at 12:33 P.M. During an interview on 8/16/23 at 2:29 P.M., Unit Manager (UM) #1 said the Resident's vital signs and his/her multiple changes in his/her baseline (usual state) were concerning, that the Physician should have been notified immediately and was not, resulting in a delay in transferring the Resident to the Emergency Room, where he/she was later admitted to the Critical Care Unit. During a telephone interview on 8/17/23 at 9:18 A.M., the Attending Physician said that if a Resident's temperature was 90 degrees and BP was 84/40, he would expect to be notified and did not recall being notified about the change in status for Resident #199. During an interview on 8/17/23 at 2:10 P.M., the Director of Nursing (DON) said the Nurse should have alerted the UM, and contacted the Attending Physician immediately when she discovered the Resident's vital signs were abnormal and his/her assessment indicated changes in his/her status and she did not, as required. see F684

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews for one Resident (#199) out of a total sample of 12 residents, the facility failed to ensure standards of quality of care were provided to the Resident. Specifically, the facility failed to: 1. Recognize a significant decline in the Resident's status and notify the Attending Physician timely resulting in delay in transferring the critically ill Resident to the hospital. 2. Appropriately document and monitor areas of concern on the Resident's skin which was ultimately diagnosed as a pressure injury (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device). Findings include: Resident #199 was admitted to the facility in June 2023 with the following diagnoses: encounter for surgical aftercare following surgery on the nervous system (tumor removal from the spinal cord), history of urinary retention (the inability to fully empty the contents of the bladder) with a Foley catheter (a thin flexible tube inserted into the bladder to drain urine outside the body) and muscle weakness. Review of the facility's policy titled Physician Notification, reviewed 8/15/22, included but was not limited to: -Upon the identification of a resident who has demonstrated clinical changes, changes in condition and/or changes in diagnostic testing, the licensed nurse will perform the appropriate clinical assessments, data collection and update the physician. -Urgent notification will occur by the licensed nurse calling the physician, nurse practitioner or covering physician by phone if: >clinical status and findings indicate need to transfer to the hospital, >a significant change in the resident's physical, mental or psychosocial status and abnormal diagnostic results. Review of the National Library of Medicine website, www.ncbi.nlm.nih.gov, dated 4/5/18, indicated: The urinary bladder can store up to 700 milliliters (ml) in some cases. Review of Admit/Readmit Screener (Nursing admission Assessment) dated 6/21/23, indicated: - The Resident was admitted from the hospital, post spinal surgery for removal of a mass. - The Resident possessed no open areas on his/her skin other than a surgical wound on the back of his/her neck. - The Resident was alert and oriented times four (knows who he/she is, where he/she is, the date and what is happening to them) and was verbally appropriate. - The Resident possessed an irregular heartbeat, pulses could be palpated (felt) and were equal on both sides with no edema (swelling caused by fluid collecting within the tissues). - The Resident had normal bowel sounds with a round, firm abdomen. - The Resident had not been up walking and had not wheeled himself/herself in a wheelchair. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated: -the Resident was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 13 out of 15, -required extensive assistance of two plus persons for bed mobility, -utilized a Foley catheter, -and was at risk for developing a pressure injury however had no pressure injuries at the time of the assessment. Review of the Resident's June 2023 Vitals and Weights Summary indicated the following: -Blood Pressure (BP) ranged from a low of 106/85 to a high of 140/76. -Temperature ranged from a low of 97.5 degrees to a high of 98.2 degrees. -Pulse ranged from a low of 68 beats per minute to a high of 82 beats per minute. -Oxygen saturation (the amount of oxygen circulating in the bloodstream) from a low of 91 percent (%) to a high of 96%. Review of the Nursing Home to Hospital Transfer Form dated 7/11/23 at 11:30 A.M., indicated the Resident was being transferred to the hospital due to altered mental status (AMS) and left-sided twitching with the following vital signs recorded: BP 84/46 and pulse 53. In addition, the transfer form indicated a shearing injury (separation of skin from underlying tissue) to the buttocks. 1. Review of Nursing Progress Notes authored by Nurse #1 indicated the following: *On 7/11/23 at 7:26 A.M., the Resident was calling out and moaning which was atypical behavior. -The Resident had dry lips, teeth and mouth, was confused and exhibited body twitching which was not previously noted. -The note further indicated that his/her temperature was 90.5 degrees (normal is approximately 98.6 degrees), BP was 84/40 (normal is between 90/60 and 120/80) and his/her oxygen saturation was 90% (normal is between 95-100%). Further review of the Nursing Progress Notes did not indicate any evidence that the Attending Physician had been notified of the abnormal assessment. *On 7/11/23 at 11:18 A.M., the Occupational Therapist (OT) requested the Nurse to re-assess the Resident at 10:15 A.M. because he/she seemed like he/she had a stroke (a medical event when the blood flow to the brain is blocked or there is sudden bleeding in the brain). Nurse #1's assessment of the Resident indicated: his/her skin was warm, pale and dry and he/she did not appear at his/her baseline (usual state) as evidenced by confusion, inattentiveness, oriented to person only, did not know which body part underwent surgery, hypoactive bowel sounds (indicating intestinal activity has slowed), abnormal lung sounds, swelling to his/her left toes, and not reacting to painful stimuli that he/she usually reacted to. The note further indicated that his/her temperature was 95.4 degrees, BP was 74/40 and oxygen saturation was 92%. At this time the Unit Manager (UM) and Attending Physician were notified, and an order was initiated to send the Resident to the emergency room (ER) for evaluation. Review of Occupational Therapy Notes indicated the following: -7/10/23 - Upon therapist entering, the Resident's spouse verbalized they were fearful the Resident is going to die here and was also concerned about the Resident's mental status (signed at 4:45 P.M.). - 7/11/23 - Attempted to engage in therapy however the Resident presented with increased confusion and increased lower extremity edema. BP 78/40 and oxygen saturation 92%. Therapy halted due to medical concerns (signed at 12:10 P.M.). Review of the receiving hospital admission History and Physical Report dated 7/11/23, indicated the following: - Resident was admitted to the hospital and found to be in septic shock (a serious medical condition that can occur when an infection in the body causes extremely low blood pressure and organ failure due to sepsis. Septic shock is life-threatening and requires immediate medical treatment, it is the most severe stage of sepsis) secondary to a urinary tract infection (UTI-an infection in the urinary system), requiring vasopressors (a drug that is used to make the blood vessels constrict (narrow) and used for people in shock who are unable to get enough blood to their vital organs) and was admitted to the Critical Care Unit for further management. - Upon arrival to the ER, the Resident had a Foley catheter placed with 1600 ml of urine output obtained, was noted to be hypothermic (low body temperature) requiring a [NAME] (a device designed to manage hypothermia by warming and stabilizing a person's body temperature) and acute kidney injury likely due to obstructive uropathy (when kidneys suddenly stop working properly due to obstructed urine flow). During an interview on 8/16/23 at 12:59 P.M., with Nurse #1 who provided care for Resident #199 on 7/11/23, Nurse #1 said it was uncharacteristic of the Resident to be calling out for help. She further said she was not concerned about the Resident's temperature because the fan was blowing on him/her and she thought that the upper extremity twitching was because the Resident was trying to pull his/her leg back into the bed. When the surveyor asked Nurse #1 about the Resident's low blood pressure, she said she was unsure if that blood pressure was low for him/her and would have to go back and check his/her usual readings. She further said she did not see a reason to alert the Attending Physician or reassess the Resident until the OT voiced her concerns. At that time, she and the UM assessed the Resident and the Unit Manager (UM) #1 initiated contact with the Attending Physician, who then ordered the facility to transfer the Resident to the hospital. During an interview on 8/16/23 at 2:29 P.M., UM #1 said the Resident's vital signs and the multiple changes in his/her baseline (usual state) on 7/11/23 at 7:26 A.M. were concerning, that the Physician should have been notified immediately and was not, resulting in a delay in transferring the Resident to the Emergency Room. During a telephone interview on 8/17/23 at 9:18 A.M., the Attending Physician said that if a Resident's temperature was 90 degrees and the BP was 84/40, he would expect to be notified and did not recall being notified about the change in status and at that time of the telephone interview, he had no personal knowledge that the Resident had been hospitalized . Review of the SBAR (situation, background, assessment, recommendations) Communication Form (a technique that provides framework for communication between members of the health care team about a patient's condition) dated 7/11/23, indicated the Attending Physician was notified of the Resident's condition at 11:15 A.M., and his recommendation was to transfer the Resident to the ER for evaluation. During a follow up interview on 8/17/23 at 11:22 A.M., Nurse #1 said Resident #199 was the most complicated case she ever had on her unit (the Long-Term Care Unit), and she had worked at the facility for many years. Nurse #1 further said, we don't often get complicated cases up here. Additionally she said that the Resident's temperature was regularly 90 in the morning and that the staff routinely used forehead thermometers. Review of the Resident's Medical Record indicated the vital signs obtained during the morning of 7/11/23 were not the Resident's baseline. In addition, there was no documented evidence in the Medical Record the Resident's body temperature was ever 90 degrees. During a follow up interview on 8/17/23 at 12:22 P.M., UM #1 said if she were caring for the Resident on 7/11/22 at 7:26 A.M., she would have taken a second set of vital signs and if they remained abnormal, she would have called the Attending Physician right away. She further said the Resident should have been reassessed by Nurse #1 prior to the OT alerting the Nurse of her concerns at 10:15 A.M., that three hours was too long to wait given the Resident's status. During an interview on 8/17/23 at 2:10 P.M., the Director of Nursing (DON) said Nurse #1 did not notify the Attending Physician as soon as she assessed the Resident's vital signs to be abnormal on 7/11/22 at 7:26 A.M., and she should have. 2. Review of the facility's policy titled, Proper Wound Documentation and Measuring of Wounds, undated, indicated the following: -All wounds should be documented with every dressing change and measured weekly. The person doing the weekly measurements will be required to fill out the Skin Assessment in the Electronic Medical Record (EMR). -The following should be included in the documentation: >location of wound >any odor >ulcer category-stage for pressure (determine the severity), necrotic (dead) tissue, dimension (shape, length and width in centimeters (cm) >pain >describe the surrounding tissue, color of the wound bed, tunneling (when wound extends deeper than the surface) and undermining (separation of wound edges from surrounding tissue, creating a pocket), redness or other discoloration in the surrounding skin, and whether the surrounding skin is loose, tightly adhered, flat or rolled under. Review of Norton Scale for Predicting Risk of Pressure Ulcer (a tool used to assess risk for developing pressure injuries or ulcers), dated 6/21/23 indicated the Resident was at moderate risk for developing a pressure injury. Review of the Nursing Progress Notes indicated the Resident's Foley catheter had been removed on 6/1/23, he/she remained mostly bed bound and was incontinent of bladder and bowel, increasing the Resident's risk, along with his/her immobility for developing a pressure injury. Review of the Resident's Care Plan indicated the following: - Resident at risk for skin breakdown related to recent surgery and immobility (initiated 6/27/23). - Resident needs an alternating pressure mattress set between soft and firm to protect skin while in bed (initiated 6/27/23). - Follow facility protocols for treatment of injury (initiated 6/27/23). Review of Weekly Skin Assessments indicated the following: -6/30/23: Skin intact, limited assessment related to pain and limited mobility, no concerning areas visualized. -7/7/23: Skin intact, no concerns. Review of the Nursing Progress Notes indicated the following: -7/1/23: 10:57 A.M., Bilateral inner buttocks with reddened irritation, has denuded area (loss of outer layer of skin due to exposure of urine, feces, body fluids or friction) measuring 2 centimeters (cm) by (x) 0.75 cm between the butt cheeks at the coccyx area (area at the base of the tailbone). Skin intact except for the right inner buttock cheek. Calmoseptine (an ointment intended as a moisture barrier that protects and helps heal skin irritations) applied to denuded area and inner bilateral buttocks. -7/1/23: 9:27 P.M., Calmoseptine to open areas and buttocks. -7/2/23: 10:24 A.M., Bilateral inner buttocks nearly healed, coccyx denuded slit improved. -7/6/23: 10:57 A.M., Denuded slit above rectal area healed, new slit noted today measuring 1 cm x 0.25 cm in the sacral area (area above the tailbone and below the spine). Bilateral inner buttocks with scattered discolored purplish irritated areas, Calmoseptine applied. -7/6/23: 2:51 P.M., Resident complained of pain in right butt cheek after transfer by mechanical lift. -7/7/23: 11:36 A.M., Slit in sacral area noted, Calmoseptine applied per orders. -7/7/23: 9:02 P.M., Nursing Assistant requested for Nurse to assess slit between coccyx. Right buttocks is purple in color with three blisters 2-3 cm round. When Calmoseptine was applied, blisters slid off buttocks and there are now three open areas measuring 2-3 cm round. -7/8/23: 15:35 P.M., Right buttocks continue to be purple in color with three open areas 2-3 cm round. The Resident complained of pain to the buttocks, Calmoseptine applied. Review of the Hospital admission History and Physical dated 7/11/23, indicated the Resident was noted to have a wound on the buttocks that appeared infected. Review of the Hospital Wound Care Consultation dated 7/15/23, indicated a Wound Specialist was consulted to assess and treat a Deep Tissue Pressure Injury (DTPI- a persistent non-blanchable (does not turn white when pressed) deep red, maroon or purple discoloration due to damage of underlying soft tissue) present on arrival to the hospital to the sacrococcygeal area (base of the spine by the tailbone) region extending to the soft tissue of the bilateral buttocks. Further review of the Wound Care Consultation notes indicated the Resident required sharp debridement (removal of dead tissue using a sharp instrument such as a scalpel) on 7/18/23. During an interview on 8/16/23 at 9:41 A.M., UM #1 said Resident #199 came in with no skin issues other than his/her surgical incision and when a skin issue occurs our policy is to complete an incident report. She further said the facility did not contract with an outside wound specialist, their Minimum Data Set (MDS) Nurse acts as the wound specialist, and if a skin issue arises, we request her to assess the Resident. UM #1 said she did not know if an incident report was completed for Resident #199 because the area was not truly open when it was first identified as a slit. She further said the Weekly Skin Assessment recorded on 7/7/23 was inaccurate because the same Nurse indicated the Resident had an open area in a progress note on the same day. In addition, UM #1 said purple skin could indicate a DTPI and should have been fully assessed, measured and monitored in order to determine whether the area was improving or worsening. She also said there was no evidence in the medical record that the purple areas on the Resident's buttocks were monitored or determined to be a DTPI. During an interview on 8/16/23 at 12:59 P.M., Nurse #1 said Resident #199 had scattered purple areas located in his/her inner buttocks that seemed to be there one day then gone the next, and she did not feel the need to report this on an incident report. She further said that if she suspected a pressure injury, she would let the UM know and she would contact the Attending Physician. In addition, Nurse #1 said she did not know if she had to complete incident reports for a pressure injury. She said she did not measure the Resident's purple area, and the measuring is usually left up to the UM and the MDS nurse who seemed to be the designated wound specialist in the facility. During an interview on 8/17/23 at 1:20 P.M., the MDS Nurse said she did not have any official wound care credentials, her wound care experience came from working with wound specialists and she had served as the dedicated wound nurse in a different facility in the past. She further said she remembered seeing the Resident's wound early on, however she did not normally document her findings in the progress notes. The MDS Nurse said she visits the Residents along with the UM and will recommend a treatment for the UM, who would then obtain a Physician's order for the treatment. In addition, she said the facility policy was to perform weekly skin assessments and document in the EMR, and even small areas, including those described as slits should be assessed daily, however they are not always entered into the Weekly Skin Assessment. She said that anything purple in color on an area that is subject to pressure (such as a buttock) is concerning for a DTPI. She further said that a DTPI or unstageable wound should be recognized as a pressure injury, measured and tracked in the Weekly Skin Assessment. During an interview on 8/17/23 at 2:10 P.M., the DON said when there was skin breakdown, an incident report should be completed and for Resident #199 she confirmed there were no incident reports or Skin Assessments related to the purple area on his/her buttocks. She further said the areas should have been monitored and measured to determine whether they were getting better or worse and for Resident #199 this was not done, as required.