**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation pertains to Intake Number MI00142207. Based on interview and record review, the facility failed to protect Resident #103's (R103) right to be free from neglect, which resulted in R103's physical deterioration and subsequent death. Immediate Jeopardy: The Immediate Jeopardy began on 12/12/23 when Resident #103 (R103) was admitted to the facility from the hospital for short-term rehab following a left arm fracture and a Urinary Tract Infection (UTI). An admission nursing assessment identified only a pressure injury on the right heel. The facility failed to follow hospital discharge instructions, physician's orders, and did not obtain follow-up consults for wound care which resulted in the worsening of and development of wounds on the right 5th toe, right heel, right lateral foot, right lateral lower leg, sacrum, coccyx and thoracic spine. The facility failed to ensure hydration and nutrition were accessible, and provide needed assistance to drink and eat. The facility left the resident in the wheelchair for an extended period of time and the resident fell and hit his head. Multiple staff were made aware of concerns related to R103's care and overall decline and failed to act, including but not limited to, being made aware: that the resident could not call for help if needed, that the resident was found sitting in urine soaked bedding, the resident's broken arm was not cared to facilitate healing, and pain and swelling reduction. The resident was placed in a room with a Covid-positive resident and subsequently developed Covid 19. R103 was admitted to the hospital on [DATE] with septic shock, malnutrition, a 25-pound weight loss since admission on [DATE], a Stage 3 thoracic injury, a Stage 4 sacrococcygeal injury, unstageable pressure injuries to the right leg, right heel, and right 5th toe and deep tissue injuries to the left leg and left heel. On 01/17/24 R103 was placed on hospice care and died on [DATE]. The death certificate stated that R103 died of sepsis. Findings: Resident #103 (R103): Review of an admission Record revealed R103 was an [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: left arm fracture, acute cystitis with hematuria (a bladder infection with blood in the urine), diabetes, and heart disease. Review of a Minimum Data Set (MDS) assessment for R103, with a reference date of 12/18/23, revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated R103 was cognitively intact. Review of a hospital discharge summary reflected R103 was discharged to the facility on [DATE] in the following condition .confusion improved and back to baseline .follow up with orthopedics in 2-3 weeks for left arm fracture . wound care: buttocks-liberally apply Desitin twice per day and PRN (as needed) until skin is healed. Right heel-paint with betadine and cover with dry gauze daily .follow up with wound healing center within 7 days. Review of R103's Hospital Medical Nutrition Therapy - RD Chart Review note dated 12/11/23 revealed, No weight loss seen in chart during these visits . R103's weight had remained stable. Review of R103's facility admission Assessment dated 12/12/23 revealed: (a) R103 was alert and oriented to person, place, and time (no cognitive impairments), had no behavioral symptoms, and had no diagnoses affecting his cognitive status or memory, (b) admission weight-178.9, (c) R103 had a right heel pressure injury measuring 3 cm x 6.5 cm and was staged as unstageable, (d) R103 had an abrasion on his left gluteal fold measuring 6 cm by 3.5 cm with a depth of 0.1 cm, (e) R103's pedal pulses were palpable, equal, and weak/thready, indicating R103 had poor/impaired blood flow to bilateral feet. (Impairments in blood flow to the feet increase the risk for heel pressure injuries). Review of R103's Electronic Health Record revealed no documentation that the provider was notified of R103's wounds identified on the admission assessment. Review of R103's Order Summary revealed the wound care treatment for R103's right heel was not ordered, initiated, or completed upon admission to the facility per the hospital discharge orders. (An order for wound treatment for R103's right heel was not ordered until 1/10/24.) Review of R103's Order Summary revealed the wound care treatment for R103's buttocks was not ordered, initiated, or completed upon admission to the facility per the hospital discharge orders. (An order for wound treatment for R103's buttocks was not ordered until 12/19/23.) Review of R103's Electronic Health Record revealed no order and/or appointment scheduled for a wound consult following his admission to the facility per the hospital discharge orders. (A wound care consult was not initiated until 1/5/24 and he was not evaluated by the wound consultant until 1/11/24). Review of R103's Care Plan for skin integrity revealed, I have actual impairment to skin integrity r/t left buttock abrasion and right cheek abrasion Date Initiated: 12/12/2023 .Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx (signs and symptoms) of infection, maceration etc. to MD (physician). Date Initiated: 12/12/2023. It was identified that R103 had poor BLE perfusion (pedal pulse assessment-weak/thready) during the admission assessment which increased R103's risk for the worsening of the right heel pressure injury and the development of additional wounds on R103's feet. There were no interventions implemented in R103's Care Plan to prevent the worsening of R103's right heel pressure injury and/or the development of new pressure injuries to R103's feet. Review of R103's Social Service admission Note dated 12/13/23 revealed, .Resident was admitted from hospital for a fall that resulted in a broken shoulder .Resident plans to gain strength and heal through P/T (physical therapy), O/T (occupational therapy) and S/T (speech therapy) .Resident is able to communicate verbally and answer questions .Resident is their own person .BIMS-14. The admission note revealed R103 did not have any behavioral concern or a history of trauma requiring follow-up. Review of R103's Social Work Discharge Assessment dated 12/13/23 revealed, 1. Resident's Discharge Plan: Gain strength in order to safely discharge home .Prior to coming to the SNF (skilled nursing facility), where was he/she living? Independent living .is this living arrangement still available to them? Yes .Discharge Potential: Fair. Review of R103's Care Conference Summary dated 12/13/23 at 10:04 AM revealed, IDT (interdisciplinary team) met with resident to discuss resident's stay at the facility. Resident is hopeful about gaining strength and healing in order to safely discharge back home. Resident does live alone and is open to home health care needs, if necessary, upon discharge .Discharge Potential: Fair. Confirming R103 was admitted to the facility for rehab services and had the potential to return to his home. Review of R103's Care Plan revealed, I am here for a short term stay and will be offered therapeutic activities that support my rehab goals. Date Initiated: 12/18/2023. Confirming R103 was expected to return home following the completion of therapy. Review of R103's Occupational Therapy Treatment Encounter Note dated 12/13/23 at 6:23 PM revealed, Pt (patient) supine needed full bed change and to be changed, pt in room for Covid precautions and door is shut. Nursing notified of pt needing full bed change. Review of R103's Practitioner Progress Note completed by Nurse Practitioner (NP) B and dated 12/13/23 at 9:00 PM revealed, (R103) is discharged to (facility) for SAR (subacute rehab) 12/12/23. Today he is seen in his room in no apparent distress, endorses minimal use of left arm with significant swelling .Is hoping for therapy evaluation today so he can get out bed. A/O x 4 (alert and oriented to person, place, time, and situation). R103's wounds identified during the admission assessment were not addressed confirming the provider was not notified at the time the wounds were identified. Review of R103's Physical Therapy Treatment Encounter Note(s) dated 12/14/23 at 8:30 AM revealed, .rolling two assist to max assist to get changed and new sheets as current sheets were soiled, patient declined to sit up, stated he was too fatigued. Review of R103's Nursing Progress Note dated 12/14/23 at 9:21 AM revealed, Called and spoke to RN on the ER operating line to give nurse to nurse report. I stated the following. Upon entering the room the author noticed that (R103) was acting strange unable to speak, labored breathing diaphoretic and lethargic. He was responding inappropriately and BGL (blood glucose level) at 9:04 was 40 and received 1 mg IM (intramuscular) of glucagon and at 9:12 am his BGL was retested and was at 42 he was unable to swallow the oral Glucose 15. Review of R103's Hospital Discharge Documents dated 12/14/23 at 10:06 AM revealed, Patient seen and examined by myself for a chief complaint hypoglycemia prior to arrival . Patient states he felt okay and does not know exactly why his blood sugar went down but that he thinks maybe he had missed a meal. Review of R103's Practitioner Progress Note completed by NP B and dated 12/15/23 at 8:26 PM revealed, Today he is seen in his room in no apparent distress, endorses minimal use of left arm with significant swelling secondary to non-surgical fracture of left arm .He was sent to ED (emergency department) yesterday am by facility staff for hypoglycemic episode, bg (blood glucose) 40 per EMR (electronic medical record), apparently facility did not administer glucagon, EMS did upon arrival. He was evaluated in ED, he said he had not been getting food or much to drink the day prior, suspect hypoglycemia secondary to poor intake. Today he has no fluids at his bedside, states has not had anything to drink since yesterday. I did discuss this with his nurse and unit manager .He thanked me and states I just want to go home. NP B documented that at the time of the assessment R103 was alert and oriented x 4. Review of R103's Care Plans revealed there were no new interventions initiated to ensure R103 had water/fluids and adequate food/snacks to prevent hypoglycemic events following NP B's discussion with the nurse and unit manager. Review of R103's Skilled Assessment dated 12/16/23 revealed no assessment of R103's pedal pulses. Review of R103's Nutrition Summary Note dated 12/18/23 revealed, (R103's) nutritional status was evaluated and food preferences were obtained. My appetite is good. My nutrition goals while here are: maintain weight. Met with resident, who reports an okay appetite. Denies issues with chewing or swallowing. Review of R103's Occupational Therapy Treatment Encounter Note dated 12/15/23 revealed, Pt (patient) found with LUE (left upper extremity) thumb and palm under leg, LUE elevated and STM (soft tissue mobilization) to shoulder joint to open lymph pathway. Review of R103's Care Plans revealed no interventions for elevating R103's left upper extremity to reduce swelling. Review of R103's Occupational Therapy Treatment Encounter Note dated 12/18/23 revealed, OTA (Occupational Therapy Assistant) observed blisters on Pt's back and had DON (Director of Nursing) assess. OTA and DON coordinated to have pt (patient) get air mattress .OTA directed pt in brief change, noting pt soiled upon arrival. Review of R103's Nursing Progress Note completed by DON and dated 12/18/23 at 7:19 PM revealed, This nurse was called to room by therapy to assess resident's skin. Therapist had noted areas of concern. Resident found to have blisters on his back, a DTI (deep tissue injury) to thoracic spine and stage 2 pressure injury to his coccyx. Care plan updated and order for air mattress. Maintenance care submission to switch out mattress. Please see detailed wound assessment for measurements. Review of R103's Wound Assessment completed by the DON and dated 12/18/23 revealed: Wound #1: right heel suspected deep tissue injury measuring 5 cm x 2.5 cm. Treatment/Changes/Notifications: Continue current treatment. Wound #2: vertebrae (upper-mid) suspected deep tissue injury measuring 1.5 cm x 1 cm. Acquired in-house. Treatment/Changes/Notifications: Air mattress ordered. Wound #3: left scapula blister measuring 4 cm x 0.5 cm. This was not documented as a pressure injury. Acquired in-house. Treatment/Changes/Notifications: Air mattress ordered. Wound #4: right scapula blister measuring 16.5 cm x 4.0 cm. This was not documented as a pressure injury. Acquired in-house. Treatment/Changes/Notifications: Air mattress ordered. Wound #5: coccyx Stage II pressure injury measuring 7 cm x 4.5 cm with a depth of 0.1 cm. Acquired in-house. Note: hospital discharge order dated 12/12/23 for liberally apply Desitin twice per day and PRN (as needed) until skin is healed which had not been initiated since R103's admission. Review of R103's Care Plan revealed new interventions to prevent the worsening of R103's pressure injuries discovered on 12/18/23. Encourage good nutrition and hydration in order to promote healthier skin and I need air mattress and pressure relieving boots to protect the skin while in bed. The intervention to apply house barrier cream was not included until 1/9/24. Review of R103's Order Summary revealed: No order for the treatment of Wound #1: right heel suspected deep tissue injury measuring 5 cm x 2.5 cm. (An order for wound care for R103's right heel was not ordered until 1/11/24.) No order for the treatment of Wound #2: vertebrae (upper-mid) suspected deep tissue injury measuring 1.5 cm x 1 cm. (An order for wound care for R103's vertebrae was not ordered until 1/5/24.) Wound #3 and #4: WOUND CARE: Blisters bilateral back. Cleanse gently with soap and water or house wound cleanser. Apply skin prep BID (twice a day) if blisters are intact. Cover with non-adherent dressing ONLY if blisters are open. Change dressing BID. two times a day- Start Date 12/19/2023. Wound #5: WOUND CARE STAGE II - until healed Cleanse the area with soap and water or saline and dry. Apply hydrocolloid dressing, change q 3d (every 3 days) and prn if dressing soiled or for accidental removal. one time a day every 3 day(s) for Stage II Coccyx -Start Date 12/19/2023. Review of R103's Occupational Therapy Treatment Encounter Note dated 12/19/23 at 9:52 AM revealed, Pt with increased edema on this date due to sitting in wc (wheelchair) for extended amount of time without arm elevated. Review of R103's Practitioner Progress Note completed by NP B and dated 12/19/23 at 12:51 PM revealed . resident had appointment with Ortho today who gave orders for PT/OT and reinforced elevation of LUE (left upper extremity) to decrease swelling. He is observed laying in bed, states he has not gotten up for meals since arrival to facility. NP B documented that at the time of the assessment R103 was alert and oriented x 4. R103's 5 pressure injuries/wounds were not addressed during NP B's assessment. Review of R103's Order Summary revealed, Orthopedic follow-up recommendation- Encourage patient to elevate left arm above the level of the heart 3-4x/day for 30-45 minutes order date 12/19/23. Review of R103's Care Plans revealed no intervention to elevate R103's left upper extremity to decrease swelling recommended by the facility provider and orthopedic provider. R103 did not have a Weekly Skin Sweep completed on 12/19/23 following the facility's policy and procedure Skin and Pressure Injury Risk Assessment and Prevention for a skin assessment to be completed upon admission and weekly thereafter. Review of R103's Care Plan revealed no intervention for timed (every 2 hour) repositioning. Noting only Assist me to turn &/or reposition routinely during CNA (Certified Nursing Assistant) rounds while in bed and frequently redistribute my weight if/when I am up in my chair, (not initiated until 1/9/24). Review of R103's Practitioner Progress Note completed by NP B and dated 12/20/23 at 3:03 PM revealed, resident is seen in his room in no apparent distress, unfortunately he tested + (positive) for COVID yesterday, of note this pt. was tested during recent ED visit with negative results, he was placed in room in facility with COVID + roommate upon return from ED. He reports frustration with this and states I just want to go back to my home .He is here for SAR (subacute rehab), he states he is almost always in bed and wishes to be up for meals, this is communicated verbally to facility staff. R103's pressure injuries were not addressed during NP B's assessment. Review of R103's Care Plans revealed there were no new interventions initiated to ensure R103 was assisted out of bed for meals. Review of the COVID outbreak Line List confirmed R103's roommate tested positive for COVID with the 1st COVID test obtained on 12/13/23. R103 received treatment for hypoglycemia in the emergency department on 12/14/23 and per the Hospital Discharge Summary tested negative for both COVID. Upon return to the facility, R103 returned to his room (where his COVID positive roommate continued to reside) and tested positive for COVID on 12/19/23. Review of R103's Occupational Therapy Treatment Encounter Note dated 12/21/23 revealed, OTA provided positioning in bed to elevate LUE to decrease edema. Patient not feeling well. Patient with change in medical status with new illness and demonstrating fatigue and decreased alertness during session on this date .Upon arrival pt with soiled brief and bed pad .Pt with blood in brief and visible wound on bottom, noting OTA updated DON on visual appearance of wound. OTA inquired with contract wound nurse if pt was on her schedule for this date and he was not .Complexities/Barriers Impacting Session: Change in medical status, pain from wound. Confirming DON was notified of a change in R103's medical status change and the need for a wound consult. Review of R103's Wound Assessment dated 12/21/23 revealed: Wound #1: sacrum Stage II pressure injury measuring 8 cm x 3 cm. Documented as a new skin condition. No other wounds were addressed in the wound assessment (previous assessment on 12/18/23 included 5 pressure injuries/wounds.) Review of R103's Care Plans revealed the intervention/education notified aides to have more frequent turning and cleaning was not added to R103's Care Plan until 1/9/24. Review of R103's Skilled Assessment dated 12/22/23 revealed no assessment of R103's pedal pulses. Review of R103's Weekly Skin Sweep dated 12/24/23 revealed, sacrum-open area, treatment in place for pt. The documentation of the areas of impairment did not include the type of wound, measurements, color, type of tissue in wound bed, drainage, odor, and/or pain (as required in the facility policy Skin and Pressure Injury Risk Assessment and Prevention.) Review of R103's Weekly Skin Sweep dated 12/28/23 revealed: Sacrum-open area noted to sacrum. Macerated edges discolored .Discoloration noted to BLE (bilateral lower extremities).Left arm swollen and discolored. The documentation of the areas of impairment did not include a pedal pulse assessment (pertinent assessment with the discoloration of BLE), the type of wound, measurements, color, type of tissue in wound bed, drainage, odor, and/or pain (as required in the facility policy Skin and Pressure Injury Risk Assessment and Prevention.) Review of R103's Electronic Health Record revealed no documentation that the provider was notified of the deterioration of the sacral wound (macerated edges) or the discoloration of R103's BLE, left arm, or sacrum which was a change from R103's baseline. There was no follow up from the DON/Wound Team following the 12/28/23 Weekly Skin Sweep and no follow up from the facility providers. Review of R103's Behavior Management Program Review and Symptom Analysis dated 12/21/23 revealed, Resident is not showing any behaviors at this time. IDT (interdisciplinary team) will continue to monitor this resident. Confirming R103 did not have a history of refusing care and/or treatment. R103 did not have a Wound Assessment completed on 12/28/23 following the facility's policy and procedure Wound Treatment Management and Documentation (last wound assessment was on 12/21/23). Review of R103's Skilled Assessment dated 1/1/24 revealed no assessment of R103's pedal pulses. Review of R103's Skilled Assessment dated 1/2/24 revealed R103's left pedal pulse was weak and thready and his right pedal pulse was normal. Review of R103's Nursing Progress Note dated 1/3/24 at 5:03 PM revealed, Event occurred on 01/03/2024 4:30 PM. author alerted that patient slid out of his wheelchair and stated that he hit his head. DON came and got nurse assigned to patient, but cena's (Certified Nursing Assistants) on hall placed patient back in bed prior to a nursing assessment. Order from (NP B) to send patient out for eval and CT of head. Review of R103's Care Plan did not reflect the use of a high back/reclining wheelchair or resident focused interventions for the use of the high back/reclining wheelchair to ensure resident safety and prevent falls. Review of R103's Antigravity Team Note dated 1/4/24 revealed, Date of Fall: 1/3/24. Root Cause(s) of Fall: Resident was up in wheelchair for an extended period of time upon returning from an appointment. During an interview on 01/31/24 at 2:32 PM, Director of Therapy (DT) J reported that R103 required extensive assistance with sitting up because he was non weight bearing to his left arm and was receiving therapy services for weakness. DT J reported that a high back wheelchair was obtained for R103 due to his weakness and fractured left arm. DT J reported that R103 fell from his chair because staff left him sitting straight up and down at a 90-degree angle for an extensive period of time following his appointment. DT J reported staff should have reclined the high back wheelchair for his safety and comfort. Review of R103's Practitioner Progress Note completed by NP B dated 1/4/24 at 7:13 PM revealed, Patient seen today in his room for fall occurring 1 day ago in facility. NN reviewed, per NN patient slid out of his wheelchair and stated that he hit his head. Today he is observed laying in his bed, appears uncomfortable. He states he is thirsty, breakfast tray noted to be on table untouched, patient is laying down in bed unable to reach call light. He states his head hurts, facility nurse manager notified. R103's wounds were not addressed during the provider assessment. Review of R103's Care Plan revealed, Offer resident fluids with every interaction was not initiated until 1/4/24. The nurse manager did not update the care plan to reflect that R103 required meal set-up. Review of R103's Wound Assessment completed by DON dated 1/4/24 at 9:21 PM revealed: Wound #1: sacrum suspected deep tissue injury measuring 14 cm x 12 cm x 0.2 cm depth. Treatment/Changes/Notifications- Tx (treatment) in place. Referral to (contracted wound consulting company) sent 1/4/24. R103's sacral pressure injury had a significant increase in size from previous assessment on 12/21/23. There was no documentation that the provider was notified of the worsening of the wound. Wound #2: vertebrae (upper-mid) suspected deep tissue injury measuring 5.5 cm x 5.0 cm. Treatment/Changes/Notifications- Tx (treatment) in place. Referral to (contracted wound consulting company) sent 1/4/24. R103's vertebral pressure injury had a significant increase in size from previous assessment on 12/18/23. No other pressure injuries/wounds were addressed in the wound assessment. There was no documentation that the provider was notified of the worsening of the wound. Review of R103's Electronic Health Record revealed no documentation that the provider was notified that R103 was too weak to sign his own name which was a deviation from his baseline. Review of R103's Weekly Skin Sweep dated 1/9/24 revealed: Hydration Screen .Mucous membranes-Dry. Mucous Membrane color-Pale. Indicating R103 was exhibiting signs of dehydration. Review of R103's Electronic Health Record revealed no documentation that the provider was notified that R103 was exhibiting signs of dehydration (dry and pale mucous membranes) or the nursing management team to ensure appropriate on-going assessments. Review of R103's Care Plans revealed the care planned intervention initiated on 1/4/24 to Offer resident fluids with every interaction was ineffective. There were no new interventions initiated to prevent continued and/or worsening dehydration. Review of R103's Order Summary revealed, Elevate left arm d/t (due to) edema in left hand/ arm every shift for swelling order date 1/9/24. This order was not reflected in R103's Care Plans. Review of R103's Physical Therapy Treatment Encounter Note dated 1/11/24 revealed, Left UE (upper extremity) very swollen and hanging off bed. Review of R103's Dietary Note dated 1/11/24 at 12:50 PM revealed, Following resident r/t new wound. Resident with stage II open wound on coccyx. Wound developed in LTC (long term care). The dietary assessment did not include R103's multiple new facility acquired pressure injuries, weight loss/weight assessment, or his dehydration. Review of R103's IDT Review Note completed by DON and dated 1/12/24 at 4:14 PM revealed, Note: Resident was seen in consultation with (contracted wound consulting company) (Wound Consultant Physician assistant (WCPA) D on 1/11/2 and the following 6 wounds were noted: Wound #1: R (right) Upper Back Stage II Pressure Ulcer. Initial measurements were 2.9 x 4.1 x 0.1 cm. Wound #2: Unstageable Pressure Injury with full thickness skin and tissue loss. Initial measurements were 22 x 15 x 0.1 cm. WCPA D opted not to perform debridement due to evolving status of the wound, eschar was not amenable to debridement (sacrococcygeal area). Wound #3: R Lateral Lower Leg Unstageable Pressure Injury. Initial measurements were 2.5 x 4.2 x 0 cm. Wound #4: R heel DTI (deep tissue injury). Initial measurements 2.54.2. Wound #5: R Lateral foot Unstageable Pressure injury. Initial measurements 4.8 x 1.5 x 0.1 cm Wound #6: R fifth toe DTI. Initial measurements 1.1 x 1 cm. Mechanical debridement was performed to wound #5 with a blade and forceps. Pain control was achieved with 4% lidocaine spray. Post debridement measurements were 5.8 x 1.5 x 0.2 cm Note: R103 received a surgical debridement and not a mechanical debridement (surgical debridement uses a scalpel/blade where mechanical debridement uses moist to wet dressings and/or hydrotherapy). Review of R103's IDT Review Note dated 1/12/24 at 4:37 PM revealed, Note: Correction: Measurements to wound #3, R lateral lower leg are 22.3 x 3.9 cm. Review of R103's Contracted Wound Consultants Progress Note Detail completed by WCPA D and dated 1/11/24 revealed, Associated Signs and Symptoms: Complains of pain and drainage. Patient admitted with a pressure injury of his right heel. Patient has developed several additional wounds. Patient is non-ambulatory and incontinent of bowel and bladder. Facility DON reports patient has been overall declining with poor appetite, little PO (oral) intake, and increased weakness .Physical Exam .Cardiovascular: the DP (dorsalis pedis) and PT (posterior tibial) pedal pulses are not palpable bilaterally (indicating significantly diminished and/or absent blood flow to feet) (last pedal pulse assessment was completed on 1/2/24 with noted irregularities).Wound #1 Right Upper Back is a Stage 2 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 2.9 cm length x 4.1 cm width x 0.1 cm depth, with an area of 11.89 sq cm (square centimeters) and a volume of 1.189 cubic cm. There is a small amount of serous drainage noted which has no odor. Wound#2 Sacral is an Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 22 cm length x 15 cm width x 0.1 cm depth, with an area of 330 sq cm and a volume of 33 cubic cm. There is a small amount of serosanguineous drainage noted which has no odor. General Notes: Extensive sacral wound extending to the bilateral buttocks and lower back. Debridement not performed due to: Wound is still evolving, and eschar is not amenable to debridement at this time. Wound #3 Right, Lateral Lower Leg is an Unstageable Pressure Injury, Obscured full-thickness skin and tissue loss pressure ulcer and has received a status of Not Healed. Initial wound encounter measurements are 22.3 cm length x 3.9 cm width with no measurable depth, with an area of 86.97 sq cm. There was no drainage noted. General Notes: Wound along the fibula. Small area of dry, stable eschar distally. Superior area with deep tissue pressure injury. Wound #4 Right Heel is a Deep Tissue Pressure Injury Persistent non-blanchable deep red, maroon or purple discoloration, Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 2.5 cm length x 4.2 cm width with no measurable depth, with an area of 10.5 sq cm. There was no drainage noted. Wound #5 Right, Lateral Foot is an Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 5.8 cm length x 1.5 cm width x 0.1 cm depth, with an area of 8.7 sq cm and a volume of 0.87 cubic cm. There is a Scant amount of serous drainage noted which has no odor. Wound #6 Right Fifth Toe is a Deep Tissue Pressure Injury Persistent non-blanchable deep red, maroon or purple discoloration Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 1.1 cm length x 1 cm width with no measurable depth, with an area of 1.1 sq cm. There was no drainage noted. Additional Orders .Turn in bed at least once every 2 hours if able (specific turn schedule of every 2 hours was not initiated on care plan during entire length of stay). During an interview on 2/1/24 at 2:35 PM, WCPA D reported she was consulted to assess R103 due to multiple wounds. WCPA D reported that she had not been consulted on R103 until the week before and he was not on my radar. WCPA D re[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake # MI00139197, MI000136833, MI000137737. This citation has multiple Deficient Practice Statements (DPS), A & B. DPS A Based on interview and record review, the facility failed to acknowledge, identify, and provide adequate supervision to prevent an elopement and ensure the safety of 1 resident (Resident #66), reviewed for risk of elopement, placing all residents with a history of wandering and/or elopement behavior at risk of serious harm and/or death. This deficient practice resulted in an Immediate Jeopardy beginning on 8/29/23 at 2:40 PM, when R66, a known elopement risk, eloped from the facility after Receptionist F allowed him to leave the building unattended. Receptionist F did not immediately recognize R66 as a resident and R66 was not included in the elopement risk binder. Receptionist F eventually identified R66 as a resident but had lost sight of him, adjacent to a 35 MPH 4 lane, high traffic volume road nearby a moving water source. Furthermore, Receptionist F did not follow the policy and activate an internal alert notifying all staff of a missing resident. Receptionist F sent out an email at 2:51 PM notifying management staff that R66 had eloped which was not seen by a member of management until 2:56 PM. At 3:24 PM (44 minutes after his elopement) R66 was located by facility staff approximately 0.25 miles from the facility. R66 arrived back to the facility at 3:30 PM. Findings: Resident #66 (R66) Review of an admission Record revealed R66 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: mild cognitive impairment, major depressive disorder, alcohol abuse, epilepsy, and stroke. R66 had an activated DPOA (Durable Power of Attorney)/decision maker. Review of a Minimum Data Set (MDS) assessment for R66, with a reference date of 6/21/23 revealed a Brief Interview for Mental Status (BIMS) score of 8, out of a total possible score of 15, which indicated R66 was moderately cognitively impaired. Review of R66's Hospital Records dated 6/14/23 (prior to admission to the facility) revealed, .Reviewed neuro-psychology consult which indicates an impaired cognitive profile, marked by his verbal and visual learning and memory and information processing speed. Executive functioning is notably variable. With functional declines reported by (R66), his updated cognitive profile now meets criteria for the diagnosis of Major Neurocognitive Disorder .Cognitively, his memory functioning has progressively worsened since 2020. He acknowledged that he most likely would not remember important information over time. Decreased information processing speed and attention and intermittent word finding difficulties were also endorsed . Review of R66's Admission/readmission Assessment dated 6/15/23 revealed R66 was identified as at risk for elopement. Review of R66's Care Plan dated 6/15/23 revealed, I am at risk for elopement r/t (related to): confusion secondary to a hx (history) of ETOH (alcohol) usage and cardiac insufficiency, dizziness, dx (diagnosis) of depression, incontinence, and forgetfulness .I need direct supervision while outside the facility . Place information in the elopement book per policy . During an interview on 08/30/2023 at 2:59 PM, Licensed Practical Nurse (LPN) V reported that she was working on 8/29/23 when she heard an overhead page of a code search which indicated a resident was missing. LPN V reported that she was not working on R66's unit at the time but reported that he had since been moved to her unit (dementia unit) and now had a wander-guard (alarm bracelet) because of his elopement and his continued risk for elopement. Review of the Witness Statement written by Receptionist F and dated 8/29/23 revealed, FOLLOWING IS MY STATEMENT REGARDING THE ELOPEMENT OF (R66) WHICH OCCURRED TUESDAY, AUGUST 29, 2023, AT 2:40 PM. THIS STATEMENT SUPERCEDES THE INCOMPLETE HANDWRITTEN STATEMENT I PROVIDED EARLIER TODAY WHEN I WAS UNABLE TO CLEARLY UNDERSTAND WHAT WAS BEING ASKED OF ME. On Tuesday, August 29, 2023, (R66) a resident at (facility), approached the front desk and asked me for directions to (shopping center). I did not recognize (R66) as a resident as I was unfamiliar with him, and he was not in the elopement binder (there are 86 residents at (facility) and I know about 30 of them by name and by sight.) Additionally, he was not in a wheelchair or using a walker or cane; he was appropriately dressed and appeared coherent to me. After I gave him directions, he went to look for (R66) sign out page. Again, I did not know he was (R66). He then signed out. I didn't think this was strange as I thought he was signing out the resident, (R66), and then going to go get him and take him to (shopping center). When he finished signing out and walked out without going to get the resident was when I thought something was wrong. I went to look at the page where he signed out and saw that (R66) was supposed to be accompanied when going outside the facility. I then realized that the person I was talking to was in fact (R66). I attempted to chase after him for five minutes. He walked very quickly, and I realized I wasn't going to be able to catch up to him. I also knew I needed to get back to my station at the facility as I'm not supposed to leave it for very long. I spent the next five minutes looking for the administrator. I could not locate her down the hallways nor did I see any other managers. I was unable to call the administrator's cell phone on (sic) it was not at the desk at the time and there isn't anything else at the front desk that might have the number. Because I thought this was an emergency situation, I sent an email to the leadership team explaining what happened because that was the best thing I could think of to do, and there was no one to speak with in person. I sent the email as a last resort. I was never instructed on elopement procedures; I was only instructed what to do during a Code Search. No one ever gave me the specific protocol as to what I was supposed to do if a resident actually eloped. No one ever specifically told me that elopement falls under abuse and neglect. During this entire time, I was unsure what I needed to do because of the lack of training (Do A; if not A, then B; if not B, then C). At this point after I sent the email the phone started ringing and I answered it. While I was on the phone, I noticed that the managers were up and about looking for the resident so at that point I stopped looking for someone to help. Very shortly after that, as I was sitting at the desk I overheard a nurse or aide say that she knew that (R66) was going to (shopping center). At this time the Code Search was initiated. Review of the Witness Statement written by Nursing Home Administrator in Training (NHAIT) Z and dated 8/29/23 revealed, (name omitted) the recreation director told me in the lobby area the (sic) (R66) had left the faciity on foot and the receptionist sent an email out about it. The administrator was also in the lobby and staff members began to disperse in searching. I was told by another resident that (R66) left the parking lot and went left on (facility road). I walked a few streets down to the right on (facility road) and did not see (R66). I came back to the facility where I met back up with (name omitted) who had walked to the left on (facility road). (name omitted) and I searched the creek and did a full perimeter of the outside of the facility .I saw a man in the distance that looked like (R66) and I ran to him (R66) returned safely to the facility where I stayed with him until we relocated him to the memory care unit and placed a wander guard on him with guardians permission. Review of the R66's elopement investigation revealed: Timeline of Events (8/29/23) 2:40 pm- Resident, (R66) signed himself out of the facility and was witnessed leaving the facility by (Receptionist F). Once [Name of Receptionist] realized he was not allowed out of the facility by himself, (Receptionist F) followed him into the parking lot. 2:50 pm- (Receptionist F) came back inside the facility to locate Administrator to inform them of the eloped resident. 2:51 pm- (Receptionist F) sent an email to (facility) Leadership Team informing them of the elopement. 2:56 pm- the email was read, and Code Search Drill was initiated, and members of the management team were dispatched into the surrounding area to locate the resident. 3:01 pm- (Nursing Home Administrator) called (name omitted) Police Department with description of resident to aide in community search for him. 3:09 pm- DPOA (name omitted) was notified by the administrator that (R66) had eloped from the facility and asked her if there were any locations in the immediate area that he would know to go to. (name omitted) said there was not. 3:24 pm- Resident was located on the corner of [NAME] Ave and [NAME] St by (NHAIT Z) and escorted back to the facility on foot. He was safe and assessed with no concerns noted . Root Cause Analysis It was determined that the facility mechanisms/ emergency door alarms were functioning properly and were sounding properly. Staff executed the process appropriately. Resident was found safe and immediately brought back into the facility with no concerns. The resident was identified as an elopement risk upon signing out and exiting the facility, and the staff member did initially follow him out into the parking lot. After determining she could not keep up with him the staff member returned to the building but did take several minutes to notify the team and have the Code Search Drill initiated. The receptionist on duty failed to follow through and initiate the drill in a timely manner. Once the drill was initiated, the procedure was followed correctly. Investigation Summary Upon review of staff, resident interviews, and investigation the facility confirms that resident exited the facility and was unsupervised for approximately 30 minutes. The facility does substantiate neglect. Although the receptionist, (Receptionist F), initially responded to the elopement, she failed to continue to follow the resident and initiate the missing resident procedure immediately. (Receptionist F) has been terminated as a result of this investigation due to substantiated neglect. Once Code Search was called the staff executed looking for the resident according to procedure. Staff successfully redirected resident (R66) back into the facility. He currently resides in our memory care unit and has decreased risk of being able to exit the facility without supervision . Review of the facility policy Elopements and Wandering Residents last reviewed/revised 4/23 revealed, Policy: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk .5. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. 6. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering a. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay. b. The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. c. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff. d. Adequate supervision will be provided to help prevent accidents or elopements. e. Staff will monitor the implementation of interventions, response to interventions, and document accordingly. f. The effectiveness of interventions will be evaluated, and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff. 7. Procedure for Locating Missing Resident a. Any staff member becoming aware of a missing resident will alert personnel using facility approved protocol (e.g. internal alert code). b. The designated facility staff will look for the resident. c. If the resident is not located in the building or on the grounds, Administrator or designee will notify the police department and serve as the designated liaison between the facility and the police department. The administrator or designee should also notify the company's corporate office . The Immediate Jeopardy began on 8/29/23 when the facility failed to provide adequate supervision for a resident at risk of elopement and follow the facility elopement procedure. The Director of Nursing and the Nursing Home Administrator were notified of the Immediate Jeopardy on 8/31/23 at 4:45 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 8/31/23, but noncompliance remains at isolated with the likelihood of serious injury, harm, impairment, or death due to sustained compliance has not been verified by the State Agency. The Immediate Jeopardy that began on 8/29/23 was removed on 8/31/23 when the facility took the following actions to remove the immediacy: Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address the deficient practice and prevent any additional residents from a potential adverse outcome. Completion Date: 8/31/2023. *During investigation of elopement on 8/29/2023 the facility identified that the resident did not have proper interventions in place to reduce risk of elopement for a resident identified as an elopement risk upon admission. *The facility identified that residents residing in the facility were determined to be at risk. On 8/31/2023, the facility assessed all residents for elopement risk and implementation of elopement care plans with appropriate interventions; proper assessments and care plans were implemented if applicable. *The elopement binder was updated on 8/31/2023. *Education of elopement policy and care planning of elopement with proper interventions was initiated on 8/29/2023, given by the administrator and administrator in training; any facility staff member and agency staff member who did not receive education by 8/29/2023 will receive education prior to the start of their next shift. All facility staff and agency staff who were present at the time of the incident were immediately educated. Education is completed for all new hires prior to their first shift. *The EVS (Environmental Services) Director assessed the facility doors for proper function of the alarm system on 8/29/2023; deemed to be functioning appropriately. *The Administrator notified the DPOA of the incident and discussed proper interventions, she agreed with the implementation of the interventions including relocation to the memory care unit. Law Enforcement, Physician and Director of Nursing also notified. Law enforcement promptly dispatched two units to assist staff in the search for the resident after receiving the resident description. *Resident was placed on 1:1 supervision immediately after return to the facility until further interventions could be implemented. *Resident received a wander guard and was relocated to the memory care unit on 8/29/2023 where 1:1 supervision was later deemed unnecessary, and resident was put on frequent checks. *Assessments were completed on the resident to ensure the resident did not experience any adverse effects of the elopement, including skin assessment, nursing assessment and vitals signs were obtained. *On 8/29/23, the care plan for the resident was reviewed and updated with proper interventions to reduce future risk of elopement. *Risk Management report was completed on 8/29/2023. *Witness statements were obtained by primary care staff on 8/29/2023. Actions to Prevent Occurrence/Reoccurrence: *The Elopement and Wandering Policy was reviewed by the facility Administrator and deemed appropriate. *Staff member responsible for deficiency removed from facility and terminated as result of the investigation. *Beginning on 8/29/2023, education with facility staff and agency staff was initiated on the Elopement and Wandering Policy. Any facility staff and agency staff who did not receive the education by 8/29/2023 will be educated prior to the start of their next shift. All facility staff and agency staff who were present at the time of the incident were immediately educated. Education is completed for all new hires prior to their first shift. This was completed by administrator and the administrator in training. *Beginning on 8/29/2023, education with licensed nurses was initiated on proper implementation of elopement care plans and interventions. Any facility staff and agency staff who did not receive the education by 8/29/2023 were educated prior to the start of their next shift. All facility staff or agency staff who were present at the time of the incident were immediately educated. Education is completed for all new hires prior to their first shift. *Director of Nursing/designee will conduct an audit with three licensed nurses weekly for four weeks and then monthly for three months to ensure understanding of proper implementation of care planning and interventions for resident at risk of elopement, until substantial compliance has been maintained. Results of these audits will be submitted to the QAA committee for review and any further recommendations. *Director of Nursing/designee will conduct an audit with five random staff members once a week for four weeks and monthly for three months to ensure understanding of elopement and wandering policy, until substantial compliance has been maintained. Results of the audits will be submitted to the QAA committee for review and any further recommendations. *Residents will be evaluated for elopement risk quarterly beginning 8/29/2023, and as needed, new residents will be assessed for elopement risk upon admission. The initial assessment and reassessment for all residents is deemed appropriate to capture any other residents that could potentially be at risk for elopement; implementation of possible interventions to reduce occurrence. All licensed nursing staff have begun receiving education on completing the elopement assessment with proper implementation of interventions. *Results of audits will be reviewed with the QAA committee to ensure compliance and any further recommendations. Areas identified requiring quality improvement: Failure to implement appropriate interventions for a resident at risk of elopement. How facility identified resident affected and residents with potential to be affected: *All residents currently residing in the facility reviewed for appropriate elopement assessments and appropriate care plans implemented with immediate correction if applicable. How the facility monitors the effectiveness of its quality improvement measures (sustained compliance): *Director of Nursing/designee will conduct an audit with three licensed nurses weekly for four weeks and then monthly for three months to ensure understanding of proper implementation of care planning and interventions for resident at risk of elopement, until substantial compliance has been maintained. Results of these audits will be submitted to the QAA committee for review and any further recommendations. *Director of Nursing/designee will conduct an audit with five random staff members once a week for four weeks and monthly for three months to ensure understanding of elopement and wandering policy, until substantial compliance has been maintained. Results of the audits will be submitted to the QAA committee for review and any further recommendations. *The Administrator will be responsible for maintaining compliance with this plan of correction. The facility asserts the likelihood of immediate harm has been mitigated since 8/31/2023. *The facility is alleging compliance of 8/31/23 DPS B Based on interview and record review the facility failed to implement effective interventions to prevent accidents and hazards for 1 resident (Resident #58) resulting in harm from a fall and serious injury. Findings: Resident #58 Review of an admission Record reflected R58 originally admitted to the facility on [DATE] with diagnoses that included dementia, atrial fibrillation, syncope and collapse, difficulty in walking, unsteadiness on feet, peripheral vascular disease, a history of falling and muscle weakness. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected R58's cognitive status was not assessed. R58 required extensive assistance from one person for bed mobility, transfers, locomotion on and off the unit, dressing, toilet use and personal hygiene. The assessment did not indicate R58 had any falls since the previous assessment. Review of a Brief Interview for Mental Status (BIMS) assessment dated [DATE] (not included in the MDS) reflected R58 was severely cognitively impaired as evidenced by a BIMS score of 4/15. Review of a Care Plan initiated on 1/4/2022 reflected R58 was on anticoagulant (blood thinner) therapy related to atrial fibrillation and had the potential for bruising. The goal of the care plan was that R58 would be free from discomfort or adverse reactions related to anticoagulant use. Interventions to meet that goal included Monitor/document/report to MD (doctor) PRN (as needed) signs of anticoagulant complications: blood tinged or frank (obvious) blood in urine, black tarry stools, dark or bright red blood in stools, coffee ground emesis, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, SOB (short of breath), loss of appetite, sudden mental changes in mental status, significant or sudden changes in v/s (vital signs). Review of a Nursing Progress Note dated 6/6/23 at 9:47 AM revealed Nurse was notified the Pt (patient, R58) has bruises on her right lower extremity and 4th digit toe right foot, Pt occasionally moaning in pain, restless and trying to get up without assist. Pt is unable to communicate effectively if she is having pain. Provider (name omitted) was notified and x-rays ordered. The progress note did not indicate a medication review was ordered or conducted. Review of an Other-Injury incident report dated 6/6/23 at 11:04 AM reflected Resident (R58) presents with swelling and discoloration to RLE (right lower extremity), tender to touch, denies pain at rest. The Resident Description reflected R58 said I really don't know (what happened). The injuries documented on the incident report indicated R58 had bruises to the front of her right lower leg. No further information was documented. Review of a Nursing Progress Note dated 6/6/23 at 1:06 PM reflected Observation of resident complete with discoloration to RLE (right lower extremity), denies pain at rest, ROM (range of motion) intact without indicators of pain but does tense during palpation of discoloration, resident unable to describe what happened, when asked if resident fell she stated I don't think so when asked if anyone injured her she stated No not at all and confirms feeling safe in the facility, message left for (name of Power of Attorney for Healthcare (POA) EE) requesting call back with phone number provided, awaiting STAT (right away) X-ray results. Review of a Nursing Progress Note dated 6/7/23 at 9:26 AM reflected the x-ray taken on 6/6/2023 was negative. Review of a Nursing Progress Note dated 6/7/23 at 3:34 PM, documented by the Director of Nursing (DON) reflected Resident stated to nurse that she had fallen a few days ago and hurt her leg. Responsible party notified, Physician notified, Administrator notified, DON notified. It was not clear from the progress note if R58's report of falling a few days ago was in any way related to the bruising on the right lower extremity. Review of a Fall incident report dated 6/10/23 at 7:31 PM reflected R58 had an unwitnessed fall without injury related to an attempt by R58 to transfer herself to bed from her wheelchair. Review of a Care Plan initiated on 1/4/2022 reflected R58 was at risk for falls related to problems with mobility and a history of falling. The goal of the care plan was that R58 would be free from injury from falls. No new interventions were added to the care plan to increase supervision or prevent injury from falling after R58's alleged reported fall a few days before as mentioned in the nurse progress note written on 6/7/23. An intervention to add anti-rollback device to the wheelchair was added after R58's unwitnessed fall on 6/10/23. During a telephone interview on 9/6/23 at 11:15 AM, POA EE reported that R58 had lived at the facility for 5 years and had not previously had issues with falling. POA EE said that she first learned about R58's bruised legs after her sister had visited her and had NOT been informed by the facility of R58's bruising. POA EE said the family didn't know what happened. POA EE said that R58 could not walk on her own and that if she had fallen in the facility, she would not be able to get herself back up again. During an interview on 9/6/23 at 12:15 PM, the Nursing Home Administrator (NHA) reported that she did not report R58's injury of unknown origin identified on 6/6/23 to the State Agency because the resident said she had fallen. The NHA said that she asked the DON to create a soft file investigation into the bruising injury. When asked, the NHA said that a soft file is an internal investigation that is not reported to the State Agency and would include a review of staffing and staff interviews. During a telephone interview on 9/6/23 at 1:30 PM, the DON reported she was familiar with R58 but could not recall the name of the nurse she referred to in the progress note she had written in R58's record on 6/7/23 (stating 'resident told the nurse' that she fell a few days ago). The DON said that she would typically do an investigation into the bruising identified on R58 on 6/6/23 and that all the documentation would be at the facility. Review of an Order Details report dated 6/19/23 reflected a doppler venous ultrasound of RLE had been ordered to rule out a deep vein thrombosis, edema (swelling). Review of a Physician Assessment reflected a Comprehensive Follow-up was conducted on 6/20/2023. The Chief Complaint was a Resident oriented review. The vital signs included a weight taken on 5/1/2023, blood pressure, pulse, temperature and oxygen saturations measured on 4/19/2023 (two months prior) and a blood glucose reading obtained on 5/31/23. The Exam reflected R58 had no edema in her extremities. The Assessment & Plan indicated R58 had Atrial Fibrillation . -continue Eliquis 5 mg twice daily. No reference to R58's recently identified injury of unknown origin/bruising or fall was made. No discussion related to the R58's injury of unknown origin/possible fall, R58's fall on 6/10/23 or order for a doppler venous ultrasound of the RLE was mentioned. Review of a Fall incident report dated 6/21/23 at 4:45 PM revealed (R58) was observed on the floor next to bed. Resident had a laceration to right leg noted after fall. The report indicated R58 was not able to give a description of the event. The physical assessment noted a deep laceration noted to lower right leg. Discoloration noted to bilateral toes and feet. Review of hospital records, including ED (Emergency Department) Provider Notes reflected that on 6/21/23 R58 was transferred to the hospital via ambulance after falling at the facility and sustaining a deep laceration with extensive bleeding. The Laceration Repair note written on 6/21/23 at 7:21 PM reflected R58 has a laceration to her right lower leg that was 15 centimeters long and to the bone. The records indicated that R58 was admitted to the hospital for monitoring due to the laceration and bleeding that was difficult to control. During a follow-up interview on 9/6/23 at 2:45 PM, the NHA reported she did not have an investigation/soft file into the injury of unknown origin sustained by R58 on 6/6/23. The NHA also reported there was no record any neurological assessments were completed on R58 after the unwitnessed fall on 6/10/2023. The NHA said there was no additional assessment documentation or provider progress notes in the clinical record to explain why a doppler scan had been ordered to rule out a DVT on R58 prior to her being transferred to the hospital on 6/21/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #: MI00135410 Based on interview and record review, the facility failed to ensure staff initiated timely and appropriate Cardiopulmonary Resuscitation (CPR) per standards of care, federal regulation, and their own facility policy and procedures, resulting in an immediate jeopardy when 1 resident (Resident #103), who was a full code (desired full life saving measures), was found unresponsive in respiratory distress and subsequently cardiac arrest. Licensed nursing staff did not know how to appropriately respond causing a delay in rescue attempts and R103's death. This deficient practice placed all residents, who are designated as a Full Code and who suffer cardiac arrest, or are found unresponsive, at risk for serious harm and/or death. Resident #103 (R103) Review of an admission Record revealed R103 was an [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: diabetes and heart disease. Review of R103's Physician Order dated [DATE] revealed R103 code status was CPR-Full Resuscitation. Review of R103's Nursing Progress Note dated [DATE] at 8:40 PM revealed, Entered residents room and observed that she was non-responsive, (blood pressure) 93/51-(heartrate) 43-(respirations) 8-(temperature) 96.3 O2 sat (oxygen saturation) 80% on room air. O2 started at 5L/m. Call placed to NP (Nurse Practitioner) (name omitted), order to send to ER (Emergency Room), called daughter and informed her, and called (ambulance service name omitted). Within a few minutes (ambulance service) and Fire dept. were here. (Respiration range for adults 12-20, pulse range for adults 60-100, Oxygen saturation range 93-100%). During an interview on [DATE] at 8:53 AM, Licensed Practical Nurse (LPN) Q was asked to describe the events that led to R103's cardiac arrest. LPN Q reported that she was R103's nurse at the time R103 coded (respiratory/cardiac arrest). LPN Q reported R103's blood sugar level was assessed around 4:00 PM which was the last time LPN Q had observed R103. LPN Q reported she returned to R103's room to administer evening medications around 8-8:15 PM and found R103 sitting in her chair and unresponsive. LPN Q reported 2 Certified Nursing Assistant (CNAs) assisted with getting R103 back to bed and placed a backboard behind R103 in the event she would require CPR. LPN Q reported vital signs were obtained and R103 was breathing (8 respirations a minute) but did not describe ventilatory depth or rhythm (deep, shallow, normal, labored, regular, irregular). LPN Q reported R103's oxygen level and heart rate were assessed via pulse oximeter and identified R103's pulse in the 40's and oxygen level at 80%. LPN Q was asked if she assessed R103's pulse other than by the pulse oximeter and she reported that she had palpated R103's pulse via radial and carotid. LPN Q was unable to recall the pulse (rate, rhythm, force) or the frequency it was assessed and confirmed that subsequent pulse assessments were not documented. LPN Q reported that she had continued to assess R103's pulse until EMS arrived but did not report that R103 had additional oxygen saturation or respiration assessments. LPN Q reported LPN HH was assisting with R103's care and the crash cart (cart containing medications and equipment used for emergency resuscitation) and the ambu bag (device used for manual ventilation) were brought to R103's room. Although the facility was equipped with an AED (automated external defibrillator portable machine that automatically diagnoses the heart rhythm and determines if a shock or CPR is needed) it was not applied to R103. LPN Q reported that she had not identified asystole and CPR had not been initiated prior to EMS arrival. LPN Q reported that once EMS arrived, EMS identified that R103 was in asystole and directed her to begin CPR. Review of R103's Ambulance Report dated [DATE] revealed the ambulance dispatcher received a call for emergency service at 9:02 PM. At 9:10 PM the paramedics made contact with R103. Narrative History Text: EVENTS LEADING TO ILLNESS/INJURY: staff states Pt (patient) was steadily declining for several hours and complaining of difficulty breathing. POSITION PT FOUND/INITIAL SCENE FINDINGS: pt lying supine on her bed with a backboard under her. Agonal respirations, no pulses, staff was not performing CPR. (Agonal breathing is characterized by slow, very shallow irregular respirations that result from anoxic brain injury. This will often progress to apnea (absence of breath) depending on the underlying cause NIH 2023). PT LAST SEEN AT AND BY: (Staff at the nursing facility throughout the evening) COMPLAINT(S) PRIOR TO ARREST: (Dyspnea) . CHECK THE FOLLOWING CONDITIONS CONSIDERED AS THE CAUSE OF THE CARDIAC ARREST .hypoxia (low oxygen level) ADDITIONAL ASSESSMENT NOTES (IF APPLICABLE): Prior to arrival, the call came across as a cardiac arrest. On arrival, Pt (patient) was lying in her bed unresponsive with agonal respirations and secretions coming out of her mouth. Staff were not performing CPR. no pulses were found. CPR was initiated by ALS. ALS directed available staff to assist in chest compressions and ventilations. Staff needed constant coaching on compression rate and depth and were unable to complete two minute cycles of compressions. Average time of compressions was about 30 seconds and then they were too tired and would switch out. Staff also needed constant coaching on mask seal, respiration rate and amount of oxygen per breath. Initial pulse and rhythm check showed asystole with no pulses . Review of R103's Emergency Department Hospital Records dated [DATE] at 10:38 PM revealed This is a [AGE] year-old female with unknown past medical history presenting after cardiac arrest. On arrival, the patient is pulseless. CPR is initiated . After 2 rounds of CPR and 1 dose of epinephrine, the patient regained pulses .Based on the degree of anasarca (fluid accumulation), as well as pulmonary edema, suspect this was likely a respiratory arrest at this time . This is a [AGE] year-old female with unknown past medical history presenting after cardiac arrest. Per EMS, patient was declining at his care facility for 3 hours. When EMS arrived, she was agonal breathing and was pulseless. They started CPR . Review of R103's Emergency Department Hospital Records dated [DATE] at 11:04 PM revealed, This is a 85 y.o. female who presents today as a post arrest. Patient reportedly per EMS had been going downhill for 3 hours before she went down in front of staff. They did not start CPR on the patient. EMS found her to be agonal with PA .She got 5 rounds of epinephrine from EMS and they did get a pulse back. As they were wheeling her into the Trauma Bay, patient lost her pulse and she have CPR started by us. She did get a dose of epinephrine and her pulse came back .Patient was found to be hypoglycemic (low blood sugar) and was given D50 .Patient was admitted to the intensive care unit. The resident did update the family and family wants to pursue all aggressive measures. R103's blood sugar level was 45 (normal range 70-99). Review of R103's Inpatient Hospital Records dated [DATE] at 3:34 AM revealed, Pt (patient) is an 85 y/o female with history of DM (diabetes mellitus), PVD (peripheral vascular disease), s/p right BKA (status post right below knee amputation), dementia admitted after cardiac arrest. By report, she was having respiratory distress at her facility and EMS was called. On EMS arrival, she was agonally breathing and found to be in PEA (pulseless electrical activity) arrest. CPR initiated. She received 5 doses of epinephrine prior to ROSC (return of spontaneous circulation). On arrival to the ER, she again was found pulseless and received 2 more rounds of CPR .Her daughter (DPOA) arrived shortly after admission and the patient's grave prognosis was discussed. The patient had escalating presssor (raises blood pressure) requirements and remained unresponsive throughout her stay. Her daughter opted to transition to comfort care after having her pastor come to the bedside. Her high dose pressors were discontinued, a morphine drip started and she was extubated. On 3/13 at 0330 she was found without spontaneous pulses or respirations. She was unresponsive to any stimuli and her pupils were fixed and dilated. She was pronounced deceased at that time. On [DATE] the Nursing Home Administrator was verbally notified and received written notification of the immediate jeopardy identified on [DATE] that began on [DATE] due to the facility's failure to immediately perform Cardiopulmonary Resuscitation on a Full Code resident. A written plan for removal for the immediate jeopardy was received on [DATE] and the following was verified on [DATE]: 1. Identification of Residents Affected or Likely to be Affected: *On [DATE], the facility completed a root cause analysis of the event and determined the licensed nurse did not identify the immediate need to initiate CPR on the resident. The licensed nurse was provided education by the facility Director of Nursing/designee on the BLS guidelines for the initiation of CPR with return demonstration. *The facility determined all other FULL CODE residents are at risk. On [DATE], the facility audited all resident deaths in the last 30 days via review of their electronic health record. The audit results showed that there were no other FULL CODE residents who had a medical emergency who did not receive CPR per current standards of practice. Current residents were assessed for an acute change in condition on [DATE] with no notable deviation from baseline or medical emergency requiring CPR. *Facility Medical Director was notified of the incident on [DATE]. *The DON/designee completed a chart audit on current residents and compared the Medical Treatment Decision Forms to the physician order for accuracy on [DATE]. Identified discrepancies were addressed at the time of the event. *On [DATE], the emergency carts at the facility were audited by the DON/designee to ensure all necessary items are present - no concerns were identified. *On [DATE], all current residents were assessed by a licensed nurse for an acute change in condition. *On [DATE], the Administrator and DON were provided counseling by the Regional Director of Operations on the Mission Point expectations related to investigations and the systemic reporting of adverse events to ensure appropriate personnel are notified of such matters. 2. Actions to Prevent Occurrence/Recurrence: *The Cardiopulmonary Resuscitation Policy was reviewed by the facility Administrator, DON and Medical Director and deemed appropriate. *Beginning on [DATE], the DON/designee educated the licensed nurses on the Cardiopulmonary Resuscitation Policy, including how to assess the need, monitor and perform CPR. *On [DATE], the facility Human Resources Business Partner performed an audit of all licensed nurses CPR certifications - all licensed nurses are up to date with certification. *Beginning on [DATE], DON/designee performed a Code Blue drill and/or return demonstration on all shifts until every nurse had participated at least once. This will continue until all nurses have been educated. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: [DATE] Although the immediate jeopardy was removed on [DATE], the facility remained out of compliance at a scope of isolated and severity of actual harm due the fact that not all facility staff have received education and sustained compliance has not been verified by the State Agency. Review of the facility policy Cardiopulmonary Resuscitation (CPR) - Adult dated 12/21 revealed, Appropriate cardiac and respiratory function will be maintained until a definitive treatment can be given. CPR will be initiated on all residents with an Advanced Directive stating CPR-Full Resuscitation except in circumstances where you are responding to an emergency (drowning, choking, or electrocution). It is the policy of this facility to respect each resident's individual, informed decision regarding advance directives and code status. Cardiopulmonary Resuscitation (CPR) will be initiated for residents who have requested CPR, for residents who have not formulated an advance directive and for residents who do not have a valid DNR order. To provide Basic Life Support (BLS) to residents with absence of respirations and pulse, as designated by resident or legal guardian except in circumstances listed above. Policy Explanation and Compliance Guidelines: 1. In the event a resident is identified unresponsive and upon a thorough assessment determines that there is no pulse or respiratory activity and the resident has declared a full-code status, a BLS certified staff member will: a. Simultaneously with the initiation of chest compressions direct a staff member to immediately retrieve the emergency cart. b. Continue to administer chest compressions and rescue respirations per the American Heart Association recommendations. c. Direct a staff member to contact the Emergency Response Team (911) immediately to inform them of a full code requiring life support interventions and possible transportation to the emergency department. d. Direct a member of the response team to contact the attending physician and responsible party/DPOA/guardian. This staff member shall also complete a hospital transfer sheet including a copy of advance directives/code status and make these documents available to Emergency Response Personnel. e. Identify a member of the response team to be responsible for documenting the time of each intervention and resulting response. Documentation should include but not limited to: 1) Date and time of arrest and name(s) of person(s) assisting with CPR, including the recorder. 2) Medications given. 3) Treatments performed. 4) Results of resuscitation. 5) Time AED was placed and whether or not shock advised if available. 6) Date and time family and doctor notified. 7) Assessment done. 8) Where resident was transferred to (i.e., EMS Agency or Mortuary). Mission Point Healthcare Systems 9) A debriefing with staff involved in the code response as needed. f. Facility staff shall defer all resuscitation efforts to Emergency Response Personnel once they arrive at the location and declare that they will assume the responsibility of maintaining life support interventions. Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, A saturation greater than 93% is acceptable while a saturation of less than 90% is a clinical emergency. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 483). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, Hypoxia is inadequate tissue oxygenation at the cellular level. It results from a deficiency in oxygen delivery or oxygen use at the cellular level. It is a life-threatening condition. Untreated, it has the potential to produce fatal cardiac dysrhythmias ([NAME] and [NAME], 2019). [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 917). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, Patients with sudden changes in their vital signs, LOC (level of consciousness), or behavior may be experiencing profound hypoxia .If a patient's hypoxia is severe and prolonged, cardiac arrest results. A cardiac arrest is a sudden cessation of cardiac output and circulation. When this occurs, oxygen is not delivered to tissues, carbon dioxide is not transported from tissues, tissue metabolism becomes anaerobic, and metabolic and respiratory acidosis occur. Permanent damage to the heart, brain, and other tissue occurs within 4 to 6 minutes. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 940-944). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, Cardiopulmonary Resuscitation During cardiac arrest there is an absence of pulse and respiration. Patients in cardiac arrest require immediate cardiopulmonary resuscitation (CPR), a basic emergency procedure of artificial respiration and manual external cardiac massage. The sequence for CPR is C-A-B: chest compression, early defibrillation, establishing an airway, and rescue breathing (Link et al., 2015). The American Heart Association (AHA, 2015) continues to research cardiac arrest treatment and outcomes. In adults (the majority of cardiac arrests) the critical initial elements found to be essential for survival were adequate chest compressions and early defibrillation. Adequate compressions in adults need to occur at a rate of 100 to 120/ minute with a depth of at least 2 inches and allowance for time for the chest to recoil. Passive ventilation is no longer recommended in patients undergoing conventional CPR in the community setting, although it may be used in emergency medical service settings (Neumar et al., 2015). Defibrillation delivers an electrical current to the myocardium that stops all electrical activity and allows the heart's normal pacemaker to resume its normal activity ([NAME], 2017). It is recommended that defibrillation occur within 5 minutes for an out-of-hospital sudden cardiac arrest and within 3 minutes for a patient in a hospital. An automated external defibrillator (AED) (Box 41.10), available in many public places, such as schools, airports, and workplaces, can be used by health care providers and lay individuals alike to defibrillate people with cardiac arrest (AHA, 2018; Neumar et al., 2015). [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 944). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, Automated External Defibrillator o The automated external defibrillator (AED) is a device used to administer an electrical shock through the chest wall to the heart to stop the abnormal rhythm and restore a normal heart rhythm. The AED has built-in computers that assess a patient's heart rhythm and determine whether defibrillation is necessary. New technology has made them user friendly, with audio and visual cues telling users what to do when using them. The AED delivers a shock to the patient after announcing, Everyone stand clear of patient. A shock is delivered only if the patient needs it (NHLBI, n.d.b). Lay rescuer AED programs train lay personnel on the use of the AED (AHA, 2018). The AED is used to strengthen the chain of survival. Patients who received a shock from an AED available in the public had a higher survival rate and rate of discharge from the hospital than those who did not (AHA, 2018). For witnessed ventricular fibrillation, early cardiopulmonary resuscitation with defibrillation within the first 3 to 5 minutes results in greater survival rates ([NAME] et al., 2017). [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 944). Elsevier Health Sciences. Kindle Edition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #: MI00135410 Based on observation, interview, and record review the facility failed to 1.) stock or re-stock medication carts with necessary medications for residents and 2.) ensure that all on-duty nurses had access to the pyxis (medication dispensing system) in the event of a medical emergency resulting in an immediate jeopardy when, beginning on 3/16/23, the facility licensed nurses did not have access to and were unable to administer emergency/life-saving medication to a resident in hypoglycemic crisis (R102) resulting in her death. This deficient practice places all diabetic residents at risk for serious harm, injury and/or death. Findings: Resident #102 (R102) Review of an admission Record revealed R102 was an [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: Type 2 Diabetes. Review of the Standing Orders revealed that Glucose Gel (Hypoglycemic event-Conscious), Glucose IM (Hypoglycemic event-Unconscious), and Hypoglycemic Crisis-May follow facility policy were available to order as an order set by nursing staff. Review of R102's Order Summary revealed no Standing Orders for hypoglycemic event medications. Review of R102's Blood Sugar Log revealed on 3/10/23 at 7:23 AM R102's blood sugar was 49 (blood sugar range 70-100). Review of R102's Electronic Health Record (EHR) revealed the provider was not notified of the critical low blood sugar result. Review of R102's Nursing Progress Note dated 3/12/23 at 10:15 AM revealed, Called to residents room- resident with garbled speech and drooling. - Accucheck (blood sugar check) completed- was 37. Pudding , OJ (orange juice), 1 tube glucose, Accucheck 45-provider called- new order for glucagon given. and a repeat glucagon given. Accucheck 123- Resident groggy but beginning to answer questions. 11am blood sugar 210. Provider notified. Will continue to offer fluids and food. Review of R102's EHR revealed the 2 doses of glucagon was not documented as ordered and was not documented as administered. On 04/12/2023 at 7:53 AM, Nursing Home Administrator (NHA) verified R102's glucagon was not ordered in the EMR and was not documented as administered. Review of R102's Nursing Progress Note dated 3/16/23 at 6:23 AM revealed, During am (morning) med (medication) pass this nurse entered resident's room to give her am medication and noted resident had small emesis on pillowcase and on shoulder. Resident not arousable. Resident breathing, R18 (respirations 18). Blood sugar checked immediately, 27. Checked unit for Glucagon and/or Glutose gel. None found. Requested assistance from other LPN (Licensed Practical Nurse). Called NP (Nurse Practitioner) on call, ordered to send patient to ER (Emergency Room). Called 911 at 0503. Glucose tab crushed and administered while waiting for EMS. Daughter notified of situation. Reentered room and found resident was no longer breathing, EMS (Emergency Medical Services) arrived and took over care. Resident DNR (Do Not Resuscitate), no CPR (Cardiopulmonary Resuscitation) provided. EMS called time of death at 0529 (5:29 AM). Notified daughter that resident had passed away. Other LPN notified DON (Director of Nursing). RN (Registered Nurse) arrived at shift changed and notified administrator. Review of R102's Emergency Medical Services Report (company name omitted) dated 3/16/23 revealed the 911 call was received at 5:05 AM and the paramedics/EMTs made contact with R102 at 5:18 AM. Patient is a nursing home resident was last spoken to at 0300 HRS (3:00 AM). Staff now found unresponsive patient and suspecting a diabetic issue. They called 911. ATF (arrived to find) unresponsive/apneic/pulseless patient in semi-Fowlers (inclined position 30-45 degrees on back) position in bed. EKG (electrocardiogram) rhythm is asystole (no heartbeat). Pupils dilated/non-reactive .Time of death 0529 HRS (5:29 AM) . During an interview on 04/10/2023 at 9:41 AM, Confidential Informant (CI) A reported that R102 had an incident of hypoglycemic crisis on 3/12/23 where she required glucagon which resolved her symptoms and raised her blood sugar. On 3/16/23 in the early morning, R102 was found unresponsive with a blood sugar of 27 and the nursing staff on duty did not have access to glucagon resulting in R102's death. CI A reported R102 was admitted to the facility for short term rehab and was to be discharged home on 3/17/23. CI A reported that R102's death was avoidable and felt that facility management did not appropriately handle R102's death, investigate the incident, or put a system in place to ensure this could not happen again. During an interview on 04/12/2023 at 5:35 AM, Licensed Practical Nurse (LPN) E reported that during his shift (3/15/23-3/16/23 night shift) R102 had been stable throughout the night. LPN E reported that during morning medication pass around 5:00 AM, R102 would not wake up. LPN E reported he assessed her blood sugar level, and it was incredibly low. LPN E immediately accessed the medication cart to obtain a glucagon IM (intramuscular) injection or gel (emergency medication used to treat severe hypoglycemia) and there was no glucagon available to administer. LPN E reported that he ran to the other units to obtain glucagon and assistance from the only other scheduled nurse in the facility (LPN L). LPN E reported that there was no glucagon available in the medication carts on the other units (4 units in the facility). LPN E and LPN L then attempted to gain access to the facility's pyxis (medication storage unit that requires login and password) but both had not been given access. LPN E reported that because he was unable to obtain the glucagon, he crushed glucose tabs and placed it in R102's mouth in an attempt to raise her blood sugar and save her life. LPN E reported that at that point R102 did have a pulse or respirations and he called 911. LPN E reported that by the time EMS arrived to the facility R102 was without a pulse and/or respirations. LPN E reported that glucagon IM, gel, and tabs were to be available in the medication cart on the unit in case of an emergency. LPN E reported that he had not been told in nurse-to-nurse report of R102's low blood sugar levels on 3/10/23 or 3/12/23 and was unaware that she had required glucagon x2 on 3/12/23 as it was not reflected in the EHR. LPN E reported that had he been aware of R102's hypoglycemic emergencies he would have ensure he had glucagon available in the case of an emergency. LPN E reported that had he had access to the emergency medication, glucagon, R102's would likely have had a different outcome (R102 would have survived). LPN E reported R102 was scheduled to discharge home in the next couple days. During an interview on 04/13/2023 at 1:06 PM, LPN J reported that she did not have access to the facility pyxis until after R102 died on 3/16/23. LPN J reported that prior to the incident that occurred on 3/16/23 R102 had had critically low blood sugar and required glucagon. LPN J reported that only an agency nurse had access to the pyxis to pull the glucagon during that incident. LPN J reported that nursing management (Unit Managers and DON) were notified at that time that the facility nurses needed to pull glucagon from the facility pyxis but were unable to because the facility nurses did not have access. LPN J stated, the DON knew we didn't have access to the pyxis prior to the incident. It wasn't a secret. LPN J reported that had the DON ensured all licensed nurses had access to the pyxis when they were made aware, LPN E would have had the ability to obtain the glucagon from the pyxis and administer it to R102. LPN J reported that the facility nurses were upset about R102's death because it was preventable and told the DON that all of the medication carts needed an emergency glucagon IM to ensure this didn't happen again, but the DON reported that glucagon IM expires and therefore it would be kept in the pyxis. LPN J reported R102 was to be discharged home on 3/17/23 but because the licensed nurses did not have access to emergency medication she died. During an observation and interview on 04/10/2023 at 11:37 AM, the medication carts on the 100 Unit and 200 Unit were reviewed with Registered Nurse (RN) B. The 200 Unit medication cart did not contain glucagon IM or Gel and the 100 Unit medication cart contained 1 glucagon IM injection assigned to 1 resident. The 100 Unit medication cart did not contain glucagon gel. RN B reported concerns that in the case of a hypoglycemic emergency there would be no way to quickly administer glucagon and reported the 100 Unit and 200 Unit had multiple residents on insulin. During an observation and interview on 04/10/2023 at 11:57 AM, the medication cart on the 300 Unit was reviewed with Licensed Practical Nurse (LPN) C. The 300 Unit medication cart contained 1 glucagon IM injection assigned to a resident. LPN C reported that if a resident required glucagon, it would be located in the facility pyxis if there was not one assigned to them in the medication cart. LPN C reported any resident that receives insulin should have an order for glucagon IM and Gel and it should be located on their unit medication cart. During an interview on 04/13/2023 at 11:20 AM, LPN Y reported that at the time the Immediate Jeopardy was served, she had not had access to the facility pyxis. During an interview on 04/18/2023 at 9:38 AM, LPN U reported that at the time the Immediate Jeopardy was served, she had not had access to the facility pyxis. During an interview on 04/12/2023 at 8:00 AM, NHA reported that R102's hypoglycemic crisis/death and was identified and reviewed on 4/7/23. NHA reported that the root cause for the incident was lack of access to the pyxis and it was identified as a widespread issue. NHA reported that beginning on 4/7/23 the Director of Nursing (DON) was completing an audit to ensure all licensed nursing staff, including agency nurses, had access to the pyxis as well as ensuring all diabetic residents had blood sugar parameters and appropriate medications ordered in the Electronic Health Record following the facility hypoglycemia policy and standing orders. On 4/13/23 the Nursing Home Administrator was verbally notified and received written notification of the immediate jeopardy identified on 4/12/23 that began on 3/16/23 due to the facility's failure to ensure that all on-duty nurses had access to the pyxis in the event of a medical emergency. A written plan for removal for the immediate jeopardy was received on 4/17/23 and the following was verified on 4/18/23: 1. Identification of Residents Affected or Likely to be Affected: *Facility Medical Director was notified of the incident on 04/13/2023. *All diabetic residents are at risk and are considered like residents. *On 4/7/23 the DON/designee began an audit of all residents with a diabetes diagnosis for blood sugar parameters, and to ensure orders for glucagon gel/tabs in place. *On 4/11/23 the DON/designee performed an audit for glucagon gel/tabs available in carts - glucagon available on cart. *On 4/12/23 current residents were assessed by a licensed nurse for an acute change in condition. Two LOA residents on 4/12/23 were assessed by a licensed nurse on 4/13/23. *On 04/12/23 the Administrator and DON were provided counseling by the Regional Director of Operations on the Mission Point expectations related to investigations and the systemic reporting of adverse events to ensure appropriate personnel are notified. Actions to Prevent Occurrence/Recurrence: *On 4/11/23 nursing staff audited for log-in access to backup device of medications. On 4/12/23 all facility licensed nurses and Agency nurses who did not have access to the backup device were entered and provided access to emergency use medications. The staffing roster is reviewed daily to monitor for Agency nurses who need access. The DON or designee will assign log in and provide training prior to shift start time. *On 4/11/23 the Diabetes Management policy was reviewed and deemed appropriate by the facility Administrator, DON and Medical Director. *Beginning on 04/11/23, the DON/designee educated the licensed nurses on the Diabetes Management Policy. Facility licensed nurses and Agency nurses will be educated prior to working their next scheduled shift. *On 4/12/23 the facility completed an Ad Hoc QAPI and will continue to review for continued monitoring and compliance during monthly QAPI. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: 4/13/2023 Although the immediate jeopardy was removed on 4/13/23, the facility remained out of compliance at a scope of isolated and severity of actual harm due the fact that not all facility staff have received education and sustained compliance has not been verified by the State Agency. Review of the facility policy Diabetic Management: Hyper/Hypoglycemic Events last revised 3/23 revealed, .Residents with diabetes mellitus will be monitored and treated for hypoglycemia and/or hyperglycemia according to Clinical Practice Guidelines and per physician orders .1. Hypoglycemic Event: A hypoglycemic event is defined by a blood sugar less than 70 mg/dl or markedly less than usual for a resident who is exhibiting symptoms .2. Hypoglycemic Event Protocol: If blood sugar is less than 70 mg/dl or markedly less than usual for an individual resident who is exhibiting symptoms, suspect a hypoglycemic event and begin treatment as follows .b. PROTOCOL B - for Unconscious Resident: i. Administer one of the following: 1 mg or 1 unit of Glucagon subcutaneous or IM 50 ml of IV 50% Dextrose. ii. Recheck blood sugar in 30 minutes and if blood sugar remains under 100 or if resident is still unconscious or unresponsive phone emergency services .