**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #MI00129778 This citation contains three Deficient Practice Statements (DPS). DPS #1 Based on interview and record review the facility failed to consistently monitor a resident in respiratory distress, notify the physician of ineffective interventions and failed to transfer the resident to a higher level of care for appropriate treatment for one (R312) of three residents reviewed for infection prevention and control, resulting in staff to not have completed and documented consistent respiratory assessments and monitoring once staff identified R312 with a low oxygen saturation rate of 72%, staff failed to inform the physician of the supplemental oxygen to not have been effective, and failed to transfer the resident to a higher level of care for further treatment causing Immediate Jeopardy (IJ), when R312 expired two hours and twenty five minutes after staff identified the change of condition. This continued practice puts other residents at risk for serious harm and/or death. Findings include: The IJ began on [DATE]. The IJ was identified on [DATE] at 1:30 PM, the Administrator was notified and a plan to remove the immediacy was requested. The immediacy was removed on [DATE] at 1:06 PM, based on the facility's implementation of an acceptable plan of removal verified on-site by the surveyor. Review of the medical record revealed R312 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: dementia and Huntington's disease. A Minimum Data Set (MDS) assessment dated [DATE], documented severely impaired cognitive skills for daily decision making and required staff assistance for all Activities of Daily Living (ADLs). Review of a Nursing note dated [DATE] at 10:00 PM, documented in part . Resident observed having chest congestion with low SPO2 (oxygen saturation level) @ (at) 72% R/A (room air), writer applied non re-breather @10LPM (liters per minute), residents V/S (vital signs) 77/55, 60, 92.5, resident remains A/O (alert and oriented) non verbal, skin warm to touch, has no s/s (signs or symptoms) of pain, no facial grimace noted, HOB (head of bed) elevated to facilitate breathing, writer called and spoke with (Physician B name) and informed of change in condition, resident is a DNR (Do Not Resuscitate), gave v/o (verbal order) to keep 02 (oxygen) applied as needed, writer called and left message for Responsible party . DON (Director of Nursing) notified. This note was documented by Licensed Practical Nurse (LPN) A. Review of a Change in Condition Evaluation for dated [DATE] at 10:00 PM, documented in part . Abnormal vital signs . This started on: [DATE] . Primary Diagnosis (left blank) . Additional pertinent diagnosis(es) - Dementia . Specify other directives: DNR . Other resident or family preferences for care: DNR . Are these the most recent vital signs taken after the change in condition occurred? Yes . Blood Pressure 77/55 . [DATE] 22:00 . Position: Sitting r (right)/arm . Most Recent Pulse . Pulse: 60 bpm (beats per minute) . [DATE] 22:00 . Respiration: 16 (Breaths/min) . [DATE] 22:00 . Most Recent Temperature (section left blank) . Most Recent 02 sats . 02 sats: 72% . [DATE] 22:00 . Method: Room Air . Is oxygen saturation <90%? Yes . Mental Status Evaluation (compared to baseline .) Decreased level of consciousness (sleepy, lethargic) . Specify the decreased level of consciousness: Sudden change in level of consciousness or responsiveness . Describe respiratory changes: Labored breathing . Other respiratory changes . Describe labored breathing: Acute onset of change from usual pattern, OR with chest pain, labored respirations, or unstable vital signs . Describe respiratory signs and symptoms: CONGESTION WITH LABORED BREATHING . Complete the following 5 questions to evaluate the cognitively impaired resident . Breathing: (section left blank) . Negative vocalization: None . Facial expression: Smiling or inexpressive . Body language: Relaxed . Consolability: No need to console . Neurological Evaluation- No changes observed . Laboratory Tests/Diagnostic Procedures . Abnormal Results: None to report . Since the change in condition occurred have the symptoms or signs gotten: Better . Things that make the condition or symptoms better are: 02 APPLIED HOB ELEVATED . This condition, symptom or sign has occurred before: No . Other relevant information: RESIDENT IS A DNR . What do you think is going on with the resident . LPN (Licensed Practical Nurse): The resident appears: HAS SOME MILD CHEST CONGESTION, LABORED BREATHING . Have you reviewed and acknowledged the notifications? Yes . Reported to primary care clinician: (Physician B name) . Date and time of clinician notification: [DATE] 2200 (10 PM) . Orders obtained from the clinician: Oxygen . This change of condition was documented by LPN A. Review of the medical record revealed no follow up vitals obtained, no documentation of any follow up monitoring completed, no documentation of R312's SPO2 levels after the supplemental oxygen was applied, no documentation of the resident's respiration levels, no documentation of any further respiratory assessment or monitoring of the resident's condition. On [DATE] at 10:37 AM, LPN A was interviewed via telephone and asked about the change of condition incident with R312 on [DATE]. LPN A was asked about any follow up monitoring and vitals after the change of condition was identified and where it was documented at. LPN A stated they monitored the resident but didn't know why there was no documentation to reflect that. LPN A stated R312 oxygen saturation level never came back up and they were unable to stabilize R312's oxygen saturation level after providing the supplemental oxygen, when asked if the physician was aware that the supplemental oxygen was not effective, LPN A did not recall. When asked why R312 was not sent to the hospital if LPN A was unable to stabilize the resident oxygen saturation levels and LPN A documented the resident had congestion with labored breathing, LPN A stated because (R312) was a DNR. LPN A was asked to explain what a DNR is, LPN A replied Do Not Resuscitate, but if they're in distress we apply oxygen because (R312) is not resuscitated so we don't send (R312) out to the hospital . LPN A stated they realized it was difficult for the surveyor to understand but the nursing facility is different than the hospitals. LPN A stated it was the facility's protocol to try and maintain the resident at the nursing facility. When asked if they were aware of R312 to have had an Advance Directive in place, LPN A responded they did not know. LPN A stated in part . the change of condition (with R312) happened rapidly and unexpected . Review of a Advance Directive policy provided by the facility (revision date [DATE]) documented in part . Advance Directives allow residents to give directions for their care in the event that they become incapable of participating in their medical decisions due to their physical or mental condition. Often these directions deal with the resident's desires concerning end of life issues. These directives guide our health care team and allow the incapacitated resident to retain autonomy and privacy . Residents are under no obligation to provide Advance Directives. We offer the resident the opportunity to give us instruction for his/her care in the event the resident is unable to make decisions about his/her care during a terminal illness . We are obligated to follow the resident's wishes as expressed in valid Advance Directives . EMERGENCY CARE AND TREATMENT WITHOUT ADVANCE DIRECTIVES: If the resident does not have Advance Directives and a medical emergency arises, we will follow our policies to assure the resident received the emergency medical care necessary to prolong life . Call 911 and transfer to acute care hospital without prior notice to family or physician if condition is life threatening . 1:1 (one on one) care until emergency no longer exists, or resident transferred . Emergency Care not related to terminal illness with a DNR or No Hospitalization order. In the event of a life threatening crisis that is unexpected and unrelated to end of life issues the facility will operate under a conservative approach and initiate measures to stabilize the resident . Review of the admission contract signed for R312, contained the same documentation as noted above in the facility's Advance Directive policy (as documented above) and was signed by R312's representative. Review of the medical record revealed no documentation that R312 or R312's legal representative had formulated an Advance Directive. Further review of the medical record revealed no Advance Directive on file and no changes made in the social worker notes or assessment that R312's representative requested any changes to be made. Review of the most recent Code Status Form in the medical record dated [DATE], documented in part . DO-NOT-RESUSCITATE ORDER . Patient Advocate Consent/Guardian Consent . I authorize that in the event the declarants/ward's heart and breathing should stop, no person shall attempt to resuscitate the declarant. I understand the full import of this order and assume responsibility for its execution . This order will remain in effect until it is revoked as provided by law . This form was signed by R312's daughter, Physician B and witnesses. The resident's breathing or heart did not stop when LPN A initially identified the change in condition with R312 and therefore continued monitoring, continued care and/or transfer to a higher level of care should have been provided to stabilize the resident. Review of a Nursing note dated [DATE] at 11:32 PM, documented in part . Writer has made several attempts to notify family of residents changed in condition without success, messages left for (R312's family member names) . to call facility, with no return calls, endorsed to oncoming nurse . Review of a Nursing note dated [DATE] at 12:25 AM, documented in part . At approximately 12:25am: unresponsive to physical and verbal stimuli, Skin warm to touch. Absent pulse, respiration, and blood pressure noted. Advance directives: DNR. Family aware of change in condition and stated they were on the way. Family arrived, support from staff given. [Local police department] called and made aware. Police arrived at approximately 12:40am. Police spoke with the facility medical Director. DON notified and made aware of resident's change in condition. At approximately 5:15am funeral home picked up remains, family present. Funeral home signed release order. Report given to oncoming nurse . Review of the medical record contained no documentation of any comfort medications or interventions provided to the resident after the change of condition was identified. On [DATE] at 10:57 AM, the DON (who was recently hired at the facility in February 2023 and was not employed at the facility at the time of R312's inpatient care), the Clinical Regional Director (CRD) C (who was the clinical director at the time of R312's incident, however as of the end of [DATE] was no longer overseeing the facility) and CRD D (who started on [DATE] and who is the current clinical regional director of the facility) was all interviewed together and asked the expectation of staff if they identify a change of condition with a resident who has a code status of a DNR and specifically identified with an oxygen saturation level of 72%, CRD D responded the resident should be assessed, oxygen applied, review the code status and call the physician. CRD D stated staff should complete a change of condition form and notify the family. CRD D stated pulse ox monitoring should be performed and a staff member with the resident monitoring them until they are stable. When asked, CRD D stated all documentation of monitoring should be documented in the medical chart. At this time, R312's change of condition as documented on [DATE] was reviewed with the DON, CRD C and CRD D. The concerns of the lack of monitoring, obtaining follow up vitals and documentation of R312 who was identified with an oxygen saturation level of 72% and who staff applied a non rebreather mask at 10 LPM, which was not effective in stabilizing the resident's respiratory status with no documentation of notifying the physician that the intervention was ineffective and the decision made to not send the resident out to a higher level of care for further treatment was reviewed. The DON, CRD C and CRD D acknowledged the concerns and stated they would look into it and follow back up. At 11:50 AM, CRD C returned and stated they reviewed the incident and were unable to find any additional information or documentation. CRD C stated they understood the concerns. On [DATE] at 1:30 PM, the facility's Administrator was served an Immediate Jeopardy template regarding R312's change of condition and the actions of the facility staff that followed the identified change of condition. On [DATE] at 2:11 PM, CRD D entered into the conference room where the surveyors worked and stated they wanted to know why R312's change of condition incident is categorized as an Immediate Jeopardy. CRD D stated they expected the incident to be categorized as a G harm level, but not Immediate Jeopardy and wanted the surveyor to explain why it was immediate jeopardy. All concerns that were initially presented to the DON, CRD D and CRD C were again repeated and CRD D was informed that an immediate action was necessary to prevent the incident from happening to any additional residents. On [DATE] at 2:47 PM, a telephone interview was conducted with Physician B (the physician who LPN A initially contacted regarding R312's change of condition and the physician who was assigned to R312 while at the facility). Physician B was presented with the concerns that involved the change of condition, follow up monitoring and follow up notification to the physician regarding the unstable respiratory status of R312. Physician B stated they honestly did not remember the incident. Physician B stated they remembered receiving a call about R312 but could not recall what it was regarding. When read the assessment of R312 as documented by LPN A and what directive they would have given to the staff, Physician B stated To be honest with you if they called me about a patient below 90 (SPO2) I would advised them to be sent out to the hospital. Physician B stated again that they could not remember the incident. On [DATE] at 3:07 PM, the Administrator escorted Physician B into the conference room where the surveyors worked and stated that Physician B would like to have a second interview with the surveyor. Physician B started off the conversation stating they had a chance to review the resident's medical record. Physician B then went on to state that if staff contacted them now (currently) regarding a resident who is a DNR with a pulse ox of 72% they would want to make that resident comfortable. When asked if the staff informed them that the initial order to apply the oxygen was ineffective and did not raise the SPO2 levels of R312, Physician B denied to have been notified of the oxygen not being effective. Physician B was then asked if they gave the staff directive to not send R312 to the hospital and the physician replied they could not remember. When asked why the facility did not follow the facility's policies regarding R312's change of condition, Physician B stated So I should have put an order to not send to the hospital? Physician B was informed that it was documented in the medical record that R312 had legal representatives in place and that conversation and decision is one that should have been conducted with the legal representatives so that the facility could implement their wishes, this is a decision that cannot be solely decided by the physician without involving the legal representatives. Physician B was asked once again if they gave the directive to the nursing staff to not send R312 to the hospital with the resident's change of condition as documented on [DATE] and Physician B stated in part . I didn't. I don't remember with this resident. I just don't . Physician B thanked the surveyors for their time and the surveyors thanked Physician B for their time and Physician B exited the conference room. Review of the medical record revealed no physician order that documented No Hospitalization for R312. Review of a Physician note dated [DATE] at 4:24 PM, (the last physician note documented in R312's chart) documented in part . Reason for the visit E/M for dementia, anxiety, dysphagia, and Huntington's disease. Also seen for multiple medical condition more than 3 requiring monitoring and prevent decline. Patient seen and examined Vital signs, medications, labs, and chart reviewed . no reported hx (history) of vomiting, constipation, or diarrhea, no sob (shortness of breath) no hematuria (blood in urine) no loc (loss of consciousness) or seizure activity . awake, not aware, chronically debilitated . Lungs CTA (clear to auscultate) bilaterally, no acute distress, no rales, or wheezes; no clubbing/cyanosis . A&P (Assessment & Plan): 1. Dementia: no evidence of behavioral disturbances at time of exam. Continue supportive care 2. Anxiety: stable on current RX (medication). No anxiety/agitation noted on exam 3. Dysphagia: tolerating prescribed diet. Continue 1:1 feed. Maintain aspiration precautions 4. Huntington's disease: stable on current dose of Austedo. Continue supportive care . Review of the progress notes and Medical record revealed no documentation of the resident to have been under hospice services at the time of death, nor was there documentation in the medical record that indicated resident's health status to have been declining prior to the identification of the change of condition documented on [DATE], with death of the resident following two hours and twenty-five minutes later. Further review of the progress notes documented the following Infection Note dated [DATE] at 11:14 AM (four days before the resident expired), . Per CDC (Centers for Disease Control and Prevention) guidelines, all residents have been offered chemoprophylactic treatment for influenza outbreak. At this time, the pharmacy is unable to fulfill any prophylaxis orders due to national shortage of Tamiflu. Resident was made aware. DPS #2 Based on observation, interview, and record reviews the facility failed to identify left arm edema and notify the physician of the edema for one (R61) of one resident reviewed for edema. Findings include: On [DATE] at 10:46 AM, R61 was observed lying on their back in bed. The left arm was observed to have edema from the upper arm to the fingers, when compared to the right arm. Review of the medical record revealed R61 was admitted to the facility on [DATE] with a readmission date of [DATE] and diagnoses that included: dementia, dysphagia, gastrostomy, muscle weakness, history of transient ischemic attack and cerebral infarction without residual deficits and hypertension. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 4 (which indicated severely impaired cognition) and required staff assistance for all Activities of Daily Living (ADLs). Review of the physician orders documented orders for Metoprolol 25 MG (milligram) via PEG (percutaneous endoscopic gastrostomy) every 12 hours for hypertension and Losartan Potassium 100 MG once a day for hypertension. Review of the care plans revealed one intervention which was to report edema to the nurse. No further interventions were documented regarding any identified edema. Review of a Dietary note dated [DATE] at 10:59 AM, documented in part . Weight gradually increasing. Wt (weight) gain may be r/t (related to) excess energy intake via PEG . or possible edema . no labs to review . + (positive) trace edema noted 4/7 . The note does not specify where the trace edema is identified. Review of a Physician's Note dated [DATE] at 3:40 PM, documented in part . LEs (lower extremities): + trace Edema . Further review of the physician note revealed no documentation of directive given to staff regarding the monitoring or interventions for the trace edema identified in the lower extremities. Review of the medical record and progress notes revealed no documentation of the left arm edema identified by the facility staff. On [DATE] at 1:58 PM, the Director of Nursing (DON) was asked to go with the surveyor to the room of R61. It was explained to R61 that an observation would be made of their arms and legs. R61 shook their head yes. The DON then pulled down R61's top sheet revealing R61's arms and legs. Observation revealed both of R61's feet and left upper arm to fingers to have edema present. Once in the hallway the DON was asked why staff had not identified the edema on R61, documented it in the medical record and inform the physician. The DON stated they would look into it and follow back up. On [DATE] at 3:21 PM, the DON stated they completed an assessment on the resident and reported the findings to the physician. No further explanation or documentation was provided by the end of survey. Resident #4 Deficient Practice Statement #3 Based on interview and record review the facility failed to follow-up in a timely manner with Physician recommendations for one resident (R4) of three residents reviewed for quality of care. Findings include: On [DATE] at approximately 10:04 a.m., R4 was observed in their room and laying in their bed. R4 was observed to be in a hospital gown and had unclear speech. On [DATE] the medical record for R4 was reviewed and revealed the following: R4 was last admitted on [DATE] and had diagnoses including Dementia, Abdominal Pain and Constipation. A review of R4's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of [DATE] revealed R4 was dependent on staff for assistance with their activities of their daily living. R4 was documented as having severely impaired cognition. A Physical Medicine and Rehab (PM&R) evaluation dated [DATE] revealed the following: Physician's Note-Note Text: PM&R/ Pain Management at [facility] .Reason for Visit: I am seeing and treating the patient (pt) today to treat her for pain, as the pt needed her Norco pain meds refilled. Chief Complaint: Ouch when I moved her bilateral (b/l) contracted knees today. Pt seen & examined today on Tuesday [DATE]. Pt was complaining of pain, the location of the pain is to both her contracted knees, the duration of the pain has been for 16+ months, the pain is daily, the pain was described as ouch when I touched and moved her knees, the pain is worse with touching her knees and no pain meds, the pain is better with the pain meds, there is no radiation of the pain, and the pt did not rate the pain out of 10 today for me. Plan: 1.) Today I electronically prescribed the following Prescription (Rx) order online to the Pharmacy for:- Norco 5/325 mg, one (1) tab po q 8 (eight) hours prn: pain, #6 (six) count 7.) I recommend daily Senna & Colace to help prevent Opioid Induced Constipation from Norco Further review of the medical record for R4 did not reveal any Physician orders were implemented for Senna and Colace in R4's medication regimen. A review of R4's March and [DATE] medication administration record (MAR) revealed no opportunities of administration of Senna or Colace. Further review of R4's MAR revealed Norco was still a part of their medication regimen. On [DATE] at approximately 3:20 p.m. during a conversation with the Director of Nursing (DON), the DON was queried for information pertaining to the implementation delay in R4's senna and colace not being added to their medication regimen and they indicated they would have to look into the concern. On [DATE] at approximately 11:51 a.m., during a conversation with Regional Clinical Regional Director C (CRD C), CRD C followed up regarding the concern of providing senna and colace to R4. RCD C indicated that it was missed and should have been added to the medication regimen. RCD C indicated that the Nursing staff are supposed to review the reports in the clinical meetings but it was not done. RCD C indicated they would have to get it added to medication regimen.