**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the physician of one resident's (Resident #1) low lab results and to ensure the Medical Director (MD) and other physicians had full access to lab results in the system the physicians use. The MD was not aware of lab results for seizure medications for Resident #1, and the resident sustained seizure activity 18 days later. The facility also failed to ensure the physician was notified when Resident #1 had a change of condition of new purple discoloration to the resident's fingertips at 8:30 P.M. and did not notify the on call Nurse Practitioner (NP) until approximately 4:30 A.M. after the resident had a fall. The facility failed to document the initial assessment of the change of condition in the medical record. In addition, the facility failed to check gastrostomy tube (g-tube a thin, flexible tube inserted directly into the stomach through a small incision in the abdomen) residuals (the volume of fluid remaining in the stomach) for one of three residents sampled with a g-tube (Resident #13). The sample was 3. The census was 94. Review of the facility's Notification of Changes Policy, revised [DATE], showed: -Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, resident's representative when there is a change requiring notification; -Definitions: -Life threatening conditions: Examples - Heart attack or stroke; -Clinical Complications: Examples - Development of Stage Two (partial thickness loss of dermis (inner layer of the two main layers of the skin) presenting as a shallow open ulcer with a red or pink wound bed, without slough (a layer of dead, non-viable tissue that accumulates on the surface of a wound that is typically yellow, white, or gray in color and may appear moist, stringy, or adherent). May also present as an intact or open/ruptured blister) pressure injury (localized area of skin and underlying tissue damage caused by prolonged pressure, shear, or friction), recurrent episodes of delirium (mental state in which a person is confused and has reduced awareness of their surroundings), recurrent urinary tract infection (UTI) or onset of depression; -Need to alter treatment significantly: means a need to stop a form of treatment because of adverse consequences (such as adverse drug reaction) or commence a new form of treatment to deal with a problem (for example, the use of any medical procedure, or therapy that has not been used on that resident before; -Right to privacy: The facility is required to inform the resident of his/her rights upon admission and during the resident's stay including the resident's right to privacy; -Compliance Guidelines: The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification; -Circumstances requiring notification include: -1. Accidents; -a. Resulting in injury; -b. Potential to require physician intervention; -2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include: -a. Life-threatening conditions, or; -b. Clinical complications; -3. Circumstances that require a need to alter treatment. This may include: -a. New treatment; -b. Discontinuation of current treatment due to: -i. Adverse consequences; -ii. Acute condition; -iii. Exacerbation of a chronic condition; -4. A transfer or discharge of the resident from the facility; -5. A change of room or roommate assignment; -6. A change in resident rights; -Additional considerations: -1. Competent individuals: -a. The facility must still contact the resident's physician and notify resident's representative, if known; -b. A family that wishes to be informed would designate a member to receive calls; -c. When a resident is mentally competent, such a designated family member should be notified of significant changes in the resident's health status because the resident may not be able to notify them personally, especially in the case of sudden illness or accident; -2. Residents incapable of making decisions: -a. The representative would make any decisions that have to be made; -b. The resident should still be told what is happening to him or her; -3. Death of a resident: The resident's physician is to be notified immediately in accordance with State law; -4. Notice of room changes: -5. Contact information of the resident's legal representative or family member must be recorded and periodically updated; -6. Right to privacy: -a. The facility is required to inform the resident of his/her rights upon admission and during the resident's stay including the resident's right to privacy; -b. If a resident specifies that he/she wishes to exercise this right and not notify family members in the event of a significant change as specified at this requirement, the facility should respect this request, which would obviate the need to notify the resident's interested family member or legal representative, if known; -c. If a resident specifies that he/she does not wish to exercise the right to privacy, then the facility is required to comply with the notice of change requirements. Review of the facility's Laboratory Services and Reporting Policy, revised [DATE], showed: -Policy: The facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law; -Policy Explanation and Compliance Guidelines: -1. The facility must provide or obtain laboratory services to meet the needs of its residents; -2. The facility is responsible for the timeliness of the services; -3. Should the facility provide its own laboratory services, the services must meet the applicable requirement for laboratories; -4. If the laboratory chooses to refer specimens for testing to another laboratory, the referral laboratory must be certified in the appropriate specialties and subspecialties of services in accordance with the requirements; -5. Assist the resident in making transportation arrangements to and from the laboratory if necessary; -6. All laboratory reports will be dated and contain the name and address of the testing laboratory and will be filed in the resident's clinical record; -7. Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside the clinical reference range. 1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: -Severe cognitive impairment; -Diagnoses included high blood pressure, seizures, unsteadiness on feet, communication deficit, and muscle weakness. Review of the resident's undated care plan, showed: -Focus: Resident has a seizure disorder; -Interventions: -Give medications as ordered. Monitor/document for effectiveness and side effects, initiated [DATE]; -Monitor labs and report and sub therapeutic or toxic results to physician, initiated [DATE]. Review of the resident's orders, showed: -Keppra 500 milligrams (mg) give by mouth two times a day for seizures, start date [DATE], discontinue (DC) date [DATE]; -Keppra 500 mg give one tablet by mouth every morning and at bedtime related to seizures, start date [DATE], DC date [DATE]; -Dilantin tablet chewable 50 mg give three tablets by mouth two times a day for seizure, start date [DATE], DC date [DATE]; -Dilantin tablet chewable 50 mg give three tablets by mouth every morning and at bedtime for seizures, start date [DATE], DC date [DATE]; -Keppra and Dilantin levels every six months starting on the fourth, start date [DATE], DC date [DATE]. Review of the resident's lab results, showed: -Collected: [DATE] at 8:19 A.M.; -Reported [DATE] at 1:02 P.M.; -Dilantin (phenytoin, medication used to treat seizures. Measures the amount of Dilantin in the blood for therapeutic levels for treating seizures, normal therapeutic range 10-20 ug micrograms (ug) /mL); -Less than (<) 2.5 ug/mL, Low; -Keppra (levetiracetam, medication used to treat seizures. (levetiracetam, measures the amount of Keppra in the blood for therapeutic levels to treat seizures, normal therapeutic range 6-46 ug/mL); -< 2 ug/mL, Low. Review of the resident's progress notes, showed: -[DATE] at 11:02 A.M., labs reviewed, see order management; -[DATE] at 2:11 P.M., labs reviewed, see order management; -No documentation the physician was notified of the low Dilantin and Keppra levels. Review of the resident's orders, showed: -No new orders entered on [DATE]. Review of the resident's progress notes, showed: -[DATE] at 10:50 P.M., resident started to have a seizure at 10:50 P.M. lasting for five to six minutes. Emergency Medical Services (EMS) called at 11:00 P.M. EMS arrived at 11:15 P.M. and upon assessment resident was stable; -[DATE] at 4:08 A.M., resident was sitting in common area by the nurses station when this nurse noticed the resident having strange behavior. Nurse approached resident and resident was having a seizure at 4:00 A.M. lasting for five to seven minutes. On call NP notified. Review of the resident's physician progress note written by the resident's physician/Medical Director, dated [DATE], showed: -Progress Note Acute Care: -Chief Complaint: Physical acute visit: -Interval History: Resident seen and examined at bedside. Resident is reported to have had two seizures overnight earlier this week. Per resident and nursing, resident has been at baseline since seizures occurred and had no proceeding symptoms or signs of illness. Resident had recent bloodwork, but it did not include levels for his/her antiepileptic (medication used to prevent or treat seizures) medications or follow up on his/her hypothyroidism (thyroid does not produce enough thyroid hormone); -Labs: Labs listed, but did not include TSH 3 UL, Dilantin, Keppra; -Assessment/Plan: Seizures: Continue current medications and will check therapeutic levels. During an interview on [DATE] at 11:17 A.M., the MD said regarding her progress note on [DATE], she was unable to see any labs regarding the resident's Keppra levels, Dilantin levels and TSH levels. The MD said the electronic records system the facility uses, Point Click Care (PCC) and the lab system talk to the system the physicians use and those labs were not in her system. The MD logged onto PCC and went to the resident's medical record, looked under labs and opened the lab results that were collected on [DATE] and reported on [DATE]. When the MD looked at the lab results in PCC, she noticed the lab results for Keppra levels, Dilantin levels and TSH levels. The MD said she could see all the lab results were not pulled over from PCC. The MD said usually the nurse will report any abnormal lab results to the NP or herself. There was no adjustments made on the resident's seizure medication by the acting NP at that time and if the results of the Keppra and Dilantin levels were reviewed on [DATE], there would have been an adjustment made on the resident's seizure medication and an order to recheck the labs. The NPs also use the same system the MD does for reviewing resident charts. The resident ended up having two seizures after the labs were drawn and the labs showed the seizure medication was not at a therapeutic level for the resident. The resident had labs completed on [DATE] and the Keppra and Dilantin levels were in normal range at that time, so the low levels could have been because the resident was not metabolizing the medication well or the resident was not receiving the medication consistently. During an interview on [DATE] at 11:56 A.M., Licensed Practical Nurse (LPN) H said lab results are under the results tab in PCC or the nurse can call the lab to get results. The nurses are responsible for checking the results tab if a resident had labs completed to view the results. The lab will call the facility if there are critical lab results and report those critical lab results to the nurse on duty. The lab does not call if there are abnormal labs. It is the nurse's responsibility to follow up on the lab results and report them to the NP or physician. If a lab has abnormal results, LPN H sends them to the NP through fax or sends them a photo of the labs. LPN H does not look at the specific lab results prior to sending them to the NP or physician. LPN H would document in a progress note if the labs for the resident were sent to the NP or physician. During an interview on [DATE] at 12:04 P.M., LPN I said he/she goes through PCC to get lab results for residents or he/she can log into the lab portal and get the results of a resident's labs. If a resident has abnormal labs, the lab will call the facility and inform the nurse of the abnormal labs that are high or low. It does not have to be critical result. LPN I would then immediately call the physician and report the abnormal labs. With abnormal labs, the physician may want to adjust the resident's medication or send the resident to the ER depending on what labs are abnormal. If all lab results were normal, LPN I would still notify the NP or physician the labs were normal and would leave them for them to review. If there were abnormal labs, LPN I would not wait on the NP to come in and review the labs, he/she would call and notify the physician. The notification would be documented in a progress note, including if the physician had any new orders for the resident. If a resident was being checked for Keppra and Dilantin levels and the labs came back low, he/she would call the physician immediately because the physician would probably want to increase the seizure medication or may want to send the resident to the hospital. If the numbers came back low, that would increase the possibility of the resident having seizures and that is why it would be important for report it to the physician. During an interview on [DATE] at 12:30 P.M., the Administrator said the facility gets lab results electronically in PCC by the lab company. The Administrator said the lab will call the facility if there are critical results that need to be reported. It is the nurse's responsibility to look for lab results for residents who have had labs drawn. The Administrator said management also checks the lab and radiology results daily during the week when they have their clinical meetings. If a resident has abnormal labs, the expectation is the nurse will report the abnormal labs to the NP or physician. It is expected the nurse will document the notification in a progress note along with any new orders the NP or physician gives. The Administrator expected the physicians and NPs to have access to view all lab results in their system. If lab results came back as low for Keppra <2.5 and Dilantin <2, that would be a concern for that resident. The Administrator would be concerned the resident could have seizures due to the Keppra and Dilantin levels not being in a therapeutic range. The Administrator expected staff to be knowledgeable of and to follow the facility policies. During an interview on [DATE] at 1:02 P.M., the Director of Clinical Intervention (DOCI) said labs are dumped into PCC and the NP, physician, or the MD has to sign off on them. The DOCI said it is the nurse's responsibility to check the dashboard in PCC at least three times each shift and that would notify the nurse as an alert if a resident had new lab results. She expected nurses to review the labs results in PCC as they have been taught and to notify the NP or physician if there are abnormal labs. She also expected the nurse to document the notification in PCC. The DOCI said she expected the MD and NPs to be able to see all residents full lab results in their system. She would be concerned about the resident having seizures if the lab results came back low for Keppra and Dilantin, if the resident was using the medication for seizures. The DOCI expected staff to be knowledgeable of and to follow the facility policies. Review of the resident's progress notes, dated [DATE] at 4:51 A.M., showed the resident was found on the floor unable to explain how he/she got there. LPN A did full body assessment, no open areas noted upon getting resident to his/her feet. Resident unable to walk without assistance so nurse placed resident in wheelchair and brought him/her to the nurse's station to check vital signs (VS). Resident blood pressure (BP, normal 120/80) 125/92, pulse rate (P, heart beats per minute (BPM), normal range 60 - 100) 101, oxygen saturation (SpO2), 93% on room air (RA) (normal range, 95% - 100%), respiratory rate (R, breaths per minute, normal range is 12-18) 16, temperature, (T, normal 98.6 degrees Fahrenheit (F)) 98.1. Resident also has some noted blue fingertips when asked if resident was experiencing pain resident denied. Resident was placed on 2 liters (L) of oxygen for comfort resident not showing and signs or symptoms (S/S) of distress. Call placed to on call NP E. NP E stated to continue to monitor resident as normal and he/she will inform in house NP C to round on resident regarding blue fingertips. During an interview on [DATE] at 8:12 A.M., CNA F said the first time he/she worked with the resident was on [DATE] day shift (7:00 A.M. to 3:00 P.M.) and evening shift (3:00 P.M. to 11:00 P.M.). CNA F said while working the evening shift, he/she noticed the resident's fingertips were purple and that was the first time CNA F saw this and it scared her because that means no oxygen. CNA F reported the resident had purple fingertips to LPN G. During an interview on [DATE] at 11:22 A.M., LPN A said he/she worked the night shift (7:00 P.M. to 7:00 A.M.) on [DATE] and was at the facility from approximately 7:30 P.M. to 9:00 A.M. on [DATE]. LPN A said CNA F reported to him/her the resident's fingertips were purple at the start of shift change, approximately 8:30 P.M. LPN A said he/she and LPN G assessed the resident and gave the resident his/her seizure medication. The resident was in bed. LPN A said the resident was fine except his/her fingertips were purple. LPN A said the assessment he/she completed on the resident was a grip test, asked the resident if he/she was in pain, the resident denied pain, and checked the resident's SpO2 levels. It was 96% on RA. The resident was not using oxygen. LPN A said NP C was going to see the resident the next day. LPN A did not notify the on-call NP E at that time. Around 4:45 A.M., CNA D and LPN A went to the resident's room because the call light was on. When CNA D and LPN A entered the resident's room, the resident was crawling around on the floor on his/her roommate's side of the room. LPN A said he/she performed a full body assessment on the resident and found nothing abnormal. LPN A transferred the resident from the floor into a wheelchair and brought the resident up to the nurse's station in the wheelchair a little before 5:00 A.M. to take the resident's vitals. LPN A said the resident's vitals were alright. His/Her pulse was elevated, the SpO2 was kind of low at 93% and LPN A placed the resident on 2 Liters (L) of oxygen with a nasal cannula. LPN A said the resident's fingertips were still purple. LPN A wanted to send the resident to the hospital at that time to get evaluated, because he/she was a full code (in the event of no pulse, initiation of CPR and summoning 911), fell, his/her SpO2 was low, his/her pulse was elevated, and the resident had purple fingertips. LPN A said the Nurse Manager (NM) who was working the night shift said the resident's vital signs were stable, and they just needed to monitor the resident. LPN A said he/she discussed his/her concerns with NM and told the NM the resident was a full code. LPN A called NP E and notified NP E about the fall, resident's vital signs, and the purple fingertips. The NM and CNA D moved the resident to the common area in front of the nurse's station. LPN A was completing vital signs and neurological checks on the resident after the fall, and they were within normal range. The resident continued to wear oxygen during this time. When other residents began coming into the common area, LPN A and CNA D transferred the resident from the recliner into the wheelchair to take the resident back to his/her room to change the resident. The resident was breathing when he/she was transferred into the wheelchair. LPN A removed the oxygen from the resident prior to the transfer because LPN A did not want the resident to get tangled up in the oxygen tubing. The resident was not wearing oxygen when he/she was brought to his/her room. CNA D transferred the resident into his/her bed and when CNA D rolled the resident over, CNA D told LPN A, he/she did not believe the resident was breathing. LPN A assessed the resident by checking for a pulse in the resident's neck and arm, LPN A did not feel a pulse. The resident's bed was in a flat position and LPN A did not see any rising or lowering of the resident's chest. LPN A did not have a stethoscope on him/her so he/she called the NM to the resident's room to assess the resident and confirm there was no heartbeat. NM confirmed there was no heartbeat and told LPN A the resident was gone so there was no reason to perform cardiopulmonary resuscitation (CPR, a lifesaving technique that's used in emergencies in which someone's breathing or heartbeat has stopped) and two nurses could verify death. NM called NP C to report the resident's time of death. During an interview on [DATE] at 7:08 A.M., CNA D said he/she and LPN A answered the call light on [DATE] early in the morning and the resident was on the floor on his/her roommate's side of the room. The roommate said the resident walked to his/her side of the room and fell. CNA D and LPN A picked the resident up and took the resident by wheelchair to the nurse's station. CNA D said the resident's vital signs were stable, but LPN A did not like how the resident looked. CNA D said the resident's eyes were sunken in and the resident had blue fingertips. LPN A wanted to send the resident to the hospital. That was the first time CNA D noticed the resident having purplish/bluish colored fingertips. The pointer finger was discolored from the second bend to the tip and the middle finger was discolored from the first bend to tip on both hands. The resident was responsive while at the nurse's station when he/she would say the resident's name the resident would look at CNA D. When LPN A took the first set of vitals, he/she wanted to send the resident out. LPN A verbalized to NM that he/she wanted to send the resident out and NM said not to send the resident out, because the resident's vitals were stable, and the hospital complains because the facility sends residents out so frequently. NM and CNA D moved the resident onto the couch in the common area in front of the nurse's station. Then NM and CNA D moved the resident to the recliner because the resident did not look comfortable on the couch. The resident was then moved from the recliner to the wheelchair a little before 7:00 A.M. to bring the resident down to his/her room to change him/her. CNA D said the resident's eyes were closed and he/she thought the resident was just sleeping. After transferring the resident into bed, when the resident was turned over, CNA D asked LPN A if the resident passed away, because it didn't look like the resident was breathing. LPN A got the NM and the NM listened to the resident and said that the resident passed away at 6:58 A.M. CNA D said LPN A told NM the resident was a full code. The NM said the resident was already gone. During an interview on [DATE] at 8:39 A.M., the NM said he/she came into work the night shift on [DATE] around midnight and worked into the morning of [DATE]. The NM was not aware of any change of condition for the resident until around 4:40 A.M. to 4:45 A.M. when a call came to the nurse's station from the resident's roommate that the resident was on the floor. LPN A and CNA F went down to the resident's room and brought the resident up to the nurse's station in a wheelchair. LPN A used a wrist blood pressure cuff and could not get a reading on the resident, so the NM did a manual blood pressure. The blood pressure was 120/80 or 120/90. LPN A used a pulse oximeter (device that measures the oxygen saturation of the blood) on the resident's finger. The SoO2 reading was 93% on RA and his/her pulse was 101. The resident's fingertips were discolored. LPN A told the NM he/she believed the resident had Raynaud's disease (condition that causes blood vessels in the extremities (usually fingers and toes) to narrow excessively in response to cold temperatures or stress and it is often accompanied by changes in the color of the skin). NM said the resident's three fingertips, pointer finger, middle finger and ring finger on his/her right hand, were a purplish/blue color from the tips to the first bend of the finger. The resident's left hand also had the same purplish/blue discolor on the same three fingers, but it was lighter than the right hand. NM had seen the resident on [DATE] during the day with NP C and the resident's fingertips were not like that during the day. NM said the discoloration, which was not normal for the resident and was showing something acute (something that begins suddenly) and new. The NM was concerned why the resident's fingertips would be changing colors. The resident was placed on supplemental oxygen on 2L with a nasal cannula after obtaining vital signs after the resident had the fall, and before the resident was transferred onto the couch in the common area. The NM and CNA D transferred the resident onto the couch and laid him/her down and then transferred the resident into the recliner next to the couch. NM said his/her observation of the resident stopped at that time, around 5:00 A.M., because he/she began passing medications to his/her assigned residents. LPN A did not say anything about wanting to send the resident out to be evaluated at the emergency room (ER) or that the resident was a full code. LPN A was calling his/her name and said come here I think I need your help. The NM did not feel that there was any urgency when LPN A requested help. When the NM got to the resident's room, LPN A said he/she did not think the resident was breathing. The NM checked one side of the resident's neck and LPN A checked the other side. There was no pulse. LPN A did not say the resident was a full code, so the NM thought the resident was a Do Not Resuscitate (DNR, in the event no pulse no life saving measures to be taken, no CPR) because LPN A did not use any urgency when asking for assistance. LPN A told NM he/she thought the resident died in his/her sleep so the NM called NP C right then and informed NP C the resident expired in his/her sleep. The resident was pronounced expired at 6:58 A.M. NP C gave a death diagnosis of cerebrovascular accident (CVA, stroke). During an interview on [DATE] at 7:08 A.M., CNA J said he/she worked the night shift on [DATE] but was not assigned to the resident. CNA J said when the resident was brought up to the nurse's station, he/she was alright for a minute then his/her head went back, and the resident went incoherent while sitting in the wheelchair at the nurse's station. CNA J stood in front of the resident when LPN A took the resident's vital signs, and the resident went incoherent. The resident's head went back and he/she wasn't answering the nurses, LPN A and NM. The NM and CNA D transferred the resident to the couch and LPN A put oxygen on the resident. They tried to lay the resident flat on the couch, but the resident didn't look comfortable. The resident was breathing fast at first, but his/her breathing slowed down after a little while. When CNA J saw the resident next, he/she was in the recliner, the resident was on the couch maybe five to ten minutes. The resident was transferred into the wheelchair and taken to his/her room. The oxygen was removed before the resident was transferred. CNA J said the resident did not look good because the resident's jaw looked sunken in. During an interview on [DATE] at 9:38 A.M., NP E said she was on call for the facility and received a call from the facility at 4:39 A.M. on [DATE]. LPN A reported the resident had an unwitnessed fall, the resident's vital signs were stable. The resident was seen on [DATE] during the day at the facility NP C. LPN A reported the resident had purplish colored fingertips since that morning. NP E recommended to monitor and do neuro checks per facility protocol and have facility NP C round on the resident to check it ou

Based on interview and record review, the facility failed to provide pain management consistent with professional standards of practice, and care plan interventions related to pain for one of six sampled residents (Resident #3). The facility failed to timely administer pain medications in accordance with the physician's orders. Additionally, facility staff failed to follow up with resident pain medication to ensure availability for administration and failed to implement measures, including use of medication available in the facility starter kit/emergency drug kit, when the resident's pain medications were unavailable. The census was 94. Review of the Medication Reordering policy, dated 9/1/21, showed: -It is the policy of this facility to accurately and safely provide or obtain pharmaceutical services including the provision of routine and emergency medications and biologicals in a timely manner to meet the needs of each resident; -The facility will utilize a systematic approach to provide or obtain routine and emergency medications and biologicals in order to meet the needs of each resident; -Acquisition of medications should be completed in a timely manner to ensure medications are administered in a timely manner; -Each time a nurse is administering medications and observes (6) or less doses left of one kind, that nurse will reorder the medication, time permitting; -In the event of new orders, the facility is allowed (24) hours to begin a medication unless otherwise specified by the physician; -For stat medications, a supply of medications typically used in emergency situations will be maintained in limited supply by the pharmacy in a portable, but sealed emergency box or container (may be used if applicable). Review of the facility's Physician's Orders policy, revised 4/7/22, showed: -Policy: This facility shall use uniform guidelines for the ordering and following of medical provider orders; -Policy Explanation and Compliance Guidelines: Medications and/or Treatments should be administered only upon the signed order of a person lawfully authorized to prescribe; -Verbal orders should be received only by licensed nurses, or pharmacists, and confirmed in writing by the medical provider, on the next visit to the facility; -Each medication and/or treatment order should be documented with the date, time, and signature of the person receiving the order; -If using electronic medication records, input the medication and/or treatment order according to the electronic health record (EHR) instructions and facility policy; -Call, fax, or electronically transmit the medication and/or treatment order to the provider pharmacy; -Validate newly prescribed medications and/or treatment is in the electronic Medication Administration Record (MAR)/Treatment Administration Record (TAR); -When a new order changes the dosage of a previously prescribed medication, discontinue the order as per the electronic software instructions and retype the new order; -Validate the new order is in the electronic MAR/TAR; -Notify resident's sponsor/family of new medication order; -Medical provider orders should be reviewed prior to administration of medication and/or treatment to validate the orders contains all required elements; -Staff should follow all valid medical provider orders timely unless there is an emergency which would temporarily delay the implementation of the order; -If an order does not contain all the required elements, staff should contact the ordering provider for clarification of the order prior to implementation of the order; -Handwritten Order Signed by the Medical provider: The charge nurse on duty at the time the order is received should note the order and enter it on the medical provider order sheet or electronic order format, if not written by the medical provider. If necessary, the order should be clarified before the medical provider leaves the nursing station, whenever possible; -Verbal Orders: The nurse should document an order by telephone or in person on the medical provider's order sheet or input into electronic record as per facility policy, transmit the appropriate copy to the pharmacy for dispensing, and place the signed copy on the designated page in the resident's medical records. Medical provider orders should be signed per state specific guidelines. Review of Resident #3's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/31/24 , showed: -Usually understood and usually understands others; -Set up or clean up assistance for eating; -Diagnoses included anemia (deficiency of red blood cells), atrial fibrillation (abnormal heart rhythm), coronary artery disease (damage in the heart's major blood vessels), heart failure, acid reflux, renal failure, diabetes, arthritis and stroke; -Been on a scheduled pain medication regimen: Yes; -Received as needed (PRN) pain medications: Yes; -Received non-medication intervention for pain: Yes; -Pain presence: Yes; -Pain frequency: Yes; -Pain Effect on Sleep: Frequently; -Pain Interference with Therapy Activities: Frequently; -Pain Interference with Day to Day Activities: Frequently; -Pain Intensity: 8 out of 10; -At risk for pressure ulcers; -Does this resident have one or more unhealed pressure ulcer at Stage 1 or higher: Yes; -Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar: Three; -Number of these unstageable pressure ulcers that were present upon admission/reentry; -Enter the total number of venous and arterial ulcers present: one; -Diabetic foot ulcer: yes. Review of the resident's care plan, dated 2/14/24, showed: -Focus: Resident requires assist with activities of daily living related to blindness; -Goal: Resident's Activities of Daily Living (ADL) status will improve through the review date; -Interventions: Encourage resident to participate to the fullest extent possible with each interaction; -Encourage resident to use bell to call for assistance; -Monitor for changes in status, notify interdisciplinary team as needed; -Focus: The resident has diabetes; -Goal: The resident will be free from any signs and symptoms of hyperglycemia (high blood sugar); -Interventions: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness; -Dietary consult for nutritional regimen and ongoing monitoring; -Monitor/document/report PRN compliance with diet and document any problems; -Focus: The resident has pain related to arthritis, depression, diabetic neuropathy; -Goal: The resident will display a decrease in behaviors of inadequate pain control: irritability, agitation, restlessness, grimacing, perspiring, hyperventilation, groaning, crying through the review date; -Interventions: Administer analgesia (pain reliever) as per orders; -Anticipate the resident's need for pain relief and respond immediately to any complaint of pain; -Identify, record and treat resident's existing conditions which may increase pain and or discomfort. Review of the resident's MAR and progress notes, dated April 2024, showed the following physician orders and administration: -An order, dated 3/5/24, Acetaminophen Oral tablet 325 milligram (mg). Give two tablets by mouth every six hours as needed for pain: was not administered 4/1/24 through 4/7/24; -An order, dated 3/27/24, Oxycodone (opioid, treatment for severe pain) HCL Immediate Release (IR). Give 5 mg by mouth three times a day for pain, showed: -On 4/1/24: -At 6:00 A.M., documented administered; -At 2:00 P.M., medication unavailable. Review of the progress notes, dated 4/1/24 at 2:16 P.M., showed medication unavailable; -At 9:00 P.M., documented administered; -On 4/2/24: -At 6:00 A.M. and 2:00 P.M., documented administered; -At 9:00 P.M. staff documented resident was sleeping; -On 4/3/24: -At 6:00 A.M., blank; -At 2:00 P.M., Absent from home without meds; -At 9:00 P.M., documented administered; -On 4/4/24: -At 6:00 A.M. and 2:00 P.M., documented administered; -At 9:00 P.M., see progress notes. Review of the progress notes, dated 4/4/24 at 9:00 P.M., showed no documentation; -On 4/5/24: -At 6:00 A.M., 2:00 P.M. and 9:00 P.M., see progress notes. Review of the progress notes, 4/5/24 at 4:23 A.M., showed no documentation; -At 5:02 A.M., no documentation; -At 1:39 P.M., medication unavailable, phoned pharmacy; -At 10:12 P.M., reordered; -On 4/6/24: -At 6:00 A.M., 6:00 P.M., see progress notes. On 4/6/24 at 5:28 A.M., not available, awaiting from pharmacy; -At 2:00 P.M., documented administered; -At 9:00 P.M., blank; -On 4/7/24 at 6:00 A.M. and 2:00 P.M., see progress notes. On 4/7/24 at 7:04 A.M., not available, physician made aware. Pharmacy needs a script to refill -At 1:13 P.M., awaiting script. Observation and interview on 4/7/24 at 1:30 P.M., showed the resident in his/her bed. The resident was covered with a blanket with his/her lower extremities outside of the blanket. The resident's legs appeared dry and cracked. He/She had a wrap on his/her left foot. The resident said he/she had an open sore on his/her foot. He/She is a diabetic. He/she had not received Oxycodone. Staff said they did not have any Oxycodone and Tylenol was not offered to him/her. He/She had pain from his/her hip to the foot due to a previous stroke. He/She rated his/her current pain as a 7 out of 10. During an interview on 4/7/24 at 2:15 P.M., Licensed Practical Nurse (LPN) B said they were waiting for the script for Oxycodone. The pharmacy sent a fax to the physician on Friday. That was the last thing he/she heard. The resident may have an order for Tylenol, but he/she would have to ask for it because it is as needed. Tylenol is available in the facility. LPN B was unsure how long the resident has been out of the Oxycodone. He/She checked the narcotic book and it showed 3/28, but he/she wanted to check the electronic medical record. During an interview on 4/27/24 at 2:20 P.M., Regional Nurse C said the last time Oxycodone was administered was on 4/1/24. The resident receives Lyrica (medication for nerve pain) for pain as well. Regional Nurse C will call the pharmacy to see what was going on. It was documented that the pharmacy was notified. At 2:25 P.M., Regional Nurse C said once the physician signs the script, it is sent to the pharmacy, and the medications are delivered on the next run. The pharmacy was awaiting a script from the doctor. At 2:45 P.M., Regional Nurse C said the physician changed the Oxycodone order from as needed to scheduled. The pharmacy sent out what was available to the resident at the time, but there was not a new order for the script. The physician knew the pharmacy would contact him/her. The pharmacy said they tried to contact the physician, but there was no communication. During an interview on 4/7/24 at 3:14 P.M., the Administrator said she expected staff to follow physician's orders. If there are blanks in the MARs and TARs, it was not done. She expected it to take approximately 48 hours from the time the medication was ordered or changed, called out to the pharmacy and receive the medication. Pharmacy said the issue was with the script. The Administrator expected staff to notify the pharmacy and the physician. She expected the medication to be pulled from Pyxis (medication dispensing machine) if it were unavailable. She expected staff to re-order medications approximately five days before they run out of the medication. There should be no lapse in medications. She expected Tylenol to have been offered to the resident as well. The Administrator said the physician did not receive anything from the pharmacy and the pharmacy only had a fax number. Pharmacy has sent the script for the physician to sign.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their Home Dialysis Treatment policy and Notification of Changes policy for one resident readmitted to the facility on [DATE], with an order for dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) three times a week. Facility staff failed to provide or attempt to provide the resident's transportation to/from dialysis on 11/8/23 and to communicate with the dialysis facility to request a different time for dialysis. Staff also failed to contact the resident's physician of the missed appointment timely and was not notified of the missed dialysis until 11/9/23. In addition, the facility failed to reassess/monitor and notify the physician of the resident's low blood pressure (BP) obtained on the evening of 11/8/23. Approximately two hours after the resident's low BP was obtained, the resident was sent to the hospital where he/she was admitted with a diagnoses of a critically high potassium level, hypotension (low BP), abdominal and chest pain, and shortness of breath. The facility identified three residents who received dialysis, and problems were found with one (Resident #4). The census was 82. Review of the facility's Home Dialysis Treatment policy, last reviewed/revised on 9/1/21, showed: -Policy: This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving home dialysis; -Purpose: The facility will assure that each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice. This includes: -The ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility; -Ongoing assessment and oversight of the resident before, during and after dialysis treatments, including monitoring of the resident's condition during treatments, monitoring for complications, implementation of appropriate interventions, and using appropriate infection control practices; -Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services; -Compliance Guidelines includes: -Residents may receive chronic dialysis treatments which includes transporting the resident to and from an off-site facility for dialysis or treatments; -The facility must assist the resident to assure that arrangements are provided for safe transportation to and from the dialysis facility; -The facility will immediately contact and communicate with the attending practitioner (physician), nephrologist (kidney physician), or dialysis staff and resident/representative any significant changes in the resident's status related to clinical complications or emergent situations regarding dialysis; -The facility will communicate with the attending physician, dialysis facility and/or nephrologist of any canceled or postponed dialysis treatments and document any responses to the changes in treatment in the medical record. The facility will coordinate with the dialysis facility for rescheduling of the resident's dialysis treatment if canceled; -If dialysis is canceled or postponed, the facility and dialysis staff will provide or obtain ongoing monitoring and medical management for changes such as a fluid gain, respirator issues, review of relevant lab results, and any other complications that occur until dialysis can be rescheduled based on resident assessment, stability and need; -In the event circumstances do not allow dialysis to be provided by the designated trained and qualified individual, the facility must immediately notify the dialysis facility in order to make arrangements to assure that no dialysis treatments are missed. Review of the facility's Notification of Changes policy, last reviewed/revised on 9/1/21, showed: -Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, resident's representative when there is a change requiring notification; -Compliance Guidelines: The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification; -Significant change in the resident's physical, mental or psychological condition such as deterioration in health, mental or psychological status. This may include life-threatening conditions, or clinical complications; -A transfer or discharge of the resident from the facility, acute (sudden change) condition, or exacerbation of a chronic condition. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/7/23, showed: -Makes Self Understood: Understood; -Ability to Understand Others: Understands; -Cognitively intact; -Always incontinent of bowel; -Colostomy (a surgical opening in the large intestine): Blank; -Diagnoses of anemia (decrease in the number of red blood cells;), renal (kidney) insufficiency/renal failure or end-stage renal disease (ESRD), diabetes mellitus and malnutrition (protein or calorie); -Dialysis: Blank. Review of the resident's care plan showed: -8/7/23: Focus: Current functional performance. Goal: Resident's functional status will progress towards personal discharge goal during stay. Interventions: Functional mobility of ambulation (walking) to sink/bathroom with stand-by assistance. Bed mobility, eating, personal hygiene, transfer, and independent locomotion on/off the unit; -8/7/23: Renal insufficiency related to kidney disease. Goal: The resident will be able to resume normal daily activities of daily living. Interventions: Monitor and report changes in mental status: lethargy, tiredness, fatigue. Monitor for signs and symptoms of hypovolemia (a condition where the body loses fluid like blood or water), increased pulse, respirations, decreased blood pressure, sweating, anxiousness. Monitor/document/report the following: edema (swelling), weight gain of over two pounds a day, neck vein distention, difficulty breathing, increased heart rate, elevated blood pressure, skin temperature, lung sounds; -8/7/23: Receives dialysis related to renal failure. Goal: The resident will have no signs/symptoms of complications from dialysis. Interventions: Monitor and treat for side effects. Review of the resident's census report (admissions/discharges) showed the resident was discharged to the hospital on 9/18/23 and returned to the facility on [DATE]. Review of the resident's progress note, dated 11/5/23 at 8:47 P.M., showed the resident complained to writer he/she wanted to be sent back to the hospital after having several explosive episodes of loose stool in his/her colostomy. Writer attempted to put wound vacuum (a machine that applies intermittent suction to drain fluid from a wound) in place to help stool from getting into wound on mid abdomen. Writer called exchange (physician's exchange) spoke to Nurse Practitioner who gave ok to send resident to emergency department (ED). Writer made resident's spouse aware of hospital transport. Review of the resident's census report, located in the resident's medical record, showed the resident was readmitted to the facility on Tuesday, 11/7/23. Review of the resident's medical record/progress notes showed: -11/7/23: No documentation showing the resident was readmitted to the facility; -11/7/23: No documentation the facility attempted to make arrangements for transportation to/from dialysis scheduled on Wednesday 11/8/23 at 7:00 A.M. Review of the resident's November 2023 physician's order sheet (POS) showed: -11/8/23: Re-admit charting every shift for 72 hours; -11/8/23: Dialysis infusion every Monday-Wednesday-Friday from 7:00 A.M. until 11:00 A.M. The order provided the name/number of the dialysis facility. Review of the resident's November 2023 medical record/progress notes showed: -11/8/23: No documentation the facility attempted to make arrangements for the resident's transportation to/from dialysis. No documentation the facility communicated with the dialysis facility to determine if they could accommodate a later dialysis time on 11/8/23; -11/8/23 at 2:00 P.M.: Resident had three complete bed changes due to colostomy bag not adhering to skin due to excoriation. Colostomy bag was changed as well; -11/8/23 at 7:07 P.M., the resident had a BP of 93/56 (normal BP is 120/80); -No further assessment or monitoring of the resident's BP or physician/family notification regarding the low BP; -11/8/23 at 9:31 P.M., a progress note documented by Nurse A: Resident was being sent to hospital related to stoma (a surgical opening on the body) and abdomen excoriation. On-call exchange has been notified; -11/8/23: No documentation the resident missed dialysis, or on-going assessments, monitoring for complications due to missing dialysis (edema, lung sounds, shortness of breath, or complete vital signs (temperature, pulse, respirations, blood pressure). No documentation staff contacted the dialysis facility or the resident's physician/family were notified about the resident missing dialysis. Review of the Ambulance Patient Care Report, dated 11/8/23, showed: -9:25 P.M.: Call received from facility; -9:55 P.M.: At patient's side; -Narrative: Arrived to find patient in nursing home bed. Patient stated he/she was having chest pain, abdominal pain, shortness of breath, and weakness. Nursing home staff reported they are calling Emergency Medical Staff (EMS) due to patient issues with his/her colostomy bag. They reported leakage around the colostomy bag and excessive production of fecal material. Staff reported history of dialysis, kidney failure, chronic hypotension (low BP), colostomy, and diabetes. Patient reports he/she was having chest pain in the middle of his/her chest. Patient reported he/she had been feeling chest pain over the past few hours. He/She reported it stays in the middle of his/her chest and did not radiate anywhere else; -Blood Pressure: -At 10:00 P.M. 70/49; -At 10:01 P.M. 78/48; -At 10:09 P.M. 84/54; -10:10 P.M.: Transport to hospital; -10:33 P.M.: Arrival at hospital; -10:35 P.M.: Care transferred to hospital staff; -Run Completion: Patient condition upon arrival at facility: Critical (RED). Patient condition at the end of EMS care: Emergent (YELLOW). Review of the hospital admission records showed: -admission date/time: 11/8/23 at 10:38 P.M.; -10:38 P.M.: Arrived at ED; -10:40 P.M.: Chief complaint chest pain, shortness of breath, general weakness, and abdominal pain near ostomy (a surgical opening in the abdomen, changing the way waste exits the body); -10:41 P.M.: Immediate life saving interventions needed? Yes; -10:42 P.M.: BP 82/62; -10:46 P.M.: Patient presented with chest pain. Patient complains of midsternal (breast bone) chest pain and intermittent shortness of breath. Patient stated chest pain began a couple of hours ago. Patient stated he/she has been going to dialysis and his/her last dialysis was Monday (11/6/23). Per EMS BPs were 70s/40s. Patient appears fatigued with a soft spoken voice; -History of Present Illness: Today the resident missed dialysis. Last dialysis was on 11/6/23. Throughout the day he/she began having chest pressure and sharp upper abdominal pain with generalized weakness and increased ostomy drainage prompting him/her to call EMS. En route, resident found to have low BPs; -Medical Decision Making: Resident presented with chest pain and generalized abdominal pain centered mostly around his/her incision. Will place in intensive care unit (ICU) for dialysis and further evaluation; -Clinical Impression: Hyperkalemia (excess potassium (K)), ESRD, hypotension (low BP), chronic anemia (low red blood cell count), protein-calorie malnutrition, generalized abdominal pain, chest pain, uremia (blood poisoning resulting from the retention of waste products usually excreted as urine), and metabolic acidosis (the buildup of too much acid in the body due to kidney disease or kidney failure. Symptoms can include an accelerated heartbeat, confusion and fatigue); -Reason for ICU admission: Resident presented to the ED where he/she was noted to have hyperkalemic emergency, an abnormal EKG, and metabolic acidosis; -Hyperkalemia in patient with ESRD: Notified by Registered Nurse of severely elevated K level initially reported to the physician was 7.8 (normal range is 3.4 - 5.0), but after checking with the lab was apparently 7.4. Review of the resident's November 2023 facility progress notes showed: -11/9/23 at 11:09 A.M.: Spoke to physician notification service, notified resident missed dialysis due to no transportation. Resident returned back to our facility on 11/7/23 at 9:37 P.M.; -11/9/23 at 11:25 A.M.: Resident missed dialysis Wednesday on 11/8/23. During an interview on 11/21/23 at 9:40 A.M., Nurse A said the resident was admitted to the hospital a couple of weeks ago for stoma problems and had not returned. During an interview on 11/21/23 at 1:15 P.M., the Administrator said the resident was readmitted from the hospital on [DATE], late in the evening. The facility's transportation van was already scheduled to take another resident to an appointment on the morning of 11/8/23, and their van only accommodates one wheelchair resident at a time. She did not know if the admitting nurse attempted to contact the transportation company to see if they could transport the resident the next morning. During an interview on 11/22/23 at 8:19 A.M., a representative from the transportation company said someone was available to take calls 24 hours a day. Dialysis is considered an urgent need and would have been given priority for transportation. Had they been contacted on the night of 11/7/23, when the resident returned, they most likely would have been able to have arranged transportation to the dialysis facility. The representative could not find documentation showing the facility contacted them on the night of 11/7/23, or the morning of 11/8/23. The last time they transported the resident to the dialysis facility was 9/22/23. During an interview on 11/22/23 at 8:35 A.M., the Director of Nursing (DON) said it's very important for residents to receive dialysis as scheduled. She expected the admitting nurse on 11/7/23 to have contacted the transportation company that night to try and arrange transportation to dialysis on 11/8/23. If transportation could not be arranged, she expected staff to contact the dialysis facility to see if the resident could receive dialysis later that same day when the facility van was available. If that couldn't be arranged, she expected staff to have contacted the resident's physician to inform him of the transportation issue and find out if the resident could miss dialysis or if the physician wanted the resident sent to the hospital via ambulance for dialysis. She did not know if any attempts were made to contact the transportation company, the dialysis facility, or physician/family. If attempts were made, staff should have documented it in the progress notes. During an interview on 11/22/23 at 12:00 P.M., Certified Nursing Assistant D said he/she took care of the resident on the day and evening shift on 11/8/23. The only problem he/she was aware of was the resident's colostomy bag was not adhering and filling up quickly, and the resident complaining of pain at the stoma site. The resident did not complain of chest pain or shortness of breath to him/her. During an interview on 1/22/23 at 1:40 P.M., the Administrator said she expected the nurse who admitted the resident to contact the transportation company to see if they could take the resident to dialysis on the morning of 11/8/23. During a telephone interview on 11/29/23 at 12:45 P.M., the Charge Nurse at the dialysis facility listed on the POS, said their facility always has open chairs to accommodate patients. Had the facility notified them on the morning of 11/8/23, they would have been able to accommodate the resident at a later time on 11/8/23. Due to the resident being in and out of more than one hospital during the past few months, the last time the resident had received dialysis at their facility was in September. Their nephrologist has not been following the resident at the hospitals. Potassium is one of the electrolytes that is removed through dialysis. A potassium level of 7.4 is a critical high. After a dialysis session, potassium levels usually decrease by about 2 points. During an interview on 11/30/23 at 2:25 P.M., the DON reviewed the resident's vital sign page in the medical record that showed the resident had a BP of 93/56 on 11/8/23 at 7:07 P.M. She expected staff to re-check the resident's BP, and if it was that low, staff should have contacted the resident's physician. The staff member who recorded the BP is no longer working at the facility. During a telephone interview on 11/30/23 at 2:30 P.M., Nurse A said he/she sent the resident to the hospital on the evening of 11/8/23. The resident did not complain to him/her about chest pain or shortness of breath. The only thing the resident complained of was pain to the colostomy site, which was red, excoriated, and very tender. The staff member who recorded the 93/56 BP did not tell him/her about the BP. Had he/she been informed, he/she would have checked the BP himself/herself and if it was that low, he/she would have called the physician. During an interview on 12/4/23 at 4:00 P.M., the resident's physician and facility Medical Director said the last time he saw the resident at the facility was on 9/6/23. It would have been best for the resident to have gone to dialysis as scheduled on 11/8/23. The faciity should have contacted the transportation company and the dialysis facility to try and arrange dialysis on 11/8/23. If they were unable to make the arrangements for dialysis, they should have notified the nephrologist and/or him. In a perfect scenario, if the resident was doing ok, had no extra fluid or shortness of breath, it may be alright for the resident to have missed dialysis, but he would have expected periodic assessments of the resident until his/her next scheduled dialysis day. On 11/8/23 at 7:07 P.M., he said he expected the staff member who documented the low BP to have informed the nurse, and if the resident's BP remained low, he should have been notified. He expected staff to document their attempts to arrange dialysis, and on-going assessments in the resident's medical record. A potassium level of 7.4 is a critical high and cardiac arrhythmia may develop, which could be due to missing dialysis and why the resident complained of chest pain and shortness of breath. MO00227214

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policies regarding skin assessments and wounds when they failed to immediately put interventions in place when a resident (Resident #1) with a history of amputation had a new wound develop on his/her toe. Facility staff failed to obtain physician orders or send the resident to the hospital until 24 hours after becoming aware of the wound. At the hospital, the resident was diagnosed with osteomyelitis (bone infection) and required surgery. In addition, the facility failed to follow their policy by not performing a full body skin assessment weekly by a licensed nurse (Resident #1). The sample size was seven. The census was 86. Review of the facility's Wound Treatment Management Policy dated 9/1/21, showed: Policy: -To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders; Policy Explanation and Compliance Guidelines: -Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change; -In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders; This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse; -Dressings will be applied in accordance with manufacturer recommendations. Treatment decisions will be based on: -Etiology of the wound; -Pressure injuries will be differentiated from non-pressure ulcers, such as arterial, venous, diabetic, moisture or incontinence related skin damage; -Surgical: -Incidental (i.e. skin tear, medical adhesive related skin injury); -Atypical (i.e. dermatological or cancerous lesion, pyoderma (bacterial skin infection), calciphylaxis (calcium accumulation)); -Characteristics of the wound: -Pressure injury stage (or level of tissue destruction if not a pressure injury); -Size - including shape, depth, and presence of tunneling and/or undermining; -Volume and characteristics of exudate (drainage); -Presence of pain; -Presence of infection or need to address bacterial bioburden; -Condition of the tissue in the wound bed; -Condition of peri-wound skin; -Location of the wound; -Goals and preferences of the resident/representative; Guidelines for dressing selection may be utilized in obtaining physician orders: -The guidelines are to be used to assist in treatment decision making; -Due to unique needs and situations of individuals, the guidelines may not be appropriate for use in all circumstances; -The facility will follow specific physician orders for providing wound care; -Treatments will be documented on the Treatment Administration Record; -The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications include: -Lack of progression towards healing; -Changes in the characteristics of the wound (see above); -Changes in the resident's goals and preferences, such as at end-of-life or in accordance with his/her rights. Review of the facility's Skin Assessment Policy dated 9/1/21 and revised 3/3/22, showed: Policy: -It is the facility's policy to perform a full body skin assessment as part of their systematic approach to pressure injury prevention and management. This policy includes the following procedural guidelines in performing the full body skin assessment; Policy Explanation and Compliance Guidelines: A full body, or head or toe, skin assessment will be conducted by a licensed or registered nurse upon admission/ readmission and weekly thereafter. The assessment may also be performed after a change in condition or after any newly identified pressure injury. Review Resident #1's medical record, showed: -admitted to the facility from an acute care hospital on [DATE]. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/2/23, showed the following: -Cognitively intact: -Understood/understands; -Adequate hearing and vision; -Clear speech - distinct intelligible words; -One person physical assist for bed mobility, dressing, toilet use, personal hygiene and bathing; -Diagnoses of diabetes, atrial fibrillation (A-Fib, irregular heart rhythm), end stage renal disease (ESRD, chronic irreversible kidney failure), stroke, coronary artery disease (CAD, sclerosis of the arterial walls) and respiratory failure. Review of the resident's undated care plan, and in use during the survey, showed: -Focus: The resident has actual skin impairment to skin integrity; -Goal: The resident will have no complications related to the alteration of the skin integrity through the next review date; -Interventions: Encourage good nutrition and hydration, in order to promote healthier skin. Follow facility protocols for treatment of injury. Identify/document potential causative factors and eliminate/resolve where possible. Keep skin clean and dry. Use lotion on dry skin. Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection, and maceration (skin break-down due to moisture), etc to physician. Obtain blood work as ordered by the Physician. Weekly skin assessments done by a licensed nurse. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. -No documentation relating to skin/wound issues of the resident's toe, and/or the care of the resident's toe; -No documentation regarding refusals of skin assessments. Review of the resident's electronic physician's orders (POS) dated 3/7/23, showed: -An order dated 11/23/22 with a start date of 11/28/22, for resident shower days Monday and Thursday evening shift; -An order dated 11/23/22 with a start date of 11/30/22, for weekly skin assessment. Perform skin assessment weekly. Specify day and shift in routine every day shift every Wednesday, if there are any new skin issues, identify on skin assessment; -No orders for any skin related treatments prior to 3/3/23. Review of the resident's skin assessments from 2/1/23 to 2/28/23, showed: -An order dated 11/23/22 with a start date of 11/30/22, for weekly skin assessment. Perform skin assessments weekly. Specify day and shift in routine, every day shift every Wednesday, if there are any new skin issues, identify on skin assessment; -Documented as given one out of three opportunities; -2/1/23: Marked as given; -2/8/23: Blank; -2/15/23: Number (2) entered (meaning refused). Review of the progress notes, showed no progress note on the date of the refused treatment. Review of the resident's treatment administration record (TAR) dated 2/1/23, showed: -An order dated 11/23/22 with a start date of 11/28/22, for resident shower days Monday and Thursday evening shift; -Documented as given five out of five opportunities. Review of the resident's record, showed: -No progress notes from 1/28/23 to 2/17/23; -One shower sheet dated for 2/8/23: -No skin issues identified. Review of the resident's progress notes, showed: -On 2/18/23 at 5:43 P.M., the resident asked Licensed Practical Nurse (LPN) D for an antibiotic. When LPN D asked the resident why did he/she needed an antibiotic, the resident showed LPN D his/her left foot. On the resident's left foot, between the big toe and the third toe, LPN D observed slough (dead skin tissue) and skin peeling and the resident missing his/her second toe. The resident reported that his/her toe had been amputated for over five years. LPN D placed two calls out to Physician F and waited for a return call to the facility. LPN D made LPN C aware; -On 2/19/23 at 6:01 P.M., LPN D spoke with Physician F and obtained an order to collect a culture, with no antibiotic until the culture was complete, to apply silver sulfadiazine (wound treatment), dry dressing and triple antibiotic ointment (TAO), and the resident made aware. LPN D spoke with the regional nurse to make aware. LPN D faxed all orders to the pharmacy. Culture was collected. Waited on labs to pick up. LPN D was unable to complete treatment due to treatment cart being locked up; -On 2/19/23 at 7:01 P.M., this nurse was made aware on 2/18/23 at 4:33 P.M. while at home, by charge nurse that the resident approached him/her and asked for an antibiotic. It was also stated to LPN C that the resident showed the nurse his/her left foot, which had a wound on it. LPN C advised the charge nurse to call the Physician and get wound care orders, prophylactic antibiotic orders, as well as treatment supplies from central supply. LPN C told the charge nurse to apply a dry dressing until orders were obtained. This evening, LPN C was called by the regional nurse to come and assess the resident's foot. Upon assessment, LPN C observed an area between the left great toe and amputated second digit. Area measures 6.5 centimeters (cm) by 2.0 cm by 3.7 cm with 100% slough to wound base, moderate yellow drainage, and foul odor. Call placed to Physician to obtain orders to send resident to hospital; -On 2/19/23 at 7:55 P.M., Call was placed to Physician, times three, left message on voice mail. Call placed to the responsible party and left message to call facility. Call placed to local ambulance for transfer. Review of the resident's hospital record, showed: -admission date of 2/20/23; the resident was admitted for an infection of his/her left toe; -He/She underwent surgery and then treated with antibiotics; -The hospital course showed the resident had a history of a second toe amputation (2012) and presented with infection of the left second toe amputation site. The resident said he/she had pain two days prior to admission and noticed infection one day prior to admission. The resident underwent incision and drainage and first toe amputation; -On 2/28/23, he/she was discharged with a discharge diagnosis of osteomyelitis. During an interview on 3/6/23 at 2:15 P.M., the resident said he/she has diabetes. His/Her toe was infected and he/she didn't know it. He/She has neuropathy (weakness, numbness and pain from nerve damage). He/She already had a toe amputated four or five years ago. His/Her big toe was infected and amputated about three weeks ago. Before his/her toe was amputated, the facility had not been treating it. He/She didn't know until the last minute that it was infected. During an interview on 3/6/23 at approximately 4:45 P.M., Wound Nurse/LPN C said he/she started working at the facility on 2/13/23. He/She works Monday to Friday 6:30 A.M. to 3:30 P.M. or 7:00 A.M. to 3:30 P.M. or until he/she is finished. He/She was familiar with the resident. The resident had his/her toe amputated. LPN C thinks he/she may have been working at the facility for five days at the time the resident was sent to the hospital. LPN D called LPN C and said the resident had something on his/her foot. First, LPN D said the resident asked him/her for an antibiotic. LPN D asked the resident why and the resident said he/she had something on his/her foot. So then he/she showed LPN D his/her foot. LPN C was wondering why LPN D called him/her. LPN C did not know the resident had anything on his/her foot. LPN C was hired as the wound nurse but his/her first week at the facility, he/she worked on the floor due to the facility being short staffed. LPN C told LPN D that he/she did not know anything about a sore on the resident's foot. The next day, the corporate nurse called LPN C and asked him/her if he/she could go in and look at the resident's foot. LPN C went to work on Sunday (2/19/23) to look at the resident's toe. When he/she saw the resident's toe, he/she smelled it; it had a foul odor and was completely covered in yellow slough. LPN C was thinking the resident didn't need a pill; he/she was beyond that. He/she needed intravenous (IV) antibiotics. That particular toe was infected. LPN C called Physician F and the resident's family member. He/she could not get in touch with Physician F after calling him/her three times. He/She left a voice message with the resident's family member to call back to the facility. Per LPN C's nursing judgment, he/she sent the resident out to the hospital because he/she didn't want the resident to be septic. The resident stayed in the hospital for maybe a week or so, and then he/she returned back to the facility with his/her left great toe amputated. The digit next to it was already amputated. It looked like they debrided it when the resident went to the hospital the last time around because it was like one area now. After LPN C's first week, he/she was working at his/her full capacity as a wound nurse. LPN C never completed a wound report here because he/she didn't have a spreadsheet. He/She just got a access to a spreadsheet today (3/6/23). The administration was aware that he/she could not access the spreadsheet since he/she had been at the facility. LPN C does not know if the resident's toe was being treated at all, prior to the recent hospitalization. During an interview on 03/13/23 at 1:24 P.M., LPN D said he/she recently stopped working at the facility about two weeks ago. He/she is familiar with the resident and he/she worked all the shifts. Generally, the resident does his/her own showers with someone to oversee him/her to make sure he/she doesn't fall. In the past, LPN D was the unit manager and then became a weekend staff person. LPN D returned to work on Saturday, 2/18/23, which was his/her first day back at the facility in almost two weeks. He/she worked that weekend but he/she was not the resident's nurse. When the resident came to him/her and told him/her he/she needed antibiotic, LPN D asked the resident what did he/she need the antibiotic for. The resident told him/her, he/she needed it for his/her foot. LPN D told the resident to sit so he/she could see the foot. LPN D instantly saw slough coming out of the resident's toe. There was an odor from the resident's toe. It looked bad, so he/she looked for the wound cart but couldn't find the wound cart. LPN D called the recently hired wound nurse, LPN C. LPN C said the wound cart was locked up in his/her office. LPN C said there should be some type of treatment to clean the resident's toe with to hold him/her over until LPN C arrived. LPN C never did gave a time that he/she was going to go the facility, so LPN D called Physician F, but he didn't answer that day. LPN D called the former wound nurse, LPN M for wound supplies or where to find them so he/she could do a treatment on the resident's toe. LPN D did a treatment and wrapped up the resident's toe. LPN D said he/she worked as the resident's CNA the day the resident went to the hospital (Sunday 2/19/23) because they were short CNAs but had five nurses. They called LPN D in the kitchen and the dietary manager told him/her that the resident's treatment had fallen off so everything was exposed. LPN D went to go get the assigned nurse (not sure of the name), explained to him/her what was going on and called Physician F. Physician F said to give the resident TAO, a dry dressing and do a culture of the wound. The Physician specifically said don't put the resident on any antibiotics until the cultures come back. LPN D entered the lab into the system and charted while the assigned nurse obtained the stat (immediate) culture. Prior to this, there were never any orders for the resident's foot. The resident said he/she had been telling staff he/she needed antibiotics but no one was listening to him/her. The resident did not say who he/she told and/or how long he/she had been telling them this. After LPN D put the note in, he/she called the regional nurse, and told him/her what happened. Thirty minutes after the conversation with the regional nurse, LPN C was in the building and this was about 6:00 P.M. It was the wound nurse's job to make sure residents didn't have any skin issues. When the former administration was there, they kept a log of the showers. The CNAs would document what areas they saw and the wound nurse would sign off and make everyone aware. Now they no longer do that. Somewhere between 2/6/23 to 2/18/23 (while LPN D was not working), the resident's toe became infected. Apparently, no one was doing any skin assessments during that time. LPN C went in and charted in front of LPN D and lied. LPN D spoke to the resident's family member on Saturday (2/18/23) and Sunday (2/19/23), and he/she asked LPN D to send him/her a picture of the resident's toe on that Saturday but LPN D said he/she couldn't because of privacy laws. Everybody gets skin assessments on shower days and there are already orders put in place for that. During an interview on 3/17/23 at 2:51 P.M., LPN O said he/she was is familiar with the resident. LPN O might have worked with the resident sometime before his/her amputation, but the resident didn't mention anything about his/her toe, and neither did any other staff mention anything abnormal about the resident's toe. All the residents should be getting weekly skin assessments, Nursing is usually responsible for doing the skin assessments. He/she did not know if the resident had a treatment order in place before his/her amputation but if there was a skin issue before the amputation, he/she should have had a treatment order in place. During an interview on 3/17/23 at 3:01 P.M., LPN N said he/she had worked at the facility since October of 2022. He/she was familiar with the resident. The resident had a recent toe amputation. LPN N did not remember when he/she last worked with the resident prior to his/her toe being amputated, but the resident never mentioned any issues with his/her toe. LPN N never noticed anything abnormal about the resident's toe either. The residents gets skin assessments, usually weekly depending on the resident. Depending on the aide, they will also alert the nurse if there are any new skin issues. During an interview on 3/17/23 at 3:24 P.M. LPN H said he/she was familiar with the resident, but typically didn't work on the resident's hall. The resident is alert and oriented times four, so he/she typically doesn't need any help. Through word of mouth, LPN H heard about he resident asking for antibiotics and being sent to the hospital. Staff found out through another resident, that Resident #1 had got some shoes from another resident without washing them or anything. There was nothing wrong with the other resident's foot, but LPN H did not think the other resident was too clean. The resident went to the hospital on a Sunday night (2/19/23). The treatment nurse called for the resident to be transported. LPN C came in specifically for the resident's foot. LPN H said he/she and the Assistant Director of Nursing (ADON) were there when the ambulance came to pick up the resident. The resident didn't have any skin issues of which LPN H was aware. There was nothing abnormal about his/her foot. The resident should have been getting weekly skin assessments. Skin assessments typically happen on shower days. During an interview on 3/14/23 at 12:11 P.M. and 12:24 P.M., Physician F said if a resident had a history of amputations, and/or skin issues, he would expect weekly skin assessments to be completed as ordered and reported to him. The facility has his number, as well as the number to the exchange, so they know how to contact him. He would have expected for staff to contact him if the resident was experiencing any skin issues. The facility probably wouldn't contact him if a resident was refusing skin assessments. Physician F couldn't say that if the facility was doing regular skin assessments or calling him and obtaining orders, it would have changed the outcome of the resident's toe. Since staff sent the resident out to the hospital, someone must have assessed the resident. During an interview with Administrator B and the ADON on 3/20/23 at 3:41 P.M., Administrator B initially said they didn't have a wound report log, but they had a wound care nurse. They had a pressure wound log and the wound nurse always had access to it, but at first LPN C did not know how to access it. They have a wound report now. LPN C has a wound report that she prints out daily, and he/she charts the assessments in the electronic medical record. Skin assessments should be done weekly. The ADON said skin assessments pop up on the TAR, so it would be the nurse's responsibility to complete the skin assessments. The ADON said she does plan to complete in-servicing with the nurses on skin assessments, refusals, and how to document refusals in the electronic medical record. The ADON was unsure if Resident #1 was getting skin assessments on a regular basis or not. When this situation transpired with the resident, she was on her third day in the building. During the situation, the ADON and the wound care nurse (LPN C) came into the building about the same time. Once they came to the facility, they assessed the resident and identified any areas of concern. They found that probably no one noticed the resident had an area of concern with his/her toe. Resident #1 is one of the residents who refuses skin assessments. The resident didn't know what happened. Staff found out something was wrong with the resident's toe, and he/she was sent out to the hospital, so any orders would have been put into place after the resident returned from the hospital. The Physician was contacted and the first order was to send him/her to the hospital. She could not verify what happened in the past, but once they found out what was going on with Resident #1, they took the proper steps and proper precautions to get the resident some help. The Administrator said if they were aware that something was going on with the resident, of course an order would have been put in place. Once they found out there was something amidst, staff took care of it immediately. Administrator B said if a resident refuses skin assessments, medications, and/or treatments, or any type of care, she would expect for this to be care planned, and documented in the resident's medical record. MO00214939