Based on observation, interview and record review, the facility failed provide pain management when staff failed to give the correct dose of a scheduled narcotic pain medication. The resident received a lower dose for several days, which increased the resident's pain, for one resident (Resident #3). The sample size was 11. The census was 62. Review of the facility's Physician Orders policy, reviewed 1/5/21, showed: -Protocol: At the time each resident is admitted , the facility will have physician orders for their immediate care. Physician's orders will be verified by the attending physician at the facility. All physician orders will be dated and singed according to State and Federal regulations; -Procedure: -Obtain one of the following types of physician orders: Verbal, telephone, transmitted by facsimile machine, written by the physician; -Assure physician's orders include the drug or treatment and a correlating medical diagnosis or reason; -Assure medication orders include: route, dosage, frequency, strength, reason for administration, and stop date; - Clarify unclear written orders by reviewing with the physician and documenting clarification on the Physician's Telephone Order form as an Orders Clarification; -Discontinue the original physician's order when the physician changes an order that is currently in place. Assure the new order reflects the change; -Fax all orders immediately to the pharmacy; -Confirm accuracy of orders when the new monthly orders arrive from pharmacy; -Transcription of errors; -Errors of omission. Review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/10/23, showed: -Cognitively intact; -Diagnoses included: Neurogenic bladder (the bladder does not empty properly due to a neurological condition), multiple sclerosis (MS, a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord, which may cause numbness, impairment of speech and muscular coordination, blurred vision and severe fatigue), anxiety, and depression. Review of the resident's care plan, last revised 10/1/22, showed: -Focus: Resident is at risk for pain related to decreased mobility, health status, MS, muscle spasms, depression, anxiety, fibromyalgia (chronic muscle pain), chronic pain syndrome, neurogenic bowel and bladder; -Goal: Risks associated with alteration in comfort will be minimized through review date; -Interventions: Administer pain medications per order, if non-medication interventions are ineffective. Education resident/representative on pain management treatment plan. Encourage non-medication suggestion for pain relief. Evaluate pain. Review of the resident's electronic physician order sheet (ePOS) showed: -An order, dated 2/15/23 to 3/15/23, Oxycodone Oral tablet 20 milligrams (mg). Give one tablet by mouth every six hours for pain; -An order, dated 3/15/23, Oxycodone Oral tablet 30 mg. Give one tablet by mouth every six hours for pain; -Both medication doses to be given four times a day at the following times: -12:00 A.M., 6:00 A.M., 12:00 P.M., and 6:00 P.M. Review of the Controlled Substance log for Oxycodone 20 mg tablet, showed: -3/15/23 at 6:00 P.M., 1 tablet; -3/16/23 at 12:00 P.M., 1 tablet; -3/16/23 at 12:00 A.M., 1 ½ tablet; -3/16/23 at 6:00 A.M., 1 ½ tablet; -3/17/23 at 12:00 A.M., 1 tablet; -3/17/23 at 6:00 A.M., 1 tablet; -3/18/23 at 12:00 P.M., 1 tablet; -3/19/23 at 6:00 A.M., 1 tablet; 3/20/23 at 12:00 A.M., 1 tablet; -3/20/23 at 6:00 A.M., 1 tablet. Review of the Controlled Substance log, for Oxycodone 30 mg tablet, showed: -3/17/23 at 12:00 P.M., 1 tablet; -3/17/23 at HS (bedtime), 1 tablet; -3/18/23 at 6:00 P.M., 1 tablet; -3/19/23 at 12:00 P.M., 1 tablet; -3/19/23 at 5:30 P.M., 1 tablet. Review of the resident's March medication administration record (MAR) from 3/15/23 to 3/22/23, showed Oxycodone 30 mg administered: -3/15/23 at 6:00 P.M.; -3/16/23 at 12:00 A.M., 12:00 P.M., and 6:00 P.M. (6:00 A.M. dose is blank on the MAR); -3/17/23 at 12:00 A.M., 6:00 A.M., 12:00 P.M., and 6:00 P.M.; -3/18/23 at 12:00 A.M., 6:00 A.M., 12:00 P.M., and 6:00 P.M.; -3/19/23 at 12:00 A.M., 6:00 A.M., 12:00 P.M., and 6:00 P.M.; -3/20/23 at 12:00 A.M., 6:00 A.M., 12:00 P.M., and 6:00 P.M.; -3/21/23 at 12:00 A.M., 6:00 A.M., 12:00 P.M., and 6:00 P.M.; -3/22/23 at 12:00 A.M., 6:00 A.M. dose not given with reason 7 (sleeping), 12:00 P.M. dose not given with reason 9 (other-see progress notes), 6:00 P.M., dose not given with reason 6 (hospitalized ); -Staff documented the 30 mg as given on the MAR but signed out 20 mg on the controlled substance log for several doses. During observation and interview on 3/20/23 at 11:20 A.M., Nurse C performed the resident's wound treatment. Nurse C asked the resident if he/she had pain. The resident responded that everything hurts all the time. The resident said it would be better if the nurses gave the resident his/her correct dose of his/her pain pill consistently. The resident said the dose was changed to 30 mg but he/she had been getting less than 30 mg at times. Nurse C said the nurse should check the order before giving the medication. During an interview on 3/20/23 at 11:25 A.M., Nurse B was asked to verify the resident's pain medication dosage in the electronic MAR. Nurse B looked up the orders and stated the physician orders showed 30 mg of Oxycodone every six hours for pain. During an observation and interview on 3/20/23 at 11:30 A.M., Nurse B looked in the medication cart's narcotic box to verify the dose of Oxycodone for the resident. Nurse B opened up the box and showed the resident's two Oxycodone medication cards. The cards showed a medication card for Oxycodone 20 mg and a medication card for Oxycodone 30 mg. Nurse B pulled out the Controlled Substance log and showed the night shift nurse gave the incorrect dose of 20 mg at 12:00 A.M. and 6:00 A.M. Nurse B said normally the Associate Director of Nursing (ADON) pulled out the old card to destroy per policy but had not yet for some reason. Nurse B said the night shift nurse charted they gave the right dose in the electronic MAR but signed off and gave the wrong dose. Nurse B said the nurse should verify the order before the medication is administered to the resident. Nurse B showed the correct dose was given yesterday during the day shift by cutting one of the 20 mg tablets in half. Nurse B said the nurse should not have given 1 and ½ because the medication is not scored (There is no line in the middle of the pill to ensure an accurate half dosage). Nurse B was not sure when the Oxycodone dose changed. During an interview on 3/20/23 at 11:35 A.M., the ADON said she would expect nursing staff or any staff that is certified to pass out medications to double check correct dose and give medication according to the order. The ADON said they are now aware of the error. They will call the physician to notify, fill out the medication error form and will do in-services with the night shift nurse and all staff that pass out medication. During an interview on 3/21/23 at 12:00 P.M., Nurse D verified he/she worked the night shift on 3/19/23. The nurse said he/she is familiar with the resident and knows the dosage changes all the time. It was 15 mg, then 20 mg and now 30 mg. Nurse D said he/she did not double check the order and made a mistake. Review of the resident's progress notes, showed: -A progress note, dated 3/20/23 at 12:06 P.M., This writer was asked to verify the resident's controlled substance on the cart to the MAR by the surveyor. This writer went to the medication in the MAR and saw the resident's order for Oxycodone had been changed 5 days ago to Oxycodone 30 mg. This writer was asked by the surveyor when the last time the 20 mg was given and it was signed out on the 19th and the 20th from the overnight nurse. The surveyor asked for a copy of the control log for both of the Oxycodone prescriptions. This writer informed the ADON of the medication error. This writer left a message for the physician to call back to see what he/she would like to do about the error. The resident's next dose is scheduled at 12:00 P.M. and the resident will receive the 30 mg as ordered; -A note, dated 3/20/23 at 12:30 P.M., The physician called back and was informed of the medication error. The physician said to remove the old medication card from the cart and dispose of them and to continue to give the correct dose from here on out and to be more careful in the future; -A note, dated 3/22/23 at 4:05 P.M., Ambulance here at facility to transport resident to hospital. The resident is alert and oriented and transferred without any assistance. Paperwork and report given and family notified of transfer. During an interview on 3/23/22 at 10:15 A.M., Nurse B said the resident was sent out to the hospital because of pain and he/she was out of pain medication. Nurse B opened the medication cart to show the removed card of Oxycodone 20 mg. During an interview on 3/23/23 at 12:10, the Director of Nursing (DON) said she would expect staff to notify the pharmacy if a medication was out. She said she thinks the 20 mg Oxycodone could be scored pretty accurate if a pill cutter was used. She would expect staff to check orders and follow the physician orders. The DON also said the 30 mg Oxycodone card came today for the resident but since the resident is not here, they sent the card back. They are not sure if the resident will return but if the resident returns to the facility, they will call the pharmacy to get the medication. MO00215853 MO00213710

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to adequately monitor one resident who had a physician's order and a speech therapist's recommendation for NPO (nothing by mouth). The facility staff allowed the resident to continue to eat solids foods and drink liquids after being identified as a high risk for aspiration (choking). The facility identified two residents who had orders for NPO. Both residents were sampled and problems were identified with one (Resident #18). In addition, the facility failed to implement resident-directed care and treatment consistent with the resident's preferences, physician's orders, and professional standards of practice by failing to reposition a resident with total dependence on staff for mobility, and consistently apply treatment to the resident's skin, which was 90% covered in burns (Resident #23). In addition, facility staff failed to promptly notify the physician of one closed sample resident (Resident #86) of a condition change. That resident was sent to the hospital where he/she was intubated and admitted into the intensive care unit. The sample size was 16. The census was 65. 1. Review of Resident #18's medical record, showed: -A document dated 11/14/18, signed by the resident and facility, indicating the resident was non-compliant with physician's and dietician's recommended diet. The resident chooses to eat what he/she desired. Because of this behavior, the resident releases the former named facility of any responsibility shall anything occur due to being non-compliant with physician and/or dietician's order. He/she chose to consume a regular diet and drink beverages of his/her choice; -The document did not specify the type of diet recommended on 11/14/18. Further review of the resident's medical record, showed no other documentation signed by the resident or resident's family indicating the resident was non-compliant with the recommended diet. During an interview on 10/28/20 at 8:25 A.M., Certified Nursing Assistant (CNA) K said he/she worked at the facility for 18 years. The resident has been NPO since January 2020. Review of the resident's medical record, showed: -An order dated 4/24/20 for enteral feed (tube feeding) three times per day; -On 5/28/20 at 12:23 P.M., the Social Services Director (SSD) presented the resident with a brief interview of mental status (BIMS) assessment. The resident was unresponsive to the assessment. The resident scored a zero (severe cognitive impairment); -On 7/25/20 at 11:15 P.M., the resident returned from the hospital this night, from earlier choking episode. Resident is okay, vital signs stable, no noted signs and symptoms of acute distress, no complaint of pain, distress. Head of bed elevated. Will continue to monitor; -On 7/27/20 at 3:04 A.M., the emergency room doctor reported to the evening nurse that x-ray's showed the resident had aspiration pneumonia (lung infection due to relatively large amount of material from the stomach or mouth entering the lungs). The physician was notified; -On 8/4/20 at 5:01 P.M., the resident's family brought [NAME] Castle's for dinner. The SSD called the family to remind them the resident has a doctor's order to only have food through a gastronomy tube (G-tube, a feeding tube inserted through the abdomen that brings nutrition directly to the stomach). Resident's family verbalized understanding and they will discontinue to bring food. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/28/20, showed: -Cognitively intact; -No behaviors; -Required total dependence of one staff for eating; -Feeding tube. Further review of the resident's medical record, showed: -Diagnoses included cerebral infarction, and gastrostomy status; -An order, dated 9/11/20 for skilled speech therapy to assess dysphagia (difficulty swallowing foods or liquids, arising from the throat or esophagus) and potential for by mouth intake. Review of the resident's speech therapy evaluation and plan of treatment, showed: -Start of care on 9/11/20; -Diagnoses included cerebral infarction and dysphagia; -Resident will complete trials of puree and nectar progressing up as needed with the speech therapist only with no overt signs and symptoms of aspiration; -Resident will implement safe swallow strategies into by mouth intake trials with speech therapy only; -On 9/11/20, the resident was treated upright in wheelchair in personal room. Resident with poor awareness related to deficits and reason for his/her NPO status currently. The speech therapist trialed puree, nectar thin on this date. Oral phase overall demonstrated delayed mastication (chewing) and residue on the mid-blade of the tongue. Pharyngeal phase (the vocal folds close to keep food and liquids from entering the airway) there was inconsistent coughing with all textures, given nectar and thin again inconsistent gurgled coughing. The speech therapist talked with the social worker who said he will contact the Veteran's Administration for a Modified Barium Swallow Study (MBSS) due to the resident's history of aspiration; -On 9/13/20, the resident treated at bedside on this date. Resident was noted to have a soda can at bedside and a can of a nutritional drink. When asked if the resident drank the items, he/she nodded his/her head yes. The speech therapist educated the patient regarding the concern for aspiration, with resident just looking at the therapist. Resident also educated on the need for an MBSS prior to making any changes in his/her diet due to history and risk of choking and aspirations/silent aspirations. NPO diet and if resident goes against the recommendation and consumes thin liquids/solids, he/she needs to be up on edge of the bed or in wheelchair, go slow, take small sips/bites and double swallow as needed. Resident nodded head yes but carry-over is poor by the resident and the facility does not enforce NPO restrictions; -On 9/16/20, the resident was treated at bedside on this date. Resident was reclined totally flat in bed. Noted a sign above resident's bed that he/she needed to be at 45 degrees as he/she is a tube feeder. Resident noted to be lethargic and had a wet quality to breathing at rest. The speech therapist presented puree solids with patient barely opening oral cavity for oral acceptance. Resident took one half teaspoon bite with minimal clearance. The therapist continues to recommend a MBSS prior to any diet as the patient has a history of dysphagia, aspiration and most recently choking resulting in the Heimlich maneuver (abdominal thrust used to treat upper airway obstructions by foreign objects) having to be completed by nursing and a hospital stay for resident. Resident was NPO when he/she was given food and choked; -On 10/1/20, the resident was treated upright in wheelchair in room. Resident was offered a snack, however, the he//she refused and stated a CNA was getting him/her snacks from the vending machine. The resident is still NPO and should not be getting snacks from staff. The therapist educated the resident and nurse also present, regarding NPO status and the need for the physician to be notified and diet to be addressed if patient is eating and nursing staff buying him/her solids/liquids. Continue to recommend NPO status unless with speech therapist for trials. Review of the resident's care plan, revised on 10/5/20, showed: -Focus: The resident has nutritional problems, G-Tube feeder; -Goal: The resident will comply with recommended diet for weight reduction daily through review date; -Interventions: Explain and reinforce to the resident the importance of maintaining the diet ordered. Encourage the resident to comply. Explain consequences of refusal, obesity/malnutrition risk factors. G-Tube feeding, NPO. Resident is non-compliant with feeding and visits the vending machine frequently. Review of the resident's Radiology Report, dated 10/6/20, showed: -Purpose of Visit: Swallowing Evaluation; -Test Conditions: The patient was viewed laterally in a sitting and standing position. He/she was tested with thin liquids, nectar-thick liquids, honey-thick liquids and applesauce; -Impression: Severe oropharyngeal dysphagia (problems with the preparatory phase of swallowing (chewing and preparing the food)), oral phase (moving the food or liquid through the oral cavity with the tongue into the back of the throat) and pharyngeal phase (swallowing the food or fluid and moving it through the pharynx to the esophagus) with high risk for aspiration; -Plan: No further interventions. Patient's prognosis for significant swallowing recovery remains low due to severity of dysphagia, long-lasting nature of his/her dysphagia and limited improvement in prior therapy; -Recommendations: Recommended remain NPO. If there is allowances for pleasure purposes only, recommend restrict those items to puree consistency only with further limitations to three to four teaspoon sizes only in a setting. Also, with any by mouth intake, there is a risk for aspiration. Further review of the resident's medical record, showed no documentation indicating the resident released the facility of any responsibility from not following the physician's order or the speech therapist's recommendation for NPO after the resident completed the MBSS on 10/6/20. Further review of the resident's speech therapy evaluation and plan of treatment, showed: -On 10/12/20, the resident treated in personal room, bedside. Resident was alert, reclined in bed eating crackers. He/she is NPO. Resident was educated on NPO status. Resident continued to eat crackers and then started holding. Resident motioned for trash can and vomited crackers and thick phlegm-an overt sign of aspiration. CNA was present and was educated regarding NPO status and that staff should not be going to get food or drinks out of the vending machine for patient. Speech therapist then went to the Director of Nursing (DON) and Assistant Director of Nursing (ADON) office to ask about MBSS completed on 10/6/20. There is no report in the electronic or hard medical record. The DON and ADON did not even know the resident had gone out last week for a MBSS. The DON double checked in the electronic chart for any report with DON unable to find any results and neither one had heard report from the nurse who went out with the resident. The speech therapist continues to recommend NPO with staff not buying resident any snacks or drinks. Resident is aspirating at bedside and is a higher choking and aspiration pneumonia risk. Given education, staff does not comply and is placing resident at higher risk. Session completed this date with the speech therapist putting in for a discharge, as resident and staff are all non-compliant with the speech therapists's recommendations. Further review of the resident's medical record, showed: -An order, dated 10/12/20. Therapy completed; -An order, dated 10/14/20. NPO diet; -An order, dated 10/19/20. Discharge resident from skilled speech therapy at this time with recommendations of NPO diet as resident is a high risk for aspiration and not safe on any texture of solid or liquid. Further review of the resident's speech therapy evaluation and plan of treatment, showed on 10/19/20, the resident was treated in his/her room. Speech therapist is not recommending a diet texture for resident, as he/she had previously failed his/her MBSS completed a few weeks ago. Speech therapist educated staff and DON with DON voicing understanding and agreement regarding resident's high risk for aspiration or choking if he/she continues to eat orally. CNA however, did not seem to understand the speech therapist's recommendation and stated, I was told even if we were to take one of those tests, we would fail. Education provided however attention to the speech therapist was poor by the CNA. Discharge completed at this time as patient did not pass MBSS with any texture and staff and resident aware of concern and risk for further by mouth intake and high risk for choking and aspiration. Observation on 10/22/20 at 1:52 P.M., showed the resident lay in bed on his/her back and did not respond when asked if he/she was doing okay. Observation on 10/23/20 at 8:34 A.M., showed, the resident lay in bed with his/her eyes opened. When asked how he/she was doing, the resident smiled but did not verbally respond. Observation on 10/26/20 at 8:08 A.M., showed the resident sat in his/her wheelchair in his/her room. When asked how he/she was doing, the resident smiled but did not respond verbally. Observation on 10/27/20 at 7:51 A.M., showed the resident propelled in his/her wheelchair toward the vending machine, located in the main dining room. The resident purchased a soda, opened the can and took a drink. During an interview on 10/27/20 at 7:51 A.M., the administrator, who was present when the resident drank from the soda can, said she was not sure who the resident was, when asked if the resident should have anything by mouth. She said she would ask the nurse however, she did not remove the soda can. During an interview on 10/27/20 at 7:55 A.M., the DON said the resident was NPO but non-compliant. He/she had a swallow test on 10/6/20 and the recommendation was for NPO with no pleasure foods. The resident goes to the vending machine on his/her own and sneaks food. When they see the resident, they discourage him/her from eating. The resident signed a waiver indicating he/she was non-compliant with his/her diet. The social worker also spoke with the family regarding the resident's non-compliance. If the resident insists on eating or drinking, staff should watch him/her to ensure he/she does not choke. Observations of the resident on 10/27/20, showed: -At 8:01 A.M., he/she propelled in his/her wheelchair out of the dining room, down the hallway and drank from the soda can. No staff watched the resident. He/she coughed after taking a drink; -At 8:05 A.M. and 8:09 A.M., the resident propelled in his/her wheelchair down the hallway with the soda can, taking a drink from the can and coughing. Staff walked past the resident; -At 8:09 A.M., 8:30 A.M., the resident alone in his/her room, sat in the wheelchair, drinking from the soda can. The resident coughed after he/she drank from the can. During an interview on 10/27/20 at 8:36 A.M., Nurse J was asked to come into the resident's room. He/she said the resident was non-compliant and should be watched when having food or drinks due to being at risk for choking. The resident was NPO. When asked what NPO meant, Nurse J said nothing by mouth. He/she walked into the resident's room and saw the resident with the soda can, taking a drink. He/she said all staff were responsible for watching the resident when he/she had anything to eat or drink. The nurse did not take the soda, encourage the resident or assess the resident. Nurse J left the resident's room. Further review of the resident's medical record, showed a nurse's note, dated 10/27/20 at 8:09 A.M., completed by Nurse J. The resident, whom is NPO was noted drinking a can soda this A.M. The resident was educated of the risk and danger of drinking and eating. The resident was also assessed by this nurse for aspiration precautions. His/her lungs were clear and no distress noted. Further review of the resident's medical record, dated 10/1/20 through 10/31/20, showed no documentation regarding monitoring for signs and symptoms of choking/aspiration. Observations on 10/27/20 at 8:42 A.M., 8:47 A.M., 10:04 A.M. and 11:05 A.M., showed the resident sat in his/her wheelchair in his/her room. The soda can sat on the night stand. No staff were present during the observations. The resident drank 80 percent of the soda. Observation on 10/28/20 at 7:12 A.M., showed the resident propelled in his/her wheelchair toward the vending machine. One staff member passed the resident. At 7:16 A.M., the resident placed money in the machine and made a selection. The resident had a difficult time retrieving the item from the vending machine. At 7:23 A.M., the maintenance director and Nurse J walked toward the vending machine. The maintenance director pushed the opening to retrieve the items from the vending machine and Nurse J retrieved the items and gave them to the resident. At 7:27 A.M., the resident propelled from the vending machine, down the hallway toward his/her room and ate the donut sticks purchased from the vending machine. At 7:29 A.M., two additional staff and Nurse J walked past the resident. At 7:31 A.M., the resident propelled down the hallway and ate the donut sticks. He/she coughed as he/she ate. At 7:37 A.M., the DON walked past the resident as he/she ate the donut sticks. No staff assessed the resident or tried to discourage him/her from eating the donut sticks. Further review of the resident's medical record, showed a nurse's note dated 10/28/20 at 8:14 A.M., completed by Nurse J. The resident, who is NPO was found at the vending machine purchasing snacks. The nurse educated this resident on the safety of his/her intake. Resident stated I know. He/she is being monitored for possible choking and/or aspiration. Further review of the resident's medical record, dated 10/1/20 through 10/31/20, showed no documentation regarding the monitoring for signs and symptoms of choking/aspiration. During an interview on 10/28/20 at 8:25 A.M., CNA K said the resident was alert with some confusion and was non-compliant with his/her diet. He/she signed a waiver when the facility was under a different company and management. The resident has had three swallowing tests done since January 2020 and failed each one. The resident tries to sneak food and when he/she does, staff are supposed to take the food away. If the resident is non-compliant, they are to watch the resident for signs and symptoms of choking as he/she eats or drinks and report it to the charge nurse immediately. During an interview on 10/29/20 at 12:37 P.M., the SSD said the resident was non-verbal, alert with some confusion. He spoke with the family in either late July or early August of this year because the family brought in food and the resident choked. The family was told they could no longer bring food in and agreed to no longer bring food. The resident was NPO back when he/she choked and has been NPO since he worked at the facility. The resident signed a waiver regarding his/her non-compliance. When shown the form, the social worker said he did not realize the form was signed in 2018. The form should have been updated and signed by the resident and the resident's representative at least quarterly. During an interview on 10/28/20 at 12:43 P.M., the speech therapist said the resident was NPO and she did not recommend pleasure foods. He/she was a very high risk for aspiration. When she evaluated the resident, he/she did not pass any of the tests for any textures of food. The staff will not watch the resident. Staff will watch the resident go to the vending machine and will not stop him/her. She also witnessed staff giving the resident food and tried to educate the staff and also spoke with the DON. She recommended the swallowing test, which the resident failed, and staff continued to feed him/her snacks. During an interview on 10/28/20 at 9:32 A.M., the DON said the resident had a swallow test completed on 10/6/20 and signed a waiver back in 2018. It was considered good practice to obtain a recent waiver from the resident and family. It was also considered good practice to watch the resident when he/she eats or drinks as he/she was at risk for aspiration. During an interview on 10/30/20 at 10:53 A.M., the medical director said the resident's cognition was not so great. The resident is at risk for aspiration but is non-compliant with a NPO diet. The resident or family should sign an updated form explaining the risks of eating food and drinking liquid. The staff should not give the resident any food if the order is for NPO as the resident could choke. During an interview on 10/30/20 at 11:07 A.M., the administrator and DON said the resident should be watched if he/she eats or drinks. The resident is at a high risk for aspiration and should not be eating or drinking. Staff should not provide him/her with any food or drinks. During an interview on 11/4/20 at 10:45 A.M., the resident's responsible party (RP) said the resident signed a waiver releasing the facility of any responsibility associated with not following the recommended diet back when it was another facility. They have not signed one since the facility changed names or management. The resident's physician at that time explained to the responsible party that the resident could make decisions for him/herself. The RP was not aware the resident had a new physician and had not spoken to him. In the summer, the RP spoke with the social worker, who told him/her not to bring food to the facility. He/she had not brought any since then. The RP contacted the facility for information about a month ago and spoke with the DON. The DON told the RP the resident had a swallow test and was recommended to have nothing by mouth. When asked if the resident understood this, the RP said since he/she had not physically seen the resident, he/she could not make the determination. However, the resident would call him/her on occasions and hold the phone while the RP spoke. The resident has a difficult time verbalizing, due to a stroke. Although the resident was recommended a diet of NPO, the RP said the facility leaves the resident alone and laying in bed with no schedule. Because of this, the resident is only focused on eating. 2. Review of the facility's Skin Program Policy and Procedure, dated 5/28/19, showed: -Purpose: The purpose of the skin program is to ensure that every resident's skin condition is assessed on admission and a comprehensive interdisciplinary care plan is developed and maintained to treat actual and/or prevent potential skin problems; -Policy: All residents are assessed up on admission and as needed for actual and/or potential skin problems. All residents with skin problems will receive an active skin plan of care at admission; -Procedure: -The nurse assesses/evaluates all residents upon admission. The initial skin assessment is a full body audit and completion of the Braden Skin Risk Assessment. After admission the Braden Skin Risk Assessment will be completed weekly for three weeks and then a minimum of quarterly, a significant change of condition, and annually; -A plan of care (POC) is initiated and individualized by the nurse on the day of admission; -Certified nurse aides (CNA) will complete the Bath/Shower Report Sheet with each resident's scheduled bath/shower. Each resident will be assessed/evaluated a minimum of weekly by the nurse. Review of Resident #23's quarterly MDS, dated [DATE], showed: -admitted [DATE]; -Cognitively intact; -Rejection of care not exhibited; -Total dependence of two (+) person physical assist required for bed mobility and transfers; -Total dependence of one person physical assist required for dressing and personal hygiene; -Upper and lower extremities impaired on both sides; -Diagnoses included dementia, hemiplegia or hemiparesis (paralysis on one side), depression, and burns involving 90% or more of body surface with 90% or more of third degree burns. Review of the resident's medical record, showed: -A physician's order, dated 4/17/20, for weekly skin assessments in the afternoon every Friday; -A physician's order, dated 7/31/20, to cleanse right upper extremities with wound cleanser or soap and water. Apply topical antibiotic ointment (TAO) daily and cover with dry dressing daily; -No Bath/Shower Report Sheets completed in September 2020. Review of the resident's treatment administration record (TAR) for September 2020, showed: -Skin assessment completed 9/4/20; -TAO not documented as administered 9/5, 9/7, 9/8, 9/9, 9/10/20; -Skin assessment not documented as completed 9/11/20; -TAO not documented as administered 9/11, 9/12, 9/15, 9/17/20; -Skin assessment completed 9/18/20; -TAO not documented as administered 9/18, 9/23/20; -Skin assessment completed 9/25/20; -TAO not documented as administered 9/26, 9/30/20. Further review of the resident's medical record, showed no Bath/Shower Report Sheets for October 2020. Review of the resident's TAR for October 2020, showed: -Skin assessment not documented as completed 10/2/20; -TAO not documented as administered 10/2, 10/3, 10/4/20; -Skin assessment completed 10/9/20; -TAO not documented as administered 10/9, 10/14, 10/15/20; -Skin assessment not documented as completed 10/16/20; -TAO not documented as administered 10/16, 10/17, 10/18, 10/20, 10/21/20; -Skin assessment completed 10/23/20. Review of the resident's care plan, revised 10/5/20, showed: -Focus: Resident has an activities of daily living (ADL) self-care performance deficit related to 90% or more of body surface with 90% or more of third degree burns; -Interventions/tasks included: -Resident is totally dependent on 1-2 staff for repositioning and turning in bed every 2 hours and as necessary; -Resident requires skin inspections weekly. Observe for redness, open areas, scratches, bruises, and report changes to the nurse; -Focus: Resident has hemiplegia affecting unspecified side; -Goal: Resident will maintain optimal status and quality of life within limitations imposed by hemiplegia through review date; -Interventions/tasks included: -Give medications as ordered; -Pain management as needed. See physician's orders. Provide alternative comfort measures as needed; -The care plan failed to identify the resident's preferences for repositioning and desire to be out of bed, and failed to identify his/her individual skin care needs. Observation and interview of the resident on 10/22/20, showed: -At 8:46 A.M., the resident lay on his/her back in bed. He/she had no left arm and his/her right hand was severely contracted with fingers bent backwards, approximately 45 degrees. Burns covered the resident's face and forearm, with chunks of skin flaking off; -At 9:55 A.M., the resident lay on his/her back in bed. He/she leaned to the right side of the bed with his/her head off the pillow. He/she said he/she could not reach his/her call light and asked to be repositioned; -At 1:23 P.M., the resident lay on his/her back in bed, positioned in the middle of the bed. CNA EE entered the room and the resident asked him/her to get the resident out of bed. CNA EE said he/she would find the CNA assigned to the resident's hall and exited the room; -At 1:47 P.M., the resident lay on his/her back in bed. He/she called out to CNA M, who stood in the hall outside of the resident's room. CNA M asked the resident what he/she wanted and the resident said he/she wanted to get up. CNA M entered the resident's room and shut the door; -At 1:58 P.M., CNA M exited the resident's room. The resident lay on his/her back in bed with visibly flaky skin; -At 3:38 P.M., the resident lay on his/her back in bed. He/she said he/she wanted to get out of bed, but staff would not help him/her. Observation and interview of the resident on 10/26/20, showed: -At 9:13 A.M. and 10:33 A.M., the resident lay on his/her back in bed. The resident's skin on his/her face visibly dry and flaking off his/her face; -At 11:57 A.M., the resident lay on his/her back in bed with skin visibly dry and flaking off his/her face and forearms. He/she said he/she would like to get out of bed and has been waiting on staff to help. His/her roommate pressed their call light to alert staff; -At 12:05 P.M., CNA M entered the resident's room and asked what the resident wanted. The resident said he/she wanted to get out of bed. CNA M said the facility was about to serve lunch and he/she could not get the resident out of bed at that time; -At 12:41 P.M., the resident lay on his/her back in bed. Observation and interview of the resident on 10/28/20, showed: -At 8:57 A.M., the resident lay on his/her back in bed. He/she said he/she did not enjoy spending all his/her time in bed. He/she would like to be out of bed more often because he/she gets bored. When out of bed, he/she likes to be around people and to socialize. His/her skin is very itchy and sometimes staff put ointment on it, but most of the time, they don't; -At 11:19 A.M., 12:32 P.M., and 1:46 P.M., the resident lay on his/her back in bed with visibly flaky skin. Observation and interview on 10/29/20 at 9:30 A.M., showed the resident lay on his/her back in bed, dressed in regular clothing with flaky skin on his/her face and right arm. He/she said staff dressed him/her today, but did not put topical ointment on his/her skin. Staff never got him/her out of bed yesterday. During an interview on 10/30/20 at 7:28 A.M., CNA M said the resident likes to be out of bed. The resident must be transferred via Hoyer (mechanical lift), which requires two staff to perform. Sometimes, the resident is left in bed because there is not enough staff available to get him/her out of bed. During an interview on 10/30/20 at 10:14 A.M., the ADON said she was unaware the resident preferred to be out of bed more often. If he/she expresses the desire to get out of bed, staff should accommodate his/her request. The DON and administrator agreed skin assessments should be completed on all residents on a weekly basis. If a resident refuses a skin assessment, it should be documented in their medical record. It is the nurse's responsibility to ensure treatments are applied as ordered. If a resident refuses treatment, such as application of TAO, the resident's refusal should be documented in their record. The resident's care plan should accurately reflect the resident's skin care needs and preference to be out of bed. 3. Review of Resident #86's admission MDS, dated [DATE], showed the following: -admission date of 3/13/20; -Understood/understands; -BIMS score of 13 (a score of 13-15 indicates cognitively intact); -Limited assistance of one person required for bed mobility, transfers, walking in room/corridor, locomotion on/off the unit, dressing, toilet use, personal hygiene and bathing; -Moving from seated to standing position: Not steady but able to stabilize without human assistance; -Walking (with assistive device if used): Not steady, but able to stabilize without human assistance; -Turning around and facing the opposite direction while walking: Not steady, but able to stabilize without human assistance; -Moving on and off toilet: Not steady, but able to stabilize without human assistance; -Surface to surface transfer (transfer between bed and chair or wheelchair): Not steady but able to stabilize without human assistance; -Functional limitation in range of motion: No impairment of upper/lower extremities; -Mobility devices: Wheelchair; -Diagnoses of high blood pressure, diabetes mellitus and dementia; -Did the resident have a fall any time in the last month prior to admission: No; -Did the resident have a fall any time in the last two to six months prior to admission: No; -Has the resident had any falls since admission: No. Review of the resident's progress notes, dated 7/28/20 at 3:45 A.M., showed staff found the resident on the floor in his/her room with a broken tooth and a bruise to the right upper, inner arm. Resident denies pain or discomfort, but while getting him/her up he/she showed facial grimacing. Emergency medical services (EMS) called, here at 4:20 A.M. and resident transferred to hospital. Review of the resident's progress notes, dated 7/28/20 at 10:26 A.M., showed the resident returned to the facility. Shows no signs or symptoms of distress. Resident denies pain or discomfort at this time. Resident is in bed resting quietly. Review of the resident's progress notes, showed no further documentation until 8/2/20 at 3:17 P.M., when the nurse documented the resident asleep this shift,

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of one resident (Resident #192), who the facility identified as receiving intravenous (IV) antibiotics, received a dose at the correct infusion rate and failed to ensure IV antibiotics were administered to the resident as prescribed by the physician. The resident received three different IV antibiotics due to an abcess that occurred after brain surgery. The sample size was 16._The facility census was 65. 1. Review of Resident #192's facility face sheet, showed the following: -admitted to the facility on [DATE]; -Diagnoses included high blood pressure, stroke and cerebral aneurysm-unruptured (a bulge or ballooning of a blood vessel in the brain). Review of the physician's order sheet (POS), showed an order, dated 10/20/20, to infuse Vancomycin (antibiotic) in 200 milliliters (ml) normal saline (NS) every 12 hours for a diagnosis of cerebral aneurysm, unruptured. Review of the care plan, dated 10/20/20, showed IV access and IV antibiotics not addressed. Observation on 10/22/20 at 9:05 A.M., showed 1250 milligrams (mg) of Vancomycin in 250 ml NS hung on an IV pole with an IV pump (used to control rate of flow) next to it. The label on the antibiotic read to infuse at 167 cubic centimeters (cc) an hour to infuse over 90 minutes. The IV tubing did not thread through the the resident's pump. The IV tubing valve was wide open, the medication did not drip and the bag was full. The tubing was connected to the left upper arm peripherally inserted central catheter (PICC-long catheter (tube) inserted into a vein in the arm, leg or neck. The tip of the catheter is positioned through the vein into a large vein that carries blood into the heart). Continued observation on 10/22/20 at 9:16 A.M., showed no change in the fluid level of the bag and the clamp on the tubing remained wide open. Further observation on 10/22/20 at 9:40 A.M., showed Licensed Practical Nurse (LPN) I at the bedside administering tube feeding through the gastrostomy tube (G-tube-thin catheter surgically inserted through the abdomen in to the stomach to provide nutrition and fluids). The Vancomycin bag lay empty in the sink. During an interview on 10/22/20 at approximately 9:41 A.M., LPN I said he/she hung the antibiotic at about 8:00 . He/she said It shouldn't have gone in that fast. He/she was having trouble with the IV pump not working and would have to call the pharmacy for a replacement. He/she had opened the clamp on the tubing because he/she was having trouble getting the antibiotic to infuse. It should have run over 60-90 minutes (The antibiotic would have infused in less than 30 minutes). During an interview on 10/23/20 at 12:02 P.M., the pharmacist from the facility's participating pharmacy said the facility rents the IV pumps from the pharmacy and presently the facility had one pump. He/she said the facility has a dial-a-flow (a device on IV tubing used to dial the flow rate of the liquid being infused) because the pharmacy sent it to the facility. He/she said Vancomycin is normally infused over a period of 60 to 90 minutes to avoid adverse effects such as Red Man's Syndrome (an infusion-related reaction that typically consists of pruritus (itching), a red rash that involves the face, neck, and upper torso. Low blood pressure and swelling can occur). The pharmacy determines the dose of Vancomycin and it is determined by the resident's kidney function and the peak (blood drawn immediately before a dose of Vancomycin is administered) and the trough (blood drawn within one to two hours after completion of the dose). (The peak and trough determine the drug concentration level in the body system which determines the dose of medication to be administered). During an interview on 10/23/20 at 12:26 P.M., the Director of Nursing (DON) said an IV antibiotic should never be administered without a working IV pump. The facility has dial-a-flows which the nurse could have used. The other choice was the nurse could have waited for a new pump to arrive and notify the physician that a dose will be missed or delayed. The nurse should absolutely never open the tubing, and Vancomycin should be administered for the time it is ordered. If the order for an antibiotic is ambiguous, the physician should be contacted for clarification. The antibiotic should be held until clarification is obtained. Even if it means a dose is missed, clarification should be obtained. Continued review of the POS, showed the following: -An order, dated 10/19/20 to administer Flagyl (antibiotic) 500 mg IV every six hours and discontinue after the last scheduled dose on 11/10/20; -An order, dated 10/20/20, to administer Cefipime (antibiotic) two grams (g) IV in 100 ml of NS every eight hours and discontinue after the last scheduled dose on 11/10/20. Review of the pharmacy's delivery manifest, dated 10/20/20, showed it included 16 doses of Flagyl and nine doses of Cefipime for the resident. The delivery was signed as received by facility LPN D on 10/20/20 at 1:22 A.M. Review of the pharmacy's delivery manifest, dated 10/23/20, showed it included 16 doses of Flagyl and 12 doses of Cefipime for the resident. The delivery was signed as received by facility LPN L on 10/23/20 at 1:40 A.M. Review of the October MAR, on 10/26/20 at 11:00 A.M., showed the following: -Flagyl scheduled to be administered daily at 12:00 A.M.,, 6:00 A.M., 12:00 P.M. and 6:00 P.M. Twenty-five total doses of Flagyl recorded as administered between 12:00 A.M. on 10/20/20 and 11:00 A.M. on 10/26/20; -The 6:00 A.M. dose of Flagyl on 10/26/20, not recorded as administered; -Cefipime scheduled to be administered daily at 6:00 A.M., 2:00 P.M. and 10:00 P.M. Sixteen total doses of Cefipime recorded as administered between 10:00 P.M. on 10/20 and 6:00 A.M. on 10/26/20; -The 10:00 P.M. dose on Cefipime on 10/25/20, not recorded as administered. Review of the available doses of Flagyl and Cefipime on 10/26/20 at 11:20 A.M., showed the following: -Twelve doses of Flagyl remained available in the medication room; -The pharmacy sent a total of 32 doses of Flagyl, which showed staff failed to administer seven doses of Flagyl; -Eleven doses of Cefipime remained available in the medication room; -The pharmacy sent a total of 21 doses of Cefipime, which showed staff failed to administer five doses of Cefipime. Review of the facility's Administration of Intravenous Policy, dated 2006, showed the following: -Purpose: -To maintain life by supplying the body with fluid, electrolytes, calories, vitamins, protein and medication; -To restore acid-base balance to the body; -To treat infection; -To administer medication; -Assessment Guidelines: -Condition of the intravenous insertion site; -Adverse reactions to the fluid/medication administered; -Reason for therapy; -Hydration and electrolyte levels; -General Nursing Care: -The resident should be under close observation by a licensed nurse as long as the solution is being administered in order to prevent infiltration (fluid leaks out of the vein in to surrounding tissues causing damage to the tissue) into the tissues and reassure the resident. Resident movement may alter the rate of flow or displace the needle; -All solutions administered must be free and clear of sediment; -When the resident's position is changed, care should be taken to maintain the position of the needle; -In the elderly and/or residents with conditions affecting the heart, lungs or arteries, the rate of administration must be carefully monitored for signs of fluid volume overload; -Observe sterile technique. During a follow up interview on 10/26/20 at 11:35 A.M., the representative from the facility's participating pharmacy said no further doses of Flagyl and/or Cefipime had been sent to the facility since 10/23/20. During an interview on 10/26/20 at 11:26 A.M., the DON said she expects staff to administer medications as ordered by the physician. If a medication is unavailable, staff should notify the nurse in charge and check in the emergency kit (E-kit, extra commonly used medications to be used when short on the medication cart) and order some from the pharmacy. Also staff should let the physician know the dose will more than likely be late or missed or staff could ask if a different medication can be substituted. If a medication is given, staff should sign it out. If a medication is not given, staff should not sign it out. She said she would check into the antibiotics, but if there were extra doses than what staff signed out, she can only think staff are signing out the medications but not administering them. During an interview on 10/30/20 at approximately 11:30 A.M., the resident's physician said Vancomycin doses are typically determined by the pharmacist according to the resident's kidney function and the peak and trough. If staff have a question, they should contact the pharmacist and follow the pharmacist's instructions. Vancomycin should be administered according to the time prescribed. If Vancomycin infuses too fast, it burns (damages) the vein. If a pump is not available, staff should wait for a replacement, or use a dial-a-flow. If the nurse is really good, they can count the drops, but would need to stay close by. The resident receives the antibiotics because he/she had brain surgery and developed an abscess. It is very important he/she receives the antibiotics as ordered. If a dose is missed, staff should contact him because he may have to lengthen the number of days the medication is administered. If there are extra doses he has no reason to think anything other than the drug was not administered, but recorded as though it were.