**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and responsible party (RP), staff, Medical Director, and Nurse Practitioner (NP) interviews, the facility failed to assess, diagnose and medically treat a resident who was presenting with signs of Clostridium Difficile (C. difficile) (According to the Centers for Disease Control and Prevention: C. difficile-is a highly contagious bacteria that causes diarrhea and inflammation of the colon, can be life-threatening and present with symptoms which include loose stools, abdominal cramping, loss of appetite and stools may have a foul odor). The facility failed to identify the seriousness of the symptoms of abdominal discomfort, frequent loose stools with foul odor, tiredness, loss of appetite, and inability to get out of bed and implement effective interventions. On [DATE] Resident #290 experienced decreased urine output and the facility failed to identify a medical emergency and failed to immediately transfer Resident #290 to the hospital on [DATE] when the nursing home received critical white blood cell count of 51.8 (normal range 4-11). On [DATE] Resident #290 requested to be sent to the hospital because he was unable to eat or urinate. Once evaluated at the hospital on [DATE], the resident was extremely ill, hypotensive (low blood pressure), hypothermic (low temperature) and had atrial fibrillation (irregular heart rate). Vital signs at the emergency room were recorded as blood pressure 90/53 (normal 120/80), pulse 120 (normal 60-100), respirations 18, temperature 97.5. Laboratory results at the hospital indicated the C. diff test was positive and white blood cell count was 66.0. Resident #290 was diagnosed with septic shock (a life-threatening immune system reaction to an infection) secondary to C. Diff and passed away on [DATE]. This deficient practice was discovered for 1 of 3 residents reviewed for professional standards (Resident #290). Immediate Jeopardy began on [DATE] when Resident #290 began experiencing loose, malodorous stools and the facility did not assess, evaluate or treat the resident. The immediate jeopardy was removed on [DATE] when the facility implemented an acceptable credible allegation. The facility remains out of compliance at a lower scope and severity of D (isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education and ensure monitoring of systems put in place are effective. Findings included: Resident #290's hospital Discharge summary dated [DATE] indicated resident was admitted for a subdural hematoma (collection of blood between the brain and it's covering) due to a fall. The discharge summary indicated during the hospital stay resident underwent colonic decompression (a procedure to relieve pressure and remove gas and stool from the colon) on [DATE] and tolerated this well with excellent reduction in the colonic volume. The discharge summary indicated Resident #290 had a possible pseudo-obstruction, a condition where the colon appeared to be obstructed but there was no physical blockage. Resident #290 was admitted on [DATE] with diagnosis of subdural hematoma. Review of Resident #290's physician orders revealed there were no orders for laxatives or stools softeners. Review of Resident #290's electronic bowel movement record revealed the following: [DATE]- One large loose stool [DATE]- Two large stools [DATE]- Two large stools and a medium stool [DATE]- One large liquid stool with foul odor and one medium stool [DATE]- Four large loose stools and two medium stools [DATE]- One medium stool An interview was conducted via phone with Nursing Assistant (NA) # 5 on [DATE] at 12:20 PM. NA #5 was assigned to Resident #290 on [DATE] and [DATE]. NA #5 revealed Resident #290 had loose stools continuously. NA #5 stated Resident #290 had loose stools with a foul smell. NA #5 stated she reported this to the nurse, she could recall which one, and the nurse stated okay but did not indicate what was being done about the loose stools. Review of a NP progress note dated [DATE] indicated Resident #290's RP reported resident was having burning with urination and requested a urinalysis. Urinalysis was ordered. Review of Resident #290's admission Minimum Data Set (MDS) dated [DATE] indicated resident was cognitively intact, was always incontinent of bowel and bladder and required moderate assistance with toileting. Resident's care plan dated [DATE] indicated a focus of urinary incontinence. Interventions included providing incontinence care after each incontinent episode and report signs of urinary tract infection. There was not a care plan, or interventions related to bowel incontinence or loose stools. Review of Resident #290's bowel record revealed the following: [DATE] - One large loose liquid stool [DATE] - One large and one medium stool [DATE] - Three large loose stools [DATE] - One medium and one large loose stool [DATE] - Two large and one medium stools [DATE] - One large loose stool Review of a NP progress note dated [DATE] indicated resident's RP had requested a urinalysis due to painful urination. The results of the urinalysis are pending. Review of Resident #290's physician orders revealed an order dated [DATE] for ciprofloxacin (an antibiotic used to treat infections including urinary tract infections) 500 milligrams (mg) twice per day by mouth for 7 days for urinary tract infection. Review of a NP progress note dated [DATE] indicated resident's chief complaint was urinary tract infection. Resident #290's RP requested a urinalysis due to painful urination. Urinalysis was positive for infection and antibiotic was ordered. Review of Resident #290's electronic bowel movement record revealed the following: [DATE] - Two medium and one large loose stool [DATE] - One large, loose stool [DATE] - One large stool [DATE] - One large loose stool [DATE] - One large stool [DATE] - Three medium stools [DATE] - No documentation [DATE] - One large loose liquid stool and a small stool A nursing progress note written by Nurse #11 on [DATE] stated Resident #290 refused to get up out of bed due to diarrhea. The note did not indicate any follow-up action, assessment or notification of the Nurse Practitioner or Medical Director. There was no documented nursing assessment. An interview was conducted with Nurse #11 on [DATE] at 2:15 PM. Nurse #11 was assigned to Resident #290 on the following dates: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Nurse #11 stated Resident #290 was admitted for rehabilitation and was supposed to go home. Nurse #11 stated some days Resident #290 was too tired to participate in therapy and was weak, but she did not complete an assessment of the resident and did not think this indicated he had an infection, and she did not report this to the NP. Nurse #11 stated Resident #290 had loose stools since he was admitted , and she did not know why. Nurse #11 stated the Nursing Assistants reported to her that he had loose stools, and she reported this to the Nurse Practitioner. Nurse #11 stated she did not recall if the NP did anything about the loose stools. Nurse #11 indicated Resident #290's responsible party visited often and would apologize to her and the other staff that the resident was having so many loose, foul-smelling stools. A physical therapy treatment encounter note dated [DATE] indicated Resident #290 refused treatment due to diarrhea. The note indicated nursing was made aware. An occupational therapy treatment encounter note dated [DATE] indicated the therapist approached the resident for treatment twice but resident refused due to having loose bowel movements. An interview was conducted on [DATE] at 3:30 PM with the Occupational Therapist (OT) who was assigned to Resident #290 on [DATE]. The OT stated Resident #290 had loose stools constantly while in the facility and it interfered with his therapy sessions due to the amount and frequency of the loose stools. Resident #290 complained during therapy of his stomach hurting at times. OT stated he informed the nurses assigned to Resident #290 that the resident was having frequent loose stools and assumed the nurses would follow up on this. The NAs were constantly having to change the resident. OT stated the former Rehabilitation Director reported to the nurses and NP about Resident #290's loose stools. Towards the end of his stay, the OT stated Resident #290 was refusing therapy, was more tired and complained of his stomach hurting. OT stated resident's condition was getting worse and worse just prior to him transferring to the hospital. An interview was conducted with the former Rehabilitation Director via phone on [DATE] at 10:30 AM. The former Rehabilitation Director stated she worked closely with Resident #290 and was familiar with him. The former Rehabilitation Director stated Resident #290 became progressively worse during his time in the facility and was medically declining. The former Rehabilitation Director stated the therapists communicated with the nursing staff and the Nurse Practitioner frequently regarding the changes they observed in Resident #290 and the frequent loose stools. The former Rehabilitation Director stated the nurses would say they would tell the Nurse Practitioner and that the loose stools were normal and would clear up eventually. The former Rehabilitation Director stated Resident #290 complained to the therapy staff about the loose stools and not feeling well. The former Rehabilitation Director stated the NP indicated the loose stools would resolve eventually and that was not the reason the resident was here. Review of an SBAR form (a nursing communication tool used to convey status which stands for Situation, Background, Assessment and Recommendation) indicated a change occurred on [DATE] at 3:58 PM. The form was completed by the Nursing Supervisor #3 on [DATE] at 9:51 AM. The description of the change indicated it was completed due to weight gain. It further indicated the change observed was weight loss. The Nurse Practitioner was notified of the weight change on [DATE] at 11:10 AM and no new orders were received. Review of the weights recorded in Resident #290's electronic health record revealed the following: [DATE] 211.2 pounds (lb.), [DATE] 213.6 lb., [DATE] 209 lb. Review of Resident #290's electronic bowel movement record revealed: [DATE] - One medium and a large loose stool [DATE] - No documentation A Nurse Practitioner (NP) progress note dated [DATE] revealed Resident #290 had loose stools and was started on banana flakes for 1 week. The note did not indicate any testing was ordered regarding loose stools. The manufacturer's information indicated banana flakes are a natural product that may be used for chronic diarrhea and may be used in conjunction with treatment for Clostridium Difficile (C. diff). The manufacturer's information further stated banana flakes are to be mixed with water or juice and administered up to 3 times per day until diarrhea is resolved. Review of Resident #290's physician orders revealed an order written by the NP dated [DATE] for banana flakes one packet once per day. The order was discontinued on [DATE]. Review of Resident #290's electronic Medication Administration Record (MAR) revealed an entry for banana flakes one packet once per day with a start date of [DATE] and a discontinue date of [DATE]. Entries were signed with electronic signatures as given. A Nurse Practitioner progress note dated [DATE] stated Resident #290 continued to have loose stools. The note indicated the resident's responsible party contacted the Gastroenterologist who recommended a Kidney Ureter and Bladder (KUB) x-ray and stool samples due to loose stools. The NP note stated the KUB was ordered, and the stool samples were to be done as an outpatient after discharge. The progress note further stated to continue banana flakes once per day. If banana flakes are ineffective will start loperamide 2 milligrams once per day as needed. (Loperamide is a non-prescription medication used to control occasional loose stools usually taken after each loose stool. Loperamide is contraindicated in C.difficile due to slowing the movement of stool through the body allowing the C.difficile toxins to build up in the colon leading to more severe colitis or inflammation of the colon). Review of Resident #290's electronic health record revealed an order dated [DATE] to obtain a KUB. There was no order noted to obtain stool samples. Review of Resident #290's electronic bowel movement record revealed: [DATE] - Three large loose stools and one small stool Review of Resident #290's electronic bowel movement record revealed: [DATE] - One medium loose stool [DATE] - One medium stool [DATE] - Two large loose, liquid foul-smelling stools and a small liquid stool Attempts were made to interview NA #2 who was assigned to Resident #290 on [DATE], [DATE] and [DATE]. Messages were left on [DATE], [DATE], [DATE] and [DATE] with no return call received. Resident #290's electronic Medication Administration Record (MAR) indicated loperamide 2 milligrams once per day as needed with a start date of [DATE] and discontinue date of [DATE]. The electronic MAR indicated no entries were signed for loperamide as given. Review of a nursing progress note dated [DATE] indicated the KUB test results were received and reviewed by the Nurse Practitioner with normal abdominal study results received. A Nurse Practitioner progress note dated [DATE] indicated Resident #290 continued to have loose stools. The NP progress note indicated Resident #290 was started on banana flakes with marginal improvement. The KUB was unremarkable. Stool sample to be done outpatient following discharge. Continue banana flakes and start loperamide as needed. An occupational therapy encounter note dated [DATE] indicated Resident #290 had increased fatigue. Review of Resident #290's electronic bowel movement record revealed: [DATE] - One large, loose stool [DATE] - Two large loose stools An interview was conducted with NA #8 on [DATE] at 2:22 PM. NA #8 was assigned to Resident #290 on [DATE] and [DATE]. NA #8 indicated that she was assigned to Resident #290 frequently and was familiar with his care. NA #8 stated Resident #290 had multiple loose, liquid stools during each shift. NA #8 indicated everyone knew that he was having liquid bowel movements that had a strong odor. NA #8 stated Resident #290 had liquid stools especially after he ate, and it was like everything ran right out of him. Resident #290 would ask for loperamide, and NA #8 stated she reported this to the nurse assigned to the resident, she could not recall which nurse, but she did not know if he ever received it. NA #8 stated she thought Resident #290 might have C. difficile due to the multiple liquid stools and strong odor but the nurses said it was normal for him. A Nurse Practitioner progress note dated [DATE] revealed Resident #290 continued to have loose stools and was started on banana flakes and loperamide was ordered as needed. Review of Resident #290's electronic bowel movement record revealed: [DATE] - No documentation Review of Resident #290's progress notes revealed a NP progress note dated [DATE] which indicated resident continued to have loose stools. Banana flakes were started and loperamide was ordered as needed. The KUB was unremarkable. The plan indicated continue the banana flakes and loperamide as needed. Review of Resident #290's electronic bowel movement record revealed: [DATE] - Two medium stools An interview was conducted on [DATE] at 11:15 AM with NA #4 who was assigned to Resident #290 on [DATE] and [DATE]. NA #4 stated she was assigned to Resident #290 just prior to him being sent to the hospital and he was very weak. NA #4 stated she was familiar with Resident #290 and was assigned to him often and assisted other staff with him. NA #4 stated Resident #290 had very loose, frequent stools with mucus and a strange, strong odor. NA #4 indicated the nurses were aware that he had loose, frequent stools and the nurses said he was having loose stools since admission so it must be normal for him. NA #4 stated Resident #290 had about 3 loose stools per shift. On [DATE], NA #4 stated Resident #290 was not doing well and had not urinated all day which was not normal for him. NA #4 stated she reported to Nurse #11 that the resident had not urinated that day. An interview was conducted with Nursing Supervisor #3 on [DATE] at 9:07 AM. Nursing Supervisor #3 stated she did not recall being informed of any problems with Resident #290's stools throughout his stay in the facility. Nursing Supervisor #3 stated she had not reviewed his bowel movement records. Nursing Supervisor #3 stated she recalled Resident #290's RP called her on [DATE] and reported that Resident #290 had complained of dizziness. Nursing Supervisor #3 stated she went and asked Resident #290 if he was dizzy and he said no. Nursing Supervisor #3 stated she did not obtain vital signs or complete a full assessment of the resident because she did not think it was significant. A Nurse Practitioner progress note dated [DATE] indicated Resident #290 continued with loose stools. Resident #290 started on banana flakes and loperamide as needed. The KUB was unremarkable. A stool sample was to be completed outpatient after discharge. Resident with poor appetite and weakness. Review of Resident #290's physician orders revealed an order dated [DATE] entered by the NP to perform straight catheterization (a procedure in which a hollow tube drains urine from the bladder) once and obtain laboratory tests Complete Blood Count and Comprehensive Metabolic Panel due to decreased urination. Review of Resident #290's electronic Medication Administration Record (MAR) revealed the order for straight catheterization was electronically signed by Nurse # 11 on [DATE] at 6:30 PM. The amount of urinary output obtained was recorded as 100 milliliters. Review of Resident #290's laboratory results dated [DATE] indicated blood specimens were collected at 2:40 PM on [DATE]. A critical panic white blood cell count level of 51.8 thousand per microliter was called to the facility at 11:48 PM. The normal value for a white blood cell count is 4.1-10.9 thousand per microliter. Review of Resident #290's progress notes indicated a nursing progress note written by Nurse #6 dated [DATE] at 12:46 AM indicated the Nurse Practitioner on-call was notified of the critical laboratory value and new orders were received. Review of Resident #290's electronic Medication Administration Record (MAR) revealed the order to place an indwelling catheter was electronically signed as completed by Nurse #6 on [DATE] at 1:30 AM. Review of Resident #290's electronic health record revealed physician orders dated [DATE] for ceftriaxone (an antibiotic used to treat infections of the lungs, ears, skin and urinary tract) 2 grams intramuscular one-time only STAT (immediately) and hypodermoclysis (a method of administering fluids under the skin) 75 milliliters of fluid per hour continuously. Review of Resident #290's progress notes indicated a nursing progress note written by Nurse #6 dated [DATE] at 2:47 AM which indicated hypodermoclysis was placed into the abdomen with fluids running at 75 milliliters per hour. An interview was conducted via phone with Nurse #6 on [DATE] at 5:45 PM. Nurse #6 stated she was assigned to Resident #290 on [DATE] from 7:00 PM to 7:00 AM. Nurse #6 stated Resident #290 was very sick that night. Nurse #6 did not indicate that she assessed Resident #290 for specific symptoms, just stated that he appeared to not be feeling well. When she received the critical high lab results, she called the on-call provider. The on-call provider did not say to send the resident to the hospital and Nurse #6 stated she did not ask the on-call provider if she should send the resident to the hospital. Nurse #6 could not recall if she reported to the on-call provider that Resident #290 was designated as a Full Code status. Nurse #6 stated the on-call provider gave orders to administer an antibiotic, insert an indwelling catheter and administer fluids. Nurse #6 stated she inserted the catheter and Resident #290 did not have any urinary output from the indwelling catheter. Nurse #6 stated she did not call the on-call provider back to report the lack of urinary output and did not assess the resident for further symptoms, but she tried to encourage the resident to drink fluids throughout the night. Nurse #6 stated she did not recall if Resident #290 had loose stools that night, but she recalled he had loose stools throughout his stay at the facility. An interview was conducted on [DATE] at 2:20 PM with Nursing Assistant (NA) #3. NA #3 was assigned to Resident #290 on [DATE] from 7:00 AM to 3:00 PM. NA #3 stated she was familiar with Resident #290 and was assigned to him several times including the day he was sent to the hospital. NA #3 stated Resident #290 was having loose, runny stools all the time while he was in the facility. NA #3 stated she did not recall a foul odor. NA #3 stated she did not report the loose stools to the nurse since she assumed the nurses were already aware. Review of an Interact Nursing Home to hospital transfer form dated [DATE] completed by Nursing Supervisor #2 on [DATE] at 12:17 PM indicated Resident #290 was a full code, vital signs were as follows: Blood pressure 110/50, temperature 97, respirations 22, temperature 98.3 and oxygen saturation 92%. The reason for transfer was the resident requested transfer due to decreased urination. Review of Resident #290's progress notes indicated a nursing progress note dated [DATE] written by Nursing Supervisor #2 at 12:40 PM which indicated the resident requested to be sent to the hospital because he was unable to eat or urinate. The Nurse Practitioner was notified. The note indicated the Nurse Practitioner stated the resident was competent and to send him to the emergency room if that was what he wanted. Review of Resident #290's progress notes indicated a nursing progress note dated [DATE] at 2:31 written by Nursing Supervisor #2 indicated the resident was sent to the hospital for evaluation at 2:20 PM. An interview was conducted with the Nursing Supervisor #2 on [DATE] at 2:30 PM. Nursing Supervisor #2 stated she was familiar with Resident #290 and had worked with him since he was admitted . Nursing Supervisor #2 stated Resident #290 frequently had loose stools throughout his stay and she thought it was normal for the resident. She stated she had not reported the loose stools to the Nurse Practitioner or the Physician. Nursing Supervisor #2 stated he had banana flakes ordered that were supposed to help with the loose stools. Nursing Supervisor #2 stated the resident was not eating well, did not have any appetite and seemed very tired but she did not report these findings and did not think these were signs of infection or sepsis. Nursing Supervisor #2 stated she had not noticed a foul odor from his stools and it was not reported to her by staff. Normally if there was a resident having loose stools or stools with a foul odor it was reported to the provider for further orders. Nursing Supervisor #2 stated she recalled that Resident #290's family had received an order from the Gastroenterologist for some type of stool sample to be obtained but she did not think it had been collected or sent out. Nursing Supervisor #2 stated on [DATE], she was assigned to Resident #290, and he requested to be sent to the hospital. Nursing Supervisor #2 stated Resident #290 appeared very tired, but she did not recall anything abnormal about his condition at the time and did not think that being tired was a sign of infection or sepsis. Nursing Supervisor #2 stated she did not review Resident #290's bowel movement records prior to his transfer to the hospital and did not have a record of his urinary output. Review of an Emergency Medical Services (EMS) report dated [DATE] revealed EMS arrived on the scene at 2:12 PM and departed from the facility at 2:24 PM. The EMS narrative indicated the staff stated the reason for transport was Resident #290 was unable to urinate for 2 days. Staff reported straight catheterization was attempted. Staff reported possible infection but denied sepsis diagnosis or symptoms. When assessed by EMS the resident complained of weakness and being very tired. EMS noted the resident was having a hard time staying awake, was slow to respond to questions and complained of nausea. Intravenous access was attempted 3 times unsuccessfully. Vital signs obtained during transport to the hospital were as follows: 2:28 PM Blood pressure 157/135 Pulse 73 Respirations 16 Oxygen saturation 95% 2:35 PM Blood pressure 165/106, Pulse 20, Respirations and Oxygen saturation not recorded 2:50 PM Blood pressure 64/38, Pulse 45, Respirations 16, Oxygen saturation 94 2:52 PM Blood pressure 74/47, Pulse 65, Respirations 16, Oxygen saturation not recorded. Attempt was made on [DATE] at 2:00 PM to interview via phone the EMS personnel that responded to the call to transport Resident #290 to the hospital. A message was left with no return call. The Emergency Provider emergency room Note dated [DATE] indicated the resident arrived in the emergency room and was extremely ill, hypotensive (low blood pressure), hypothermic (low temperature) and had atrial fibrillation (irregular heart rate). Triage vital signs at the emergency room were recorded as blood pressure 90/53, pulse 120, respirations 18, temperature 97.5. Laboratory results at the hospital indicated the C. diff test was positive and white blood cell count was 66.0. Resident #290 was diagnosed with Septic Shock secondary to C. Diff. The hospital Discharge summary dated [DATE] indicated Resident #290 was admitted on [DATE] with admitting diagnosis of septic shock secondary to C. difficile colitis. Resident #290 presented with a chief complaint of persistent diarrhea and dehydration with approximately 1 month of persistent malodorous diarrhea and dehydration. In the emergency department, the resident's blood pressure was 89/54 and pulse was 110. [NAME] blood count was 66 and resident tested positive for C. difficile. The resident was admitted to the intensive care unit. Resident's condition declined. Resident #290 deceased on [DATE] at 11:02 PM. Review of Resident #290's death certificate dated [DATE] indicated resident's cause of death was Sepsis, C. Diff and acute kidney injury. Review of the electronic medical record revealed no documentation in the nursing progress notes regarding Resident #290's loose stools during the duration of his stay at the facility. There was also no discovered mention of a family member or therapy staff expressing concern about the Resident #290's loose stools. An interview was conducted on [DATE] at 2:10 PM with the Evening Nursing Supervisor who stated Resident #290 had loose stools all the time since he was admitted , and she assumed this was normal for him. The Evening Nursing Supervisor stated she did not recall anyone reporting anything about resident's stools having a foul odor. The Evening Supervisor stated she had not reported the loose stools to the provider because she thought this was the baseline for him and she had not assessed him for any other symptoms. A telephone interview was conducted with Resident #290's RP on [DATE] at 9:20 AM. The RP stated she visited Resident #290 daily and sometimes twice per day indicated she observed Resident #290 had frequent loose stools that were malodorous, and the odor was noticeable in the hallway. The RP stated Resident #290 indicated he could not tell when he was urinating or having a bowel movement, that the stools were liquid and would just run out of him. The RP stated she had observed him with liquid feces running down his legs and stated she reported to the nurses' multiple times about the loose stools. The RP stated she talked to the NP frequently and reported to him the loose stools. The RP stated she called the Gastroenterologist to report the loose stools since the NP had not addressed it. The RP stated she reported to the Nursing Assistant on admission that resident had frequent bowel movements but not that he normally had loose stools. She further stated she informed the staff he had a procedure on his bowel in the hospital, but his bowel movements had returned to normal. The RP stated she was not asked by the nursing staff or the NP about C. diff and the resident did not have history of C. difficile or other bowel issues. The RP stated Resident #290 had a loss of appetite, nausea and stomach pain in the weeks before he went to the hospital. The RP indicated just prior to going to the hospital, the Nursing Assistant stated Resident #290 was not acting right and she observed this also. The RP reported this to Nurse #11 who asked her what she wanted done about it. The RP indicated on the morning of [DATE], she received a call from Nursing Supervisor #2 who informed her she thought Resident #290 was having anxiety and he requested to go to the hospital. The RP stated she arrived at the facility before the resident left via EMS to go to the hospital and indicated she observed the resident struggling to breathe and he stated he had an infection and knew something was wrong. EMS arrived and Nursing Supervisor #2 reported to EMS that Resident #290 was probably just anxious and stated she did not think he was septic. Nursing Supervisor #2 did not report to EMS that resident had loose stools. An interview conducted with the Nurse Practitioner on [DATE] at 3:00 PM revealed he was aware Resident #290 had constant loose stools during his stay in the facility and that this was a sign of C. Diff. The Nurse Practitioner stated Resident #290 was admitted for rehabilitation following a subdural hematoma and that was his focus. The NP stated Resident #290 had discharge plans during his stay so he thought the issue of loose stools would be addressed as an outpatient following discharge. The NP stated he ordered the Kidney Ureter and Bladder (KUB) x-ray after the family member consulted with the Gastroenterologist. The result of the KUB x-ray was normal. The NP stated he ordered banana flakes, but Resident #290 still could have had C. Diff. The NP stated he did not investigate why the resident was having loose stools or if he had any history of gastrointestinal issues. The NP stated continuous loose stools did not seem like a problem at the time, but in hindsight maybe he should have done something else. The NP stated he did not recall the Occupational or Physical Therapists or the Rehabilitation Director reporting that Resident #290 was weak, having diarrhea or not feeling well. A follow up interview was conducted with the Nurse Practitioner on [DATE] at 1:00 PM to obtain clarification of Resident 290's condition and the course of treatment. The Nurse Practitioner stated if he had known the resident had loose foul-smelling stools, he might have ordered a test for C. difficile. The Nurse Practitioner stated he talked to Resident #290's RP a couple of times during the resident's stay, but did not recall her having any concerns. The Nurse Practitioner stated the resident never really complained about anything, so he was not concerned. The Nurse Practitioner stated he was not notified of loose stools since admission. The NP stated if the resident was having loose stools more than 1 per day he would have expected to have been notified. The Nurse Practitioner stated the outcome of not treating C. difficile is death. A telephone interview was conducted with the Medical Director on [DATE] at 12:05 PM. The Medical Director stated she completed a history and physical for the resident on [DATE] and at that time she was not made aware of the resident having loose stools.[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews with staff, the resident's Responsible Party (RP), Medical Director, and Nurse Practitioner (NP), the NP failed to communicate and collaborate with the Medical Director for a resident (Resident #290) who was presenting with signs of Clostridium Difficile (C. difficile or C. diff) According to the Centers for Disease Control and Prevention: C. diff-is a highly contagious bacteria that causes diarrhea and inflammation of the colon, can be life-threatening and present with symptoms which include loose stools, abdominal cramping, loss of appetite and stools may have a foul odor. For the period of [DATE], date of admission, through [DATE], the first date the NP had a progress note for Resident #290, the resident was recorded as having 42 stools in 24 days. Resident #290 was documented as having loose stools during each of the 6 progress notes the NP had for the resident, starting with the progress note dated [DATE], through the last progress note on [DATE]. For the period of [DATE] through [DATE] Resident #290 was recorded as having 15 stools in 8 days. From the [DATE] progress note through the date Resident #290 was discharged to the hospital, the NP did not consult with the Medical Director despite the resident's documented persistent and foul-smelling loose stools. Due to the resident's continued loose stools, and foul odor of the stools, the resident's RP reached out to a Gastroenterologist and received a recommendation for a stool sample to be sent in for analysis. Without consultation with the Medical Director, the NP elected to postpone obtaining and submitting the stool sample until after the resident's discharge. On [DATE] Resident #290 requested to be transferred to the hospital where he tested positive for C. diff, was diagnosed with septic shock secondary to C. diff and died in the hospital on [DATE]. The death certificate indicated the cause of death was septic shock secondary to C. diff and acute kidney injury. This occurred for 1 of 1 resident reviewed for coordination of care. Immediate jeopardy began on [DATE] when the NP failed to communicate and collaborate with the Medical Director regarding his knowledge of Resident #290's repeated loose and foul-smelling stools. The immediate jeopardy was removed on [DATE] when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (isolated with no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) to complete education and ensure monitoring systems put into place are effective. The findings included: Review of the facility's Medical Director Agreement effective [DATE], indicated the Medical Director develops and periodically reviews and revises, as indicated, policies that govern practitioners in the facility other than physicians, including physician assistants and nurse practitioners; and guides the facility regarding clinical decision making and the provision of direct care. Review of the facility's Medical Director job description revealed the expectation the medical director provides guidance and oversight of the other providers in the facility. The Medical Director is available to assist providers to answer clinical questions regarding the residents to ensure that the resident-centered standard of practice is maintained. Resident #290's hospital Discharge summary dated [DATE] indicated Resident #290 was admitted with a subdural hematoma. During the hospital stay, the resident underwent decompression of the colon (a procedure to reduce gas and feces in the colon) on [DATE] and tolerated the procedure well with reduction in the colon volume. Resident #290 was admitted to the facility on [DATE] with diagnosis of subdural hematoma. For the time period of [DATE] through [DATE] Resident #290 had a total of 42 stools documented with 12 of the 42 that were loose or liquid with one (1) that was described as having a foul odor according to the bowel movement records. The NP progress note dated [DATE] revealed Resident #290 was seen for a chief complaint of loose stools and was started on banana flakes (a medication to help with loose stools) for 1 week. The note did not include an assessment of Resident #290's abdomen or bowel sounds. The progress note gave no indication that the NP communicated the resident's condition to the Medical Director. Review of Resident #290's physician orders revealed an order written by the NP dated [DATE] for banana flakes one packet once per day. The order was discontinued on [DATE]. Review of Resident #290's electronic Medication Administration Record (MAR) revealed an entry for banana flakes one packet once per day with a start date of [DATE] and a discontinue date of [DATE]. All entries were signed with electronic signatures as given. For the date of [DATE] the Resident #290 had 3 large loose stools and a small stool according to the bowel movement record for Resident #290. The NP progress note dated [DATE] stated the nature of presenting problem was discharge to home. The note indicated Resident #290 continued to have loose stools. Resident #290's responsible party contacted the Gastroenterologist who recommended a Kidney Ureter and Bladder (KUB) x ray and a stool sample panel due to loose stools. The NP progress note stated the KUB was ordered, and the stool samples would be done outpatient after discharge. The progress note further stated to continue the banana flakes and if the banana flakes were ineffective would start loperamide (an anti-diarrheal medication) 2 milligrams once per day as needed. The progress note gave no indication the NP communicated the resident's condition to the Medical Director, nor did he consult the Gastroenterologist. Review of Resident #290's electronic health record revealed an order dated [DATE] to obtain a KUB. There was no order noted to obtain stool samples. For the time period of [DATE] through [DATE] Resident #290 had 5 stools total recorded with two described as loose and foul-smelling according to the bowel movement record for Resident #290. The NP progress note dated [DATE] indicated Resident #290 continued to have loose stools. Banana flakes were ordered with marginal improvement. KUB was unremarkable. The resident will have stool samples done outpatient following discharge. Continue banana flakes and start loperamide as needed. The progress note gave no indication that the NP communicated the resident's condition to the Medical Director, nor did he consult with the Gastroenterologist. Resident #290's electronic Medication Administration Record (MAR) indicated loperamide 2 milligrams once per day as needed was ordered on [DATE]. The electronic MAR indicated no entries were signed for loperamide indicating loperamide was not administered. For the time period from [DATE] through [DATE] Resident #290 had 3 large loose stools according to the bowel movement record for Resident #290. The NP progress note dated [DATE] indicated the chief complaint was loose stools. The note indicated Resident #290 continued to have loose stools and was started on banana flakes and loperamide as needed. The progress note gave no indication that the NP communicated the resident's continued loose stools with the use of banana flakes to the Medical Director. The progress note gave no indication that the bowel movement records were evaluated to determine the effectiveness of the banana flakes. The NP progress note dated [DATE] indicated Resident #290's chief complaint was loose stools. The note indicated the resident continued to have loose stools. The note provided no indication that Resident #290's bowel movement records were reviewed. The plan indicated the KUB was unremarkable, to continue the banana flakes and continue loperamide as needed. The progress note gave no indication that the NP communicated the resident's condition to the Medical Director. A Nurse Practitioner progress note dated [DATE] indicated Resident #290 continued with loose stools, had poor appetite and weakness. Banana flakes and loperamide were ordered, the KUB was unremarkable, and a stool sample would be completed as an outpatient after discharge. The progress note gave no indication that the NP communicated the resident's condition to the Medical Director. Review of Resident #290's physician orders revealed an order dated [DATE] entered by the NP to for a nurse at the facility to perform a urinary straight catheterization (a procedure in which a temporary catheter is used to drain urine from the bladder and then the catheter is immediately removed once the bladder is emptied) once and obtain the following laboratory tests; Complete Blood Count and Comprehensive Metabolic Panel due to decreased urination. Review of Resident #290's electronic Medication Administration Record (MAR) revealed the order for straight catheterization was electronically signed by Nurse #11 on [DATE] at 6:30 PM. The amount of urinary output obtained was recorded as 100 milliliters. For the time period from [DATE] to [DATE], Resident #290 had 1 large and 2 medium stools recorded according to the bowel movement record for Resident #290. Review of Resident #290's laboratory results dated [DATE] indicated a high panic level white blood cell (part of the body's immune system to fight infection) count (WBC) of 51.3 thousand per microliter (a normal WBC would be between 4.5 thousand and 11.0 thousand per microliter) was reported to the facility at 11:48 PM. The lab report was not signed off by the nurse as reviewed or communicated, nor was it signed off as reviewed by the NP, and it was not signed off as communicated to the MD by the NP. Review of Resident #290's progress notes indicated a nursing progress note dated [DATE] (Saturday) at 12:46 AM the Nurse Practitioner on-call (not Resident #290's NP) was notified of a high panic laboratory value and new orders were received. The progress note did not document the NP had reported the panic labs to the facility Medical Director. Review of Resident #290's electronic health record revealed physician orders dated [DATE] for ceftriaxone (an antibiotic) 2 grams intramuscular one-time only STAT (as soon as possible), hypodermoclysis (a method of administering fluids under the skin) 75 milliliters of fluid per hour to run continuously with no total amount specified and no time or date to stop the infusion and insert an indwelling urinary catheter. Review of Resident #290's electronic Medication Administration Record (MAR) revealed the order to place an indwelling catheter was electronically signed as completed by Nurse #6 on [DATE] at 1:30 AM. An interview was conducted via phone with Nurse #6 on [DATE] at 5:45 PM. Nurse #6 stated she was assigned to Resident #290 on [DATE] from 7:00 PM to 7:00 AM. Nurse #6 stated Resident #290 was very sick that night. Nurse #6 stated she inserted the catheter and Resident #290 did not have any urinary output from the indwelling catheter. Nurse #6 stated she did not call the on-call provider back to report the lack of urinary output and did not assess the resident for further symptoms. Review of Resident #290's progress notes indicated a nursing progress note dated [DATE] at 12:40 PM written by the Nursing Supervisor #2 indicated the resident requested to be sent to the hospital because he was unable to eat or urinate and the NP was notified. The NP indicated the resident was competent and to send him to the ER if that was what he wanted. Review of Resident #290's progress notes indicated a nursing progress note dated [DATE] at 2:31 written by Nursing Supervisor #2 indicated resident was sent to the hospital for evaluation at 2:20 PM. The Emergency Provider/emergency room Note dated [DATE] indicated the resident arrived in the emergency room and was extremely ill, hypotensive (low blood pressure), hypothermic (low temperature) and had atrial fibrillation (irregular heart rate). Laboratory results at the hospital indicated C. diff was positive, the white blood cell count was 66.0 thousand per microliter and the resident was diagnosed with Septic Shock secondary to C. diff. The hospital Discharge summary dated [DATE] indicated Resident #290 was admitted on [DATE] with diagnosis of septic shock secondary to C. diff colitis. Resident #290 presented with a chief complaint of persistent diarrhea and dehydration with approximately 1 month of persistent malodorous diarrhea and dehydration. In the emergency department, the resident's blood pressure was 89/54 and pulse was 110. [NAME] blood count was 66 and resident tested positive for C. diff. The resident was admitted to the intensive care unit where his condition continued to decline. Resident #290 passed away on [DATE] at 11:02 PM. Review of Resident #290's death certificate dated [DATE] indicated resident's cause of death was Sepsis, C. diff and acute kidney injury. An interview conducted with the Nurse Practitioner on [DATE] at 3:00 PM revealed he was aware Resident #290 had loose stools during his stay in the facility. The NP revealed there was not a system in place for reviewing the residents he saw and their medical conditions with the Medical Director. The NP further indicated he reviewed residents he evaluated with the Medical Director on an as needed basis. The NP stated he did not think Resident #290's condition warranted consultation with the Medical Director because it did not seem that serious. The NP stated he based his assessment on what the resident told him and what was reported by the nursing staff. The NP indicated he thought the resident was being discharged several times due to potential discontinuation of insurance coverage and he wrote his notes and evaluations based on the resident only being in the facility for rehabilitation and would be returning home. Resident #290 did not in fact discharge from the facility until [DATE] when he was emergently sent to the hospital. The NP stated the resident did not report any problems and he used this as his basis for treatment. A telephone interview was conducted with Resident #290's RP on [DATE] at 9:20 AM. The RP stated she visited Resident #290 daily and sometimes twice per day. The RP indicated Resident #290 had frequent loose stools that had a foul odor that was noticeable in the hallway. The RP stated Resident #290 indicated he could not tell when he was urinating or having a bowel movement, that the stools were liquid and would just run out of him. The RP stated when she came in to visit, she had observed him with liquid feces running down his legs and she stated she reported to the nurses multiple times that the resident was having loose stools. The RP stated she talked to the NP frequently and reported to him the loose stools. The RP stated she called the Gastroenterologist to report the loose stools since the NP had not addressed it. The RP stated Resident #290 had a loss of appetite, nausea and stomach pain in the weeks before he went to the hospital. The RP stated she arrived at the facility before the resident left via EMS to go to the hospital and indicated she observed the resident struggling to breathe and he stated he had an infection and knew something was wrong. An interview was conducted via phone with the Medical Director on [DATE] at 12:05 PM. The Medical Director stated she was new in the position in the facility and new to working with the NP. She stated she visited the facility weekly mainly to complete the history and physicals for new admissions to meet the regulatory requirements. The Medical Director stated there was not a system in place for reviewing the residents seen by the NP each week. The Medical Director stated she expected she would have been notified by the NP regarding a significant change in a resident's condition including diarrhea, possible dehydration, and infection. The NP had not reported any other residents to her which were of concern. The Medical Director further stated she was not informed of the critical lab value (WBC of 51.3 thousand per microliter), and she would have expected to have been. The Medical Director stated there was not a system to ensure that she was notified of changes in residents including critical labs that were called in to the on-call provider but stated there should probably be a system for this. An interview was conducted with the Director of Nursing (DON) on [DATE] at 4:45 PM. The DON stated the NP was in the facility daily during the week and the Medical Director visited weekly. The DON stated she was not aware of what the working relationship was between the Medical Director and the NP. The DON indicated she assumed that changes were reported by the NP to the Medical Director. The DON stated she did not consult the Medical Director and did not know if the NP had consulted the Medical Director. A follow up telephone interview with the DON on [DATE] at 2:28 PM revealed prior to this incident, there was no protocol for communication between the Medical Director and the Nurse Practitioner. The DON further stated the Medical Director as the attending physician for the residents makes the regulatory visits and the Nurse Practitioner completes the acute visits. The DON stated the Medical Director, and the Nurse Practitioner were both employed by a contracted company which provided their physician, provider, and on call provider service. The contracted service provided a transcript on Monday mornings of the calls that were received over the weekend from the facility and the response. The Medical Director and the NP receive a copy of the transcript. The facility staff call the DON when a resident is sent to the hospital for evaluation on the weekend or at night. The DON updated the NP on Monday of all residents that were sent to the hospital on the weekends. The DON stated the NP wrote his own orders and progress notes and the attending physician or Medical Director did not sign off on the orders or notes. According to the DON, the Medical Director did not have a system for reviewing the visits the Nurse Practitioner completed. The Administrator was notified of immediate jeopardy on [DATE] at 4:45 PM. The facility provided the following Acceptable Allegation of Immediate Jeopardy removal. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. The Nurse Practitioner failed to communicate and collaborate with the Medical Director when Resident #290 had prolonged loose, liquid stools from admission on [DATE] through [DATE]. The Nurse Practitioner was made aware and implemented banana flakes on [DATE] and loperamide on [DATE]. Resident # 290 requested to go to the hospital on [DATE] at 12:40 PM due to not feeling well. Emergency Medical Services transferred resident to the hospital at 2:20 PM where he was diagnosed with Septic Shock Secondary to clostridium difficile. The Hospital Discharge Summary indicated Resident #290 died on [DATE] at 11:02 PM. All residents being seen by a Nurse Practitioner and/or Physician Assistant for acute change in condition have the potential to be affected. On [DATE] the Medical Director will review the provider notes for all residents with a change in condition that were seen by any of the Nurse Practitioners and/or Physician Assistants since [DATE]. Any new orders or suggestions made by the Medical Director will be communicated to the Nurse Practitioner/Physician Assistant and the Director of Nursing on [DATE] for follow-up. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. The Medical Director educated all Providers working with the facility on the clostridium difficile protocol. The protocol indicates that residents with three or more watery or loose stool in a 24 hour time span should have a medication review to ensure laxatives are not contributing to the loose stool. If the loose stool does not resolve within 24 hours of the laxatives being stopped or the resident was not receiving laxatives, a clostridium difficile test will be performed. The NP was included in the provider education. All education was implemented on [DATE] via telephone or face to face training and will be completed by [DATE]. On [DATE] the Director of Nursing was educated by the Regional Director of Clinical Services on providing the Medical Director with a list of residents that were seen by a Nurse Practitioner and/or Physician Assistant in the previous seven days, due to a change in condition, weekly for the Medical Director to review. The Director of Nursing will review all progress notes weekly to determine the residents that were seen in the past 7 days for a change in condition. The Medical Director will review the Nurse Practitioner and/or Physician Assistant progress notes weekly and communicate any suggestions to the Nurse Practitioners and/or Physician Assistants and the facility. The Regional Director of Clinical Services communicated the new review process to the provider groups Nurse Practitioners and/or Physician Assistants as well on [DATE]. The Medical Director was informed of the new review process by the Director of Nursing on [DATE] and is in agreement with the system of communication and collaboration. Alleged Date of immediate jeopardy removal: [DATE] The credible allegation of immediate jeopardy removal was validated on [DATE]. Interviews with the Nurse Practitioner, Physician Assistant, Medical Director and the Director of Nursing revealed they received education and training regarding the new process of checking residents' progress notes for significant changes. The Director of Nursing will provide the Medical Director with a list of all residents with significant changes for review. The Medical Director validated that she will review the progress notes of all residents with significant changes and communicate suggestions or changes in plan of care to the Nurse Practitioners, Physician Assistant and the facility. The Regional Clinical Consultant confirmed that she educated the Director of Nursing on the new process and auditing to be completed. The immediate jeopardy removal date of [DATE] was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, resident, staff, and Nurse Practitioner (NP) interviews, and review of the restraint manufacturer's training video, the facility failed to properly secure a resident in her wheelchair during transport in the van by not utilizing the shoulder strap for 1 of 2 residents reviewed for supervision to prevent accidents (Resident #51). During a facility van transport Resident #51's wheelchair fell over to the right resulting in a head contusion and skin lacerations to her right arm, elbow, and pinky finger, this occurred while the transport driver was in heavy traffic and making a left turn. Resident #51 was sent to the emergency room for evaluation and treatment and returned to the facility later in the evening. Findings included: The restraint manufacturer's instructional video for the proper use of the van's safety restraints during transportation was reviewed on 9/1/2022. The video specified that after the wheelchair was secured in the van, the van's lap belt strap was to be placed between the wheelchair arm and the resident to secure the resident to the wheelchair. The manufacturer's instructions further specified to make sure that the van's shoulder strap was in place once the lap belt was properly placed on the resident. Resident #51 was admitted to the facility on [DATE]. Resident #51's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and utilized a wheelchair for locomotion on and off the unit. A nursing progress note written on 8/18/2022 by the Director of Nursing (DON) revealed she had received a phone call at 1:47 PM from the Transport Driver that stated Resident #51's wheelchair had tipped over to the right side when she was turning on a curve and Resident #51 had hit her head on the floor, and she had lacerations to right arm, elbow, and pinky finger. The note further indicated when the Transport Driver returned Resident #51 to the facility, she was tearful and stated that it had scared her. The note indicated that Resident #51's vital signs were stable, neurological checks were within normal limits, and she had no complaints of pain. Pressure was applied to laceration to right side of head with scant amount of bleeding noted, skin tears to right arm areas were cleaned and dressings placed. The note further revealed the Nurse Practitioner (NP) was in the facility when the resident returned, and he assessed the resident and sent order to send her to the emergency department (ED) for evaluation and treatment. Resident #51 was not assessed by a licensed professional prior to returning to the facility. A review of the written statement written by the Transport Driver on 8/18/2022 revealed in part, I had to transport Resident #51 to a dermatology appointment. I put resident on our lift to raise up in the van while I was with her. Chair was locked both wheels. I then unlocked her wheelchair wheels and rolled her into position to secure the wheelchair. Her lap belt was secured, and her wheelchair frame was secured with 4 locks to the frame of the chair. 2 locks in front and 2 locks to the rear. Then I checked to make sure her seatbelt wasn't too tight across her stomach. I could put 2 fingers underneath and resident stated it was fine. We then started to the appointment. Construction and traffic were very heavy on Route 57 having to stop 3 times due to heavy traffic and construction. When we got to the stop light to make a left turn, the light turned green and an 18-[NAME] was in front of me, he turned and then I turned right behind him. Then driving straight, I heard a commotion in the back. Resident #51's wheelchair had turned not completely over to the right. I then pulled over immediately and I went back to Resident #51 and her wheelchair was not laying flat on the floor, the arms of the wheelchair didn't touch the floor. I was trying to help her, but the seat belt she had on, and the locks (4) of them that were on the frame of the chair were pulled so tight that I could barely budge them to unlock them to unlock the hooks that were securing her wheelchair by the frame. I finally was able to get the locks unlocked from the frame trying not to let the chair fall completely to the floor, because she was still secured from the lap belt. With all my strength I got the wheelchair back up right. Resident #51 stated her right hand was stinging and I saw she had a little skin tear, then on her right arm I saw some blood and she had a skin tear around the elbow area. After placing the wheelchair with her still in it back up, Resident #51 asked if she was going to her doctor's appointment. I am very upset what took place, but first thing I did was put a band aid on her pinky and right forearm, we then returned to the facility. The Post Fall Huddle Form dated 8/18/2022 revealed the Interdisciplinary Team had determined the root cause of the fall was the shoulder safety strap was not engaged. The emergency department Physician report for Resident #51 dated 8/18/22 at 3:32 PM revealed that after profuse irrigation and exploration the 3-millimeter (mm) x 0.5mm laceration to right arm was repaired with sterile skin adhesive. There was no evidence of nerve, vessel or tendon injury or foreign body. The 0.5mm scalp wound was repaired with Dermabond with good results. Computed Tomography (CT) scan of the brain/head was negative for acute cranial abnormality. Resident #51 was discharged back to the facility. A nursing progress note written by Nurse #9 on 8/18/22 revealed Resident #51 returned to the facility at 6:45 PM with the RP. An interview was conducted with Resident #51 on 9/1/2022 at 3:25 PM. She stated 2 weeks ago while being transported in the facility van, the driver took a sharp turn and she fell over and hit her head on the floor. She indicated her shoulder strap was not on, but her lap belt was on, and the wheelchair was strapped to the floor. Resident #51 further stated she did not drop her stuffed dog and was not leaning over the wheelchair when the incident occurred. Resident #51 stated she went to the hospital, and she had a laceration to the right side of her head and abrasions to right arm, elbow, and pinky finger. An interview was conducted with DON on 9/1/2022 at 6:55 PM, She stated that the only person that drives the transport van at the facility was the Transport Driver. She further stated that when Transport Driver is not working, the facility utilizes the contracted transport service. An interview was conducted with Transport Driver on 9/1/2022 at 7:00 PM. She stated that when the incident occurred, she had been working at the facility for about a month, and that she felt like her training was adequate. She further stated that she had secured the wheelchair to the floor of the van with the 4 retractable locks. She then secured the belt around the waist and checked with her two fingers to ensure it was secure enough. Transport Driver stated she was in a lot of heavy traffic on the road when she finally got through construction. She further stated an 18-[NAME] was in front of her and they were turning left at the stop light. The Transport Driver stated she had made the turn and started to go straight when she heard Resident #51's animated dog (resident's puppy) bark. She stated she did not see the dog; she just heard it. She further stated that when she heard the dog bark, she was no longer making the turn and was driving straight. She stated her first thought was for the resident not to bend over and reach for the dog or climb out of the wheelchair to reach it. She stated she was moving at about 8-9 miles per hour at the time and didn't know what made the wheelchair tip over. She indicated that once she heard the dog she pulled over and went immediately to the back of the van. She stated that Resident #51 was still strapped in her wheelchair with the seatbelt. She further stated that the 2 retractable locks were still secured to the front of the wheelchair and the 2 back ones were also still secured. She indicated that the wheelchair arm was about 5 inches from the floor. She stated she forgot to secure Resident #51 with the shoulder strap, and it was a mistake. The Transport driver stated that she had not asked Resident #51 what happened, she just wanted to get her back upright. She further stated that she had not seen the stuffed dog on the floor. She indicated she had been able get the wheelchair up to position because the wheelchair was not completely down on the floor. She stated that Resident #51 never came out of the wheelchair and seatbelt. She further stated that when she raised the wheelchair up it was still in the same spot it had been in originally, because the retractable locks were still secured. She stated that Resident #51 did not say much, and she wasn't crying. She stated she just kept observing Resident #51 in the mirror and she was not crying or anything. She indicated Resident #51 had a skin tear on her right forearm and some blood on the right side of her head. She stated Resident #51 did not complain of pain or headache, and she was not dizzy. An interview and observation of the Transport Driver securing a wheelchair in the transport van occurred on 9/1/2022 at 7:25 PM. The Transport Driver lowered the lift to the ground and proceeded to load the wheelchair facing forward and locked the brakes. She stated she would ask the resident to hold on to the bars as the lift was raised up into the van. She unlocked the wheelchair brakes and backed the wheelchair into place in the van and locked the brakes. The Transport Driver pulled the retractable locks one at a time from the floor and secured the wheelchair with S hooks to the front frame of the wheelchair. She then went to the back of the wheelchair and applied the retractable locks to the frame of the wheelchair one at a time. The Transport Driver checked all the straps to make sure they were secure and attached properly. She applied the seat belt and put 2 fingers underneath the strap to make sure it wasn't too tight. The Transport Driver applied the shoulder strap and stated that on 8/18/2022 she forgot to secure Resident #51 with the shoulder strap. The Transport Driver then tried to wiggle the wheelchair to see if it would move and it did not move. The Transport Driver stated that when she heard Resident #51's stuffed dog bark, she had looked in the mirror and observed the resident's wheelchair tipped over on the right side. She further stated that she had immediately pulled over in a parking lot and went back to help Resident #51. She indicated that Resident #51's head was laying up against the van lift and the wheelchair was approximately 5 inches off the floor. She stated that she knew she couldn't release the retractable locks because Resident #51 would have fallen hard on the floor. She further indicated that her written statement was wrong because she had not released the retractable locks. She further stated that it had taken all her strength to upright the wheelchair and it went right back into the same place. The Transport Driver stated that she had checked all the retractable locks and they were secure. She further stated that if the shoulder strap had been on Resident #51 the wheelchair would not have tipped over. She indicated that she had been trained that in case of an emergency, she was supposed to call 911, but all she could think of was getting the resident back to the facility as soon as possible. An interview was conducted with the Administrator on 9/1/2022 at 8:06 PM. He stated that he was the person who was responsible for the Transport Driver's training and competencies. The Administrator further stated that he had watched the wheelchair lift video and the video for the retractable locks and safety straps with the Transport Driver. He then stated that the competencies were demonstrated and repeat demonstration by the Transport Driver. He stated that she had performed all the steps correctly. The Administrator indicated that the Transport Driver was trained to engage the shoulder strap when transporting residents in wheelchairs in the van. He stated that he and the Receptionist, and the Medical Records Director, had done ride-a-longs with the Transport Driver, and she had done everything correctly. The Administrator stated that the Transport Driver had driven very safely and obeyed the posted traffic signs. He further stated that the facility had done a background check on her, and her driving record and driver's license was verified and was in good standing. The Administrator indicated the Transport Driver had no tickets or accidents on her record. He stated that he was the first person to enter the van on the day of the incident and he had verified that the retractable locks were secure to the frame of the chair and the seatbelt was on Resident #51, but the shoulder strap was not engaged. He further stated that the ADON had assessed Resident #51's head and applied gauze and the resident was unloaded from the van. He indicated that the Transport Driver stated she had forgotten to apply the shoulder strap. The Administrator stated that the Transport Driver was reeducated that evening and passed her competencies when he retested her on 8/18/2022. The Administrator stated that on 8/18/2022 corrective action was completed with the Transport Driver. He indicated that the facility staff had interviewed the alert and oriented residents on 8/18/2022 that had been transported in the van by the Transport Driver. The Administrator further indicated that all the residents stated they were secured properly in the van, and they felt safe riding with the Transport Driver. He stated that the facility staff had performed skin checks on the residents that were not alert and oriented on 8/18/2022 with no negative findings. He stated that everyone makes mistakes, and he did not think she would forget to utilize the shoulder strap again. The Administrator stated that to monitor for on-going compliance he or his designee were completing the Van/Restraint competency tool for all arrivals and departures: 5 days a week when driver has transportation x 1 month, then 3 days a week x 1 month, then weekly x 1 month. He stated that all findings would be reported to the QAPI team for review and additional follow-up as needed. A telephone interview was conducted with the Director of Nursing (DON) on 9/2/2022 at 10:14 AM. The DON stated that the Transport Driver had called her 8/18/2022 and she was very upset and crying. She further stated that the Transport Driver had told her she was driving the van and going around a curve when Resident #51's wheelchair had tipped over. She stated that the Transport Driver told her the resident was okay, and was alert and oriented, and not complaining of pain. The DON stated that the Transport Driver indicated that she was only about 10 minutes away and she was turning around and bringing the resident back to the facility. She indicated that the first thing she said to the Transport Driver was did you call 911? The DON stated that they unloaded the Resident and brought her into to the facility. She stated that the nurse practitioner (NP) was at the facility, and he assessed Resident #51 and observed that she had hit her head and it was bleeding, he stated to call EMS and send her to the hospital. The DON indicated that while they were waiting for EMS to arrive, she had called the responsible party (RP) and the Assistant Director of Nursing (ADON) treated the skin tears. A telephone interview was conducted with the Administrator's designee for the Restraint competency Audit Tool, the front desk Receptionist, on 9/2/2022 at 10:55 AM. She stated that the Administrator had trained her to check the wheelchair of the resident being transported after they are loaded on the van and before it departed. The Receptionist further stated that she ensured the shoulder strap was correctly applied and the seat belt was secure, then she checked all 4 retractable locks to make sure they were placed securely. She indicated that after she performed the checks, she would try to wiggle the wheelchair to make sure it would not move. She further stated when she was finished with the checks the van was allowed to depart. The Receptionist stated that she watched for the van to return, and then she went out and performed the same checks upon arrival. She further stated that she documented the findings on the Van Restraint Audit sheet, which is a component of the plan of correction (POC). An interview was conducted with the resident (Resident #17) who was riding in the wheelchair in the van in front of Resident #51 on 8/18/2022. She stated that was the first time she had ever been transported in the van. Resident #17 further stated that the Transport Driver had secured her wheelchair with the locks on the floor, secured her seatbelt, and applied the shoulder strap. Resident #17 stated there was a lot of traffic and construction and big vehicles like trucks and buses. The driver was not driving fast at all. She indicated that there was a lot of stop and go traffic. Resident #17 further stated she could not see the resident behind her because she was not able to turn around once she was secured in, but she and Resident #51 were conversing back and forth. She stated she heard a scream behind her, and the Transport Driver pulled over immediately and parked the van and went to help the resident behind her. Resident #17 stated she could not remember exactly what the van was doing at the time of the scream, but she thought they were going straight and not very fast. She added that the Transport Driver had done a very good job maneuvering the van in the heavy traffic and the construction. Resident #17 stated that the Transport Driver was an excellent driver, and she had felt safe in the van. She further stated she would get on the van again with the Transport Driver. A telephone interview was conducted with the NP on 9/2/2022 at 12:47 PM. He stated that when assessed Resident #51 on 8/18/2022 she had a scalp wound to her right parietal lobe and it was bleeding. The NP indicated that he spoke to the facility staff and determined that Resident #51 needed to be sent to the ER for evaluation and treatment. The Administrator was notified of the Immediate Jeopardy on 9/1/2022 at 8:44 PM. The facility submitted the following Plan of Correction: F689 Root Cause Analysis completed 8/18/2022 The Transport Driver forgot to engage the shoulder strap for Resident #51, resulting in a head contusion and abrasions to right arm. The Corrective action for noncompliance was completed on 8/19/2022. 1. On 8/18/2022 the facility driver failed to secure the shoulder strap during transport for resident #51. The wheelchair tipped to the right side in the van causing her to strike her head, resulting in a contusion and a skin tear. Once at facility the resident was assessed by the facility provider and sent to the hospital for evaluation and treatment. Resident returned to the facility later in the day. 2. On 8/18/2022 to identify other potentially affected residents the Administrator/designee interviewed all alert and oriented residents that were transported by the facility for 30 days prior to the incident to ensure that when they were transported, they were securely transported with a shoulder strap. No new issues were identified. All residents that were transported in the facility van in the past 30 days that were cognitively impaired received skin assessment with no skin issues identified. Van Driver received education QRT Max training video, Competency for securing wheelchair and resident in van, and competency for loading/unloading passenger in van. The transportation van securement straps, lab belt and shoulder belt were assessed for functionality by the Administrator with no findings noted. Drive along was done to verify van driver competency by the Administrator. On 8/18/2022 corrective action was completed with the employee. 3. To monitor for on-going compliance the Administrator/Designee will perform Van restraint competency tool: 5 days a week when driver has transportation x 1 month, then 3 days x one month, then weekly x one month. 4. Administrator/Designee to monitor for on-going patterns and trends and report findings to the QAPI team for review and additional f/u as indicated. The Quality Assurance Committee members are as follows: Administrator Director of Nursing Assistant Director of Nursing Life Enrichment Director Dietary Manager Director of Social Services Housekeeping Supervisor Medical Director Nurse Practitioner Completion Date: 8/19/2022 As part of the validation process on 9/1/2022 through 9/2/2022, the plan of correction was reviewed and included a sample of staff which included the Transport Driver, Administrator, Receptionist regarding in services and training related to deficient practice. The Transport driver verified the reeducation and training, and the continuing audits. A review of all the documents provided to correct the deficient practice was completed. The completion date of 8/19/2022 was confirmed.