**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, Pharmacist interview, Nurse Practitioners' interview, and Physician interview the facility failed to coordinate care for a resident with a seizure disorder. The resident's valproic acid medication dosage was decreased by a Psychiatric Nurse Practitioner who believed it only to be used for mood stabilization and who was unaware the medication was being using for seizure control. There was no communication with the medical provider before the change. The resident seized, was hospitalized , and intubated following the dosage decrease. Prior to transport to the hospital, Resident # 10's seizure was documented to not respond to intramuscular Ativan medication and lasted approximately 28 minutes before emergency medical services arrived for care and transport. This was for one (Resident # 10) of three sampled residents reviewed for seizure medications. Immediate Jeopardy began on 6/15/23 when Resident #10's valproic acid dosage was decreased by a Psychiatric Nurse Practitioner without consulting with the health care providers. Immediate Jeopardy was removed on 7/3/23 when the facility provided an acceptable credible allegation for immediate jeopardy removal. The facility will remain out of compliance at a scope and severity level of D (not actual harm with the potential for more than minimal harm that is not immediate jeopardy) for the facility to complete staff training and to assure monitoring systems put in place are effective. The findings included: Record review revealed Resident # 10 was initially admitted to the facility on [DATE]. The resident's diagnoses included in part traumatic brain injury and complex partial epilepsy (seizure disorder,) depression, and anxiety. Resident #10's quarterly Minimum Data Set assessment, dated 3/16/23, coded the resident as severely cognitively impaired. He was also assessed to need total assistance with his activities of daily living, have no behaviors during the assessment period, and to have a seizure disorder. Record review revealed Resident # 10 received both lacosamide and valproic acid for seizures. The last order for lacosamide was dated 5/12/23 and directed that the resident receive 10 ml (milliliters) 10 mg (milligrams)/ml two times per day. This remained as an active order up until his date of discharge. Orders and lab results related to Resident # 10's valproic acid medication were as follows: From 5/2/23 until 5/10/23, Resident # 10 was ordered to receive 11 ml (250 mg/5ml) valproic acid three times per day. (This would equate to 550 mg three times per day) On 5/10/23 a valproic acid level was done and registered 108. (A therapeutic medication level is when the blood level of the medication is in a range to be helpful but not dangerous. The facility's lab report noted therapeutic range for valproic acid to be 50 to 100 for seizures.) On 5/10/23 at 2:38 PM Nurse # 2 noted in a nursing note that she had received a critical lab value regarding a valproic acid level of 108 and called it into Medical Nurse Practitioner (NP) # 1. On 5/10/23 an order was given to decrease the valproic acid dosage to 10 ml (250 mg/ 5 ml) three times per day.( This would equate to 500 mg three times per day.) This order stayed in effect until 6/15/23. The order specifically noted the valproic acid was for seizures. On 5/11/23 the Physician ordered Resident # 10's valproic acid level be rechecked on the date of 5/15/23. The order was electronically signed by the Physician on 5/12/23. This order remained as an active order up until the resident's discharge date of 6/19/23 with no revision of the order. There was no valproic acid level drawn on 5/15/23 or a notation in the record why it was not done. On 6/15/23 Resident # 10 was seen by the Psychiatric Nurse Practitioner (NP) related to behaviors. The psychiatric NP noted that Resident # 10's valproic acid was prescribed for mood stabilization, and she was going to start a gradual dose reduction because his level had been high. On 6/15/23 Nurse # 5 entered an order into the computer for the Psychiatric NP for a lower dosage of the valproic acid. The order was for 5 ml (250 mg/ 5ml) three times per day. (This would equate to 250 mg three times per day.) The order was specifically written that the valproic acid was being used for behaviors. It did not mention that it was used for seizure control. On 6/15/23 Nurse # 5 noted in a nursing note that she had informed Resident # 10's responsible party that the valproic acid dosage had been dropped from 10 ml to 5 ml. Nurse # 5 noted this was done following a visit from the psychiatric NP and the valproic acid was given for behaviors. There was no notation that the medical physician or medical Nurse Practitioner were consulted. On 6/19/23 at 12:48 PM Nurse # 4 noted in a nursing note that Resident # 10 had a grand mal seizure (a seizure where there is loss of consciousness and violent muscle contractions), facility staff and the Medical NP responded, the resident was given IM (intramuscular) Ativan without any positive results. Nurse # 4 further noted the seizure became more intense and EMS (Emergency Medical Services) was called to transfer the resident to the hospital. On 6/19/23 Medical Nurse Practitioner # 2 entered a note in Resident # 10's record noting the resident's seizure had worsened although he had been given the Ativan. She noted he had seized for about 28 minutes when EMS arrived. According to hospital records Resident # 10 was evaluated in the emergency department on 6/19/23 and was intubated. The resident's valproic acid level was determined to be subtherapeutic at 39 and he was loaded (given an initial large dose of medication to obtain a quick response) with intravenous valproic acid. The Emergency Department physician also noted Resident # 10 had arrived in the Emergency Department in a postictal state (a period of recovery after a seizure) and within two hours started to have leftward eye deviation that was concerning for possible seizure activity. According to hospital records, the Emergency Department physician determined Resident #10 required a higher level of care. A larger hospital was contacted, and a transfer acceptance was obtained that same day (6/19/23) to their Intensive Care Unit for LTM EEG (long term electroencephalographic monitoring, which is the capability of recording electrical brain activity over long periods of time). Resident # 10 remained hospitalized as of 6/26/23. Following Resident # 10's discharge from the facility, the facility received from their lab the first valproic acid level that had been drawn since the order for the 5/15/23 level. The lab report showed the valproic acid level had been drawn on 6/17/23. The lab report noted it was received on 6/21/23 and reported to the facility on 6/22/23. The valproic acid level registered 21, which indicated the resident's level was subtherapeutic prior to his 6/19/23 seizure. The facility's pharmacy consultant was interviewed on 6/26/23 at 12:22 PM and reported the following. A therapeutic valproic acid level for seizure control would be 50 to 100. The lab had flagged the value of 108 on 5/10/23 because it was higher than the upper therapeutic range. Toxic levels (levels when serious adverse effects are brought about due to excessive medication in a person's system) would be considered 175 or greater. She had last reviewed Resident # 10's record on 5/26/23 and noted that his dosage had been changed following the lab value on 5/10/23. Resident # 10 had a history of his levels going up and down. It would have been her recommendation that no changes be made in the dosage until a repeat level be done given his history, but the dosage had been already changed before she did her review. The valproic acid dosage which had been ordered on 6/15/23 by the Psychiatric NP was historically a very low dose for Resident # 10, but she had not reviewed him again following 5/26/23 to have reported this. According to the facility pharmacy consultant the facility had been doing monthly valproic acid levels and she thought that was appropriate, and therefore she did not have any recommendation on 5/26/23. Medical Nurse Practitioner # 1 was interviewed on 6/26/23 at 4:10 PM and reported the following. She was the on- call provider when a facility nurse called her on 5/10/23 with the valproic acid level of 108 on 5/10/23. She had asked about any seizure activity the resident had, and the nurse had told her that he had none. She had decreased his dosage by 1 ml during the three times per day it was given. She had instructed the nurse to have the level repeated in a month. It would have been the nurse's responsibility to have put the order in. No one had told her that his level had been going up and down. If this had been shared with her, then she would have instructed the facility nurse to consult with the regular provider the next day and let them decide. Medical NP # 2, who generally covered the facility's residents, was interviewed on 6/23/23 at 11:38 AM and reported the following. She was not aware of any changes to the order that had been given to draw the valproic acid level on 5/15/23. She was also not aware Resident # 10's valproic acid level had been decreased on the date of 6/15/23. She found this out on 6/19/23 after he had the seizure. The facility's Psychiatric NP was interviewed on 6/23/23 at 1:25 PM and reported the following. She did not think the valproic acid was being used for seizure control. She thought it was only used for mood stabilization and behaviors. She was seeing him on 6/15/23 because of his increased behaviors. He had recently bitten a staff member. When she saw Resident # 10 on 6/15/23 she saw that his last valproic acid level had been critically high and she ordered that the dosage be decreased. She had talked to the facility nurses about this but not with the medical physician or the medical NP. Nurse # 5 was interviewed on 6/23/23 at 12:30 PM and reported the following. She had entered in the order on 6/15/23 for the decrease in the valproic acid level after the Psychiatric Nurse Practitioner wrote the order but did not talk to the medical physician or the medical Nurse Practitioner. She thought the Psychiatric NP had talked to the Medical NP about the dose change. During an interview with the DON on 6/23/23 at 1:40 PM, the DON reported the valproic acid was being used for seizure control and was also helping with some of the resident's behaviors. The facility's Medical Director was interviewed on 6/23/23 at 5:15 PM and reported the following. He felt the Nurse Practitioners could have collaborated better about the medication changes for Resident # 10. Resident # 10 had a history of having seizures regardless of seizure medications. He could not say that the lower dose of valproic acid and subtherapeutic level did not contribute to his seizure on 6/19/23. The Administrator was interviewed on 6/23/23 at 6:00 PM with the Director of Nursing. According to the Administrator and the Director of Nursing, the facility had identified that Resident # 10's seizure medication dosage had been changed by the Psychiatric Nurse Practitioner without checking with the medical provider and they had initiated but not completed a plan of correction. The Administrator was informed of Immediate jeopardy on 6/26/23 at 7:19 PM. The Administrator presented the following Immediate Jeopardy removal plan. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. Resident #10 was on Valproic Acid, as indicated for seizures. On 6/15/23 a consulting Psychiatric Nurse Practitioner (NP) decreased the dosage from Valproic Acid Oral Solution 250 MG/5ML, Give 10 ml three times a day to Valproic Acid Oral Solution 250 MG/5ML, Give 5 ml three times a day, related to a medication review regarding behaviors. However, as noted previously in the resident's medical record, its diagnosis and indication for use was for seizures. The Psychiatric NP was not aware the medication was used for seizure control because she did not conduct a thorough review of the medical record. The medical physician and/or facility medical staff (Nurse practitioner) were not consulted, and orders were not reviewed with the attending physician and/or his NP before the change in dosage. The resident seized and was hospitalized and intubated on 6/19/23 and remains there as of this date. The center staff did not follow professional standards in assuring that Nursing Policy 2303, entitled Report of Consultation, related to physician consults was followed. Previously, this internal contracted provider (in this case the Psychiatric NP) was functioning independently with no medical reviews conducted by the attending physician or medical NP, to approve, deny or change recommended orders prior to implementation. The psychiatric NP was being supervised by her contract provider, a Psychiatrist. All other residents receiving Valproic Acid and being followed by the Psychiatric NP were audited on 6/23/23 by the regional director of clinical services, to determine if there were other such discrepancies noted, such as change of indication for use or diagnosis. Any discrepancy found was reported to the attending physician and/or medical NP for immediate follow-up. The regional director of clinical services and/or DON will review all residents by 6/30/23 at the direction of the medical director/attending physician (the same individual) to assure the appropriate levels for anti-seizure medications are being monitored via lab including the mediations Valproic Acid (Depakote), Carbamazepine (Tegretol), Phenytoin (Dilantin), Levetiracetam (Keppra), to assure there are no medications not being monitored appropriately, no delayed lab results, and no failures of the provider or center to monitor other residents on these anti-seizure medications. As of 6/28/23, the Chief Nursing Officer, the Medical Director/attending physician, the consulting pharmacy group, and the DON met to determine, agree upon and implement the following process for all current residents that receive Valproic Acid (Depakote), Carbamazepine (Tegretol), Phenytoin (Dilantin), Levetiracetam (Keppra) and other seizure medications will have labs to monitor these drug levels All of those receiving these medications will be subject to the following: o Lab monitoring once every three months for two months. o Lab monitoring once every six months thereafter. o Baseline lab will occur for new admissions, then at the notated schedule above The consultant pharmacist will be involved at admission and monthly thereafter to identify anti-seizure medications and to determine if they are being monitored appropriately via the recommended labs at the recommended intervals noted above. The Chief Nursing Officer communicated with the pharmacy consultant about this expectation on 6/28/23. After the meeting of the Chief Nursing Officer, Medical Director/attending physician, consulting pharmacy group, and DON, the nurse administrative team will be educated by the DON or regional director of clinical services on this process by 6/30/23, to ensure all expected labs have been ordered on admission and ongoing. This will be tracked via the lab tracking policy outlined below, and monitored for implementation ongoing via the process outlined below in the daily clinical meeting. The Chief Nursing Officer communicated with the pharmacy consultant about this expectation on 6/28/23. 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 completed. The Psychiatric NP was educated on 6/27/23 by the Medical Director on his expectations for comprehensive medical record review, specifically review for indications of use and diagnosis for anti-seizure medications and/or for gradual dose reductions for psychotropic medications which can also be used for seizures (ie. Valproic Acid) before making recommendations for changes. Any concerns on the medical impact, related and unrelated to mood and behavior, should be discussed and coordinated with the provider (attending physician and/or medical NP) before changes are recommended. Additionally, any medication such as Valproic Acid, which can also be indicated for mood stabilization should be reviewed closer to determine actual indication for usage, and to monitor lab values prior to recommending a decrease in dosage. The Medical Director is the attending physician for all residents at the facility. Moving forward and related to this event, he will educate any current advanced care practitioners (current NPs medical and other consulting NPs), any future attending physicians, advanced care practitioners and internal consulting entities on comprehensive medical review and interdisciplinary provider discussion when consulting providers desire to make changes, and/or when the Medical NP is making changes to an anti-seizure medication. The expectation is that levels will be drawn and a comprehensive review done before dosages are being changed for all providers involved. The center DON knows who all current providers are; she will be made aware by the Administrator and/or Medical Director when new providers and consultant providers begin practicing at the facility. She has ensured all current providers have been educated by the Medical Director as of 6/29/23, and will ensure the new providers are communicated to the Medical Director for the need to education, tracked to completion, and maintain documentation of it onsite moving forward. The consultant pharmacist will be involved at admission and monthly thereafter to identify anti-seizure mediations and to determine if they are being monitored appropriately via the recommended labs. Education began for nursing staff to include licensed nurses and nursing assistants on 6/27/23 by the Director of Nursing (DON), regional director of clinical services, or a member of nursing administration. Education included Nursing policy 2303, Report of Consultation. Education included: The physician may order a consultation with another physician or healthcare provider Nurse (DON, supervisor, unit manager, charge nurse or designee) should review the report of consultation or physician progress notes as applicable. These reports are provided to center nursing staff by the contracted provider at the time of the consultation. The nurse will report findings to attending physician, Physician Assistant (PA) or Nurse Practitioner (NP). This will be reported verbally onsite or via phone call if the provider is not available onsite, at the time of the review, as indicated for order implementation, changes to current orders or rejection of orders if not approved by the provider. Implement orders as indicated and/or approved by the attending physician, PA or NP after review after review verbally. If the order was rejected, the nurse will communicate to the consulting entity and follow-up as needed with the provider. Any nursing staff member that did not receive education on 6/27/23 will receive education by the beginning of their next shift by the DON or designee. The Staff Development Coordinator will be responsible for tracking staff that still require education. Any staff that has not received education will not be allowed to work until education is received. All new hire licensed staff will be educated by the Staff Development Coordinator, DON or a member of nursing administration on this policy. This education will be added to the orientation process. Staff Development was notified of this responsibility on 6/27/23. All consultation visits and associated orders will be tracked by the DON or regional director of clinical services to ensure that the policy/process was followed as outlined above. All reports of consultation from the previous day and all new orders related to consultations will be brought to and tracked in the daily clinical meeting (M-F) and the weekend supervisor will review reports of consultation on Saturday/Sunday to ensure the process has been followed. This process will begin on 6/29/23. Date of immediate jeopardy removal is 7/3/23. Person responsible for implementation the plan is the Administrator. The facility's credible allegation of Immediate Jeopardy removal was validated on 7/5/23 and 7/6/23. The validation was evidenced by record reviews and interviews to verify all residents receiving anti-seizure medications (including valproic acid, carbamazepine, phenytoin, and levetiracetam) had lab work completed to ensure their blood levels of the medications were monitored appropriately. An interview with the facility's consultant pharmacist confirmed she would recommend newly admitted residents receiving such medications would have a baseline drug level obtained and the level monitored appropriately. Multiple interviews were conducted with licensed nurses to ensure the necessary in-service education was provided prior to working their shift. The nurses consistently reported they received in-service education, which included the process for reporting consultation findings to the facility's medical team (Medical NPs or MD) and verifying any new orders with one of these providers prior to initiating the orders. An interview conducted with the Psychiatric NP confirmed she was counseled on the need to complete a comprehensive medical review prior to recommending a change in medication. Interviews with the facility's medical team (Medical NPs and MD) indicated they would be responsible for reviewing and verifying all orders recommended by a consulting provider prior to the implementation of these orders. On 7/6/23 it was confirmed that Immediate Jeopardy was removed on 7/3/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff, Pharmacist, Nurse Practitioner, and Physician interviews the facility failed to provide effective monitoring of medication blood levels and manage dose changes for a seizure medication (valproic acid). On 5/10/23 Resident #10's valproic acid level was 108 (therapeutic level is 50-100 mcg/mL). The laboratory results were reported to the on-call provider who ordered a decrease in the daily dosage of Resident #10's valproic acid. No orders were entered into the resident's record that day for any repeat valproic acid level to be drawn. On 5/12/23 Resident #10's Physician electronically signed an order to repeat the valproic acid level on 5/15/23. This order was not received by the laboratory and remained active up until the resident's hospitalization on 6/19/23. On 6/15/23 Resident #10 was seen by the Psychiatric Nurse Practitioner (NP) related to behaviors. The Psychiatric NP noted incorrectly that Resident # 10's valproic acid was prescribed for mood stabilization and ordered a further reduction of the valproic acid daily dosage. No monitoring of the resident's valproic acid level was ordered at the time of the visit. The lab successfully drew a valproic acid level on 6/17/23, and the result revealed the level was subtherapeutic. The subtherapeutic level was not reported to the facility until 6/22/23, and there was no documentation in the record the facility tried to obtain the result prior to 6/22/23. On 6/19/23 Resident # 10 had a grand mal seizure (a seizure where there is loss of consciousness and violent muscle contractions), which was documented not to respond to intramuscular Ativan medication and lasted approximately 28 minutes before emergency medical services arrived for care and transport. Resident #10 was transported to the local hospital emergency department and intubated (a tube was inserted into the trachea for ventilation). Upon Emergency Department evaluation, Resident # 10's valproic acid level was 39, which was subtherapeutic. The Emergency Department physician determined Resident #10 required LTM EEG (long term electroencephalographic monitoring, which is the capability of recording electrical brain activity over long periods of time) and Resident #10 was transferred to the Intensive Care Unit at a larger hospital that same day. This was for 1 of 3 sampled residents reviewed for seizure medications (Resident #10). Immediate Jeopardy began on 5/15/23 when the facility did not obtain the physician ordered valproic acid level for Resident #10. The immediate jeopardy was removed on 7/03/23 when the facility provided and implemented an acceptable credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level of D to ensure monitoring of systems put into place are effective and to complete staff training. The findings included: Record review revealed Resident # 10 was initially admitted to the facility on [DATE]. The resident's diagnoses included in part traumatic brain injury and complex partial epilepsy (neurological disorder that causes seizures), depression, and anxiety. Resident #10's quarterly Minimum Data Set assessment, dated 3/16/23, coded the resident as severely cognitively impaired. He was also assessed to need total assistance with his activities of daily living, have no behaviors during the assessment period, and to have a seizure disorder. Record review revealed Resident # 10 received both lacosamide and valproic acid for seizures. The last order for lacosamide was dated 5/12/23 and directed that the resident receive 10 ml (milliliters) 10 mg (milligrams)/ml two times per day. This remained as an active order up until his date of discharge. From 5/2/23 until 5/10/23, Resident # 10 was ordered to receive 11 ml (250 mg/5ml) valproic acid three times per day. (This would equate to 550 mg three times per day). On 5/10/23 a valproic acid level was done and registered 108 mcg/mL. (A therapeutic medication level is when the blood level of the medication is in a range to be helpful but not dangerous. The facility's lab report noted therapeutic range for valproic acid to be 50 to 100 mcg/ml. A subtherapeutic level for valproic acid would be medication blood levels below 50 mcg/ml. A toxic level would indicate levels when serious adverse effects are brought about due to excessive medication in a person's system). On 5/10/23 at 2:38 PM Nurse # 2 noted in a nursing note that she had received a critical lab value regarding a valproic acid level of 108 and called it into Medical Nurse Practitioner (NP) # 1. On 5/10/23 a phone order was given by Medical NP # 1 to decrease the valproic acid dosage to 10 ml (250 mg/ 5 ml) three times per day. (This would equate to 500 mg three times per day.) This order stayed in effect until 6/15/23. The order specifically noted the valproic acid was for seizures. On 5/11/23 the Physician ordered Resident # 10's valproic acid level be rechecked on the date of 5/15/23. The order was electronically signed by the physician on 5/12/23. This order remained as an active order up until the resident's discharge date of 6/19/23 with no revision of the order. There was no valproic acid level drawn on 5/15/23 or a notation in the record why it was not done. On 5/27/23 the facility Pharmacy Consultant completed a Medication Regimen Review and noted she had no recommendations related to Resident # 10's medications. On 6/15/23 Resident # 10 was seen by the Psychiatric Nurse Practitioner (NP) related to behaviors. The Psychiatric NP noted that Resident # 10's valproic acid was prescribed for mood stabilization, and she was going to start a gradual dose reduction because his level had been high. On 6/15/23 Nurse # 5 entered the order from the Psychiatric NP into the computer for a lower dosage of the valproic acid. The order was for 5 ml (250 mg/ 5ml) three times per day. (This would equate to 250 mg three times per day.) The order was specifically written that the valproic acid was being used for behaviors. It did not mention that it was used for seizure control. On 6/15/23 Nurse # 5 noted in the record that she had informed Resident # 10's responsible party that the valproic acid dosage had been dropped from 10 ml to 5 ml in addition of increasing another medication for behaviors the resident had. Nurse # 5 noted this was done following a visit from the Psychiatric NP and the valproic acid was given for behaviors. There was no notation that the Medical Physician or Medical Nurse Practitioner were consulted. Nurse # 5 was interviewed on 6/23/23 at 12:30 PM and reported the following. She had entered the order written by the Psychiatric NP on 6/15/23 for the decrease in the valproic acid but did not talk to the Medical Physician or the Medical Nurse Practitioner. She thought the Psychiatric NP had talked to the Medical NP about the dose change. On 6/16/23 at 9:42 AM Nurse # 6 noted in a nursing noted the following. The phlebotomist said she was unable to draw the resident's lab due to the resident moving his arm. The phlebotomist recommended that the resident be given a medication to help him not move so the blood draw could be completed. Nurse # 6 further noted the Medical NP was made aware. According to a lab report, a valproic acid level was drawn on 6/17/23. On 6/19/23 at 12:48 PM Nurse # 4 noted in a nursing note that Resident # 10 had a grand mal seizure, facility staff and the Medical NP # 2 responded, the resident was given IM (intramuscular) Ativan without any positive results. Nurse # 4 further noted the seizure became more intense and EMS was called to transfer the resident to the hospital. On 6/19/23 Medical Nurse Practitioner # 2 entered a note in Resident # 10's record noting the resident's seizure had worsened although he had been given the Ativan. She noted he had seized for about 28 minutes when EMS arrived. According to hospital records Resident # 10 was evaluated in the emergency department on 6/19/23 and was intubated. The resident's valproic acid level was determined to be subtherapeutic at 39 and he was loaded (given an initial large dose of medication to obtain a quick response) with intravenous valproic acid. The Emergency Department physician also noted Resident # 10 had arrived in the Emergency Department in a postictal state (a period of recovery after a seizure) and within two hours started to have leftward eye deviation that was concerning for possible seizure activity. According to hospital records, the Emergency Department physician determined Resident #10 required a higher level of care. A larger hospital was contacted, and a transfer acceptance was obtained that same day (6/19/23) to their Intensive Care Unit for LTM EEG (long term electroencephalographic monitoring, which is the capability of recording electrical brain activity over long periods of time). Resident # 10 remained hospitalized as of 6/26/23. Following Resident # 10's discharge from the facility, the facility received from their lab the first valproic acid level that had been drawn since the order for the 5/15/23 level. The lab report showed the valproic acid level had been drawn on 6/17/23. The lab report noted it was received on 6/21/23 and reported to the facility on 6/22/23. The valproic acid level registered 21, which indicated the resident's level was subtherapeutic prior to his 6/19/23 seizure. The facility's Pharmacy Consultant was interviewed on 6/26/23 at 12:22 PM and reported the following. A therapeutic valproic acid level for seizure control would be 50 to 100. The lab had flagged the value of 108 on 5/10/23 because it was higher than the upper therapeutic range. Toxic levels would be considered 175 or greater. She had last reviewed Resident # 10's record on 5/26/23 and noted that his dosage had been changed following the lab value on 5/10/23. Resident # 10 had a history of his levels going up and down. It would have been her recommendation that no changes be made in the dosage until a repeat level be done given his history, but the dosage had already been changed before she did her review. According to the facility Pharmacy Consultant the facility had been doing monthly valproic acid levels and she thought that was appropriate, and therefore she did not have any recommendation on 5/26/23. She further reported the decreased daily dosage of valproic acid which had been ordered on 6/15/23 by the Psychiatric NP was historically a very low dose for Resident # 10, but she had not reviewed him again following 5/26/23 to have reported this. Medical Nurse Practitioner # 1 was interviewed on 6/26/23 at 4:10 PM and reported the following. She was the on- call provider when a facility nurse called her on 5/10/23 with the valproic acid level of 108 on 5/10/23. She had asked about any seizure activity the resident had, and the nurse had told her that he had none. She had decreased his dosage by 1 ml three times per day and she had instructed the nurse to have the level repeated in a month. It would have been the nurse's responsibility to have put the order in. No one had told her that his level had been going up and down. If this had been shared with her, then she would have instructed the facility nurse to consult with the regular provider the next day and let them decide. The facility's Psychiatric NP was interviewed on 6/23/23 at 1:25 PM and reported the following. She did not think Resident #10 was prescribed the valproic acid for seizure control. She thought it was only used for mood stabilization and behaviors. When she saw Resident # 10 on 6/15/23 she saw that his last valproic acid level had been critically high, and she ordered that the dosage be decreased. She had talked to the facility nurses about this but not with the Physician or the Medical NP. The Medical NP #2, who generally covered the facility's residents, was interviewed on 6/23/23 at 11:38 AM and reported the following. She was not aware of any changes to the order that had been given to draw Resident #10's valproic acid level on 5/15/23. She was also not aware Resident # 10's valproic acid dosage had been decreased on 6/15/23. On 6/19/23 after Resident # 10 had a seizure, she found the valproic acid dosage had been decreased. The Director of Nursing (DON) was interviewed on 6/23/23 at 11:00 AM and reported the following. She thought the ordered lab for valproic acid for 5/15/23 was an error in the electronic medical record system, and the order was supposed to have been drawn on 6/15/23. The DON reported it was her understanding that the lab had not obtained enough blood for the valproic acid on 6/15/23 but they had attempted to get it that day. They tried again on 6/16/23 and the resident was moving too much. The lab was obtained on 6/17/23. During a follow up interview with the DON on 6/23/23 at 1:40 PM, the DON reported the valproic acid was being used for seizure control and was also helping with some of the resident's behaviors. The facility's lab manager was interviewed on 6/23/23 at 3:35 PM and reported the following. On 6/15/23 there had been no order for a valproic acid level. The lab was trying to draw another unrelated lab which had had been ordered for Resident # 10. On 6/16/23 they had the first order from the facility to have a valproic acid level done. The lab tried to draw it on 6/16/23 along with the special-order lab, which they had been unsuccessful in obtaining the previous day. On 6/16/23 the resident moved too much, and they could not get the valproic acid lab or the specialty lab. On 6/17/23 they returned and drew both labs, the valproic acid lab and the specialty lab. They ran the valproic acid lab themselves that day (6/17/23) because it was a routine lab for them. They sent out the specialty lab to their cooperative lab they worked with. The results for the specialty lab usually took a few days to complete and both results (the valproic acid level and the specialty lab) were released to the facility on 6/22/23. The Chief Executive Officer for the facility's lab was interviewed on 6/23/23 at 4:12 PM and reported the following. They retained a scanned copy of requisitions from facilities. The first requisition for Resident # 10's valproic acid level, since the 5/10/23 level had been done was 6/16/23. It was drawn on 6/17/23 and the result was finalized on 6/17/23 at 2:15 PM that same day. They had sent the specialty lab that had been drawn along with the valproic acid level to their cooperating lab to run. Lab results automatically populate electronically when all results are completed from the lab into the facility's electronic medical record computer system. It had been several years since they had contracted to do lab services for the facility, and there had been management changes since procedures had been set up and discussed with staff. At the initiation of services, he generally went over with the facility how lab results would be delivered to them. It had been set up with the facility that labs would automatically populate to their electronic medical record. There was a way the facility staff could log directly into the lab's system and see a result, but the facility had not chosen to have access when things were set up with them. The resident's Physician, who also serves as the facility's Medical Director, was interviewed on 6/23/23 at 5:15 PM and reported the following. He felt the Nurse Practitioners could have collaborated better about the medication changes for Resident # 10. Resident # 10 had a history of having seizures regardless of seizure medications. The Physician reported that although Resident # 10 had a history of seizures while on medications, he could not say that the lower dose of valproic acid and subtherapeutic level did not contribute to his seizure on 6/19/23. The Administrator was interviewed on 6/23/23 at 6:00 PM with the Director of Nursing. According to the Administrator and the Director of Nursing, the facility had identified that Resident # 10's seizure medication dosage had been changed by the Psychiatric Nurse Practitioner without checking with the medical provider and they had initiated but not completed a plan of correction. The facility Administrator was informed of Immediate Jeopardy on 6/26/23 at 7:19 PM. The Administrator submitted the following Immediate Jeopardy removal plan. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. Resident #10 was ordered to receive two medications for seizure management, Lacosamide Oral Solution 10 MG/ML Give 10 ml by mouth two times a day and Valproic Acid Oral Solution 250 MG/5ML, Give 11 ml three times a day. On 5/10/23 a routine lab was drawn to measure the valproic acid level, an elevated level was determined high at 108, normal range 50-100 by the lab, and the high result was called from the lab to the center charge nurse. The charge reported it to the Medical NP who was not in the center, but on-call via phone at the time, who changed the dosage from 11mls three times a day to 10ml's three times day, diagnosis epilepsy. Upon further investigation, the medical NP who answered the call related to the critical lab stated she decreased the medication, but did not give follow-up lab orders. When asked why, she stated she would have left it to the provider onsite to determine the next lab date. On 6/15/23, the dosage was again decreased from Valproic Acid Oral Solution 250 MG/5ML, Give 10 ml three times a day to Valproic Acid Oral Solution 250 MG/5ML, Give 5 ml three times a day by the psychiatric NP, as part of a consult related to behaviors. The psychiatric NP failed to recognize the Valproic Acid was indicated for epilepsy, and failed to determine the current valproic acid level prior to decreasing the dosage given his history of epilepsy. An interview with the pharmacist revealed she would never have recommended an additional dosage change without a repeat level because Resident #10's levels tended to go up and down. However, this change was made without any level being checked. Upon investigation, the psychiatric NP stated she likely verbally ordered a Valproic Acid level on 6/15/23 for the next lab day, to monitor his levels, because that is her normal practice. This order was not entered into the electronic health record, but was entered in writing onto the lab requisition log. The facility lab called the center on 6/16/23 shortly after midnight to state an unrelated requisitioned lab for 6/15/23 needed to be repeated. The night shift nurse added the requisitioned lab for Valproic Acid (ordered on 6/15/23 for next lab day) to the carbon copy of the unrelated lab that was scheduled to be repeated on 6/16/23. The lab called the facility on 6/16/23, to let them know they would be unable to draw the lab, due to the behaviors of the resident and suggested that he needed Ativan prior to his labwork. This was discussed with the IDT, and it was determined that an alternative non-medicinal patient-center approach could be used to attempt the draw the lab the next lab day, on 6/17/23. The lab was successfully drawn on 6/17/23 and was sub-therapeutic at that time, but the facility did not receive the results until 6/22. The facility failed to follow procedures of critical importance, related to lab tracking, monitoring of serious medication for seizures at the time of dose changes, and timely follow up on lab results. The Valproic Acid was not monitored. The resident had a seizure, was hospitalized , and intubated in the interim on 6/19/23 and remains at the hospital at this time. The regional director of clinical services and/or DON will review all residents by 6/30/23 at the direction of the medical director/attending physician (the same individual) to assure the appropriate levels for anti-seizure medications are being monitored via lab including the mediations Valproic Acid (Depakote), Carbamazepine (Tegretol), Phenytoin (Dilantin), Levetiracetam (Keppra), to assure there are no medications not being monitored appropriately, no delayed lab results, and no failures of the provider or center to monitor other residents on these anti-seizure medications. As of 6/28/23, the Chief Nursing Officer, the Medical Director/attending physician, the consulting pharmacy group, and the DON met to determine, agree upon and implement the following process for all current residents that receive Valproic Acid (Depakote), Carbamazepine (Tegretol), Phenytoin (Dilantin), Levetiracetam (Keppra) and other seizure medications will have labs to monitor these drug levels All of those receiving these medications will be subject to the following: o Lab monitoring once every three months for two months. o Lab monitoring once every six months thereafter. o Baseline lab will occur for new admissions, then at the notated schedule above The consultant pharmacist will be involved at admission and monthly thereafter to identify anti-seizure medications and to determine if they are being monitored appropriately via the recommended labs at the recommended intervals noted above. The Chief Nursing Officer communicated with the pharmacy consultant about this expectation on 6/28/23. After the meeting of the Chief Nursing Officer, Medical Director/attending physician, consulting pharmacy group, and DON, the nurse administrative team will be educated by the DON or regional director of clinical services on this process by 6/30/23, to ensure all expected labs have been ordered on admission and ongoing. This will be tracked via the lab tracking policy outlined below, and monitored for implementation ongoing via the process outlined below in the daily clinical meeting. The Chief Nursing Officer communicated with the pharmacy consultant about this expectation on 6/28/23. 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 completed. The Psychiatric NP will be educated by the Medical Director on his expectations for comprehensive medical record review, specifically review for indications of use and diagnosis for anti-seizure medications and/or for gradual dose reductions for psychotropic medications which can also be used for seizures (ie. Valproic Acid) before making recommendations for changes. Any concerns on the medical impact, related and unrelated to mood and behavior, should be discussed and coordinated with the provider (attending physician and/or medical NP) before changes are recommended. Additionally, any medication such as Valproic Acid, which can also be indicated for mood stabilization should be reviewed closer to determine actual indication for usage, and to monitor lab values prior to recommending a decrease in dosage. This will be done by 6/28/23. The Medical Director is the attending physician for all residents at the facility. Moving forward and related to this event, he will educate any current advanced care practitioners (current NPs medical and other consulting NPs), any future attending physicians, advanced care practitioners and internal consulting entities on comprehensive medical review and interdisciplinary provider discussion when consulting providers desire to make changes, and/or when the Medical NP is making changes to an anti-seizure medication. The expectation is that levels will be drawn and a comprehensive review done before dosages are being changed for all providers involved. The center DON knows who all current providers are; she will be made aware by the Administrator and/or Medical Director when new providers and consultant providers begin practicing at the facility. She has ensured all current providers have been educated by the Medical Director as of 6/29/23, nd will ensure the new providers are communicated to the Medical Director for the need to education, tracked to completion, and maintain documentation of it onsite moving forward. Education began for nursing staff to include licensed nurses and nursing assistants on 6/27/23 by the Director of Nursing (DON) or designee. In the case of this deficient practice, the lab tracking process, from order/requisition to a timely final result was not in place and was in violation of our Laboratory Tracking Policy 1702. Education included the policy and protocols listed: -A licensed nurse will monitor and track all physician or physician extender ordered laboratory tests and will ensure that lab tests are drawn as ordered and communicate results to the physician in a timely manner. 1. The Center will obtain lab services to meet the needs of its patients. Education occurred to nurses, specifically related to the need for blood levels drawn for residents on seizure medications, such as Dilantin, Valproic Acid and Keppra. 2. Lab services will be provided only when ordered by the physician or physician extender and the physician or extender will be notified of lab results in a timely manner. 3. When an order for a lab test is received, for the current month, a licensed nurse receiving the order will complete a lab requisition form from the lab vendor. The information will include: a. patient name and room number. b. Test ordered. c. Date lab test is to be drawn. d. Medicare/Medicaid numbers. e. Other insurance information. f. Name of the physician ordering the test. g. date of birth . h. Diagnosis related to the test ordered. i. Any special instructions. 4. A licensed nurse receiving the order will document the information on the appropriate current month's lab tracking log located in the lab notebook. Routine labs will be recorded on the lab tracking log. The DON, Unit Manager or Nursing Administration monitors the lab tracking log, to assure from order, to requisition, to result, to communication to the provider is timely. The expectation is that all routine/normal labs should be back in 24 hours. Labs results not back in 24 hours should be reviewed and monitored for timeliness in the case that they are not expected to take more than 24 hours. 5. If the routine lab test order is not due in the current month, the licensed nurse will document the appropriate information onto the Lab Tracking Log indicating the type of lab test ordered and date to be completed. The 11-7 shift licensed nurse or supervisor will check the Lab Tracking Form and the Culture & Sensitivity Lab Tracking Form nightly for lab work to be drawn in the morning. The appropriate requisition will be pulled from the lab book (or completed if necessary) and placed in the Center designated location for the lab technician. 6. Upon completion of the lab draw, a licensed nurse will document the date the specimen was drawn on the appropriate Lab Tracking Log. If the lab is unable to be drawn, the information will be communicated to the attending physician, NP or PA for new orders, approval to move the lab or any follow-up as needed depending on the need of the resident. 7. Upon receipt of lab results, a licensed nurse will document the date the results were received on the appropriate Lab Tracking form. All routine lab results, such as Valproic acid, Dilantin and Keppra level should be back in 24 hours. All lab values that are not back in 24 hours where the expectation was 24 hours, should be investigated for timeliness, follow-up to the lab and report to physician for any further actions or orders needed. 8. Critical results will be called to the physician or extender and documented as indicated. The lab reports critical findings via phone to the charge nurse, and the charge nurse will report this verbally in person or via phone to the provider as soon as possible for follow-up, but not later than 9. Once the physician or extender has been notified of lab results, the nurse will document the date of notification and the method of notification in the appropriate space(s) on the appropriate Lab Tracking Log and place his/her initials in the nurse initial column on the form. 10. A licensed nurse will document any necessary information for follow up on the 24-hour shift report Any nursing staff member that did not receive education on 6/27/23 will receive education by the beginning of the next shift by the DON or designee. The Staff Development Coordinator will be responsible for tracking staff that still require education. Any staff that has not received education will not be allowed to work until education is received. All new hire licensed staff will be educated by the Staff Development Coordinator or designee on this policy. This education will be added to the orientation process. Staff Development was notified of this responsibility on 6/27/23. All lab orders will be tracked by the DON or designee to ensure that they are requisitioned, tracked for timely results, reviewed by the attending physician, NP or PA daily and follow-up as indicated. Each day (M-F) the lab tracking log along with the previous day's new lab orders will be brought to the clinical meeting by nursing administration from each unit to review for this process by the DON, and on Saturday/Sunday, the weekend supervisor will complete the same process for each unit. Date of immediate jeopardy removal is 7/3/23. Person responsible for implementation the plan is the Administrator The facility's credible allegation of Immediate Jeopardy removal was validated on 7/5/23 and 7/6/23. The validation was evidenced by record reviews and interviews to verify all residents receiving anti-seizure medications (including valproic acid, carbamazepine, phenytoin, and levetiracetam) had lab work completed to ensure their blood levels of the medications were monitored appropriately. An interview with the facility's consultant pharmacist confirmed she would recommend newly admitted residents receiving such medications would have a baseline drug level obtained and the level monitored appropriately thereafter. Multiple interviews were conducted with licensed nurses to ensure the necessary in-service education was provided prior to working their shift. The nurses consistently reported they received in-service education, which included the facility's procedures for tracking, monitoring, providing follow up, and communicating the results for all lab orders utilizing a lab tracking log (located in a lab notebook at the Nursing Station). An interview conducted with the Psychiatric NP confirmed she was counseled on the need to complete a comprehensive medical review prior to recommending a change in medication. Interviews with the facility's medical team (Medical NPs and MD) indicated they would be responsible for reviewing and verifying all orders recommended by a consulting provider prior to the implementation of these orders. The facility's Immediate Jeopardy removal date of 7/3/23 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of video surveillance footage and Emergency Medical Service (EMS) report and staff, paramedic and hospital staff interviews, the facility staff neglected to provide necessary services after a resident experienced an oxygen explosion and sustained second- and third-degree flame burns to both sides of his face, both ears, left chest, left upper arm, left forearm, and back of left hand. Resident #1 was unconscious and slumped over in his wheelchair when he was wheeled out of the facility. Facility staff moved by and stood adjacent to the resident and failed to position the resident to facilitate an open airway or render any assistance. When EMS arrived, Resident #1 remained slumped over in a wheelchair, unresponsive, and without a pulse or respirations. Resident #1 went into cardiac arrest twice before arriving at the hospital, required intubation, and became comatose due to his injuries. Resident #1 expired on [DATE]. This is evidenced for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #1). Immediate jeopardy began on [DATE] when the facility staff neglected to provide necessary services to Resident #1 after he sustained third degree burns to both sides of his face, both of his ears and second degrees burns on his left chest, upper left arm, left forearm, and back of left hand. He was wheeled out of the facility unconscious and slumped over in his wheelchair and facility staff moved by and stood adjacent to the resident with attempting to open his airway or render any assistance. Immediate jeopardy was removed on [DATE] when the facility provided an acceptable credible allegation for immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level of D (No actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure completion of education and monitoring systems put into place are effective. Findings included: Cross Refer to F684: Based on record review, review of video surveillance footage and Emergency Medical Service (EMS) report and staff, paramedic and hospital Attending Physicians/Nurse/Physician Assistant/receptionist interviews, the facility failed to identify the seriousness of 3rd degree facial burns when staff did not provide continuous monitoring of Resident #1's vital signs or assess the resident to determine the need for nursing or medical interventions until Emergency Medical Services arrived. Resident #1 sustained second and third degree burns to his face, both ears, left side of chest, left upper arm, left forearm, and back of left hand. Additionally, the low outdoor temperature on [DATE] was recorded as 29-degrees Fahrenheit, and Resident #1 was only wearing thin pajama pants and a short sleeve shirt while outside. Resident #1 was described by EMS records as being slouched/slumped over in his wheelchair when they arrived, and he was pulseless and not breathing. EMS personnel immediately began cardiopulmonary resuscitation (CPR) inside the ambulance. Resident #1 went into cardiac arrest, required intubation, and became comatose due to his injuries. This deficient practice occurred for 1 of 3 residents reviewed for supervision to prevent accidents. The Administrator was notified of immediate jeopardy on [DATE], at 10:50 AM. The facility provided the following credible allegation for immediate jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; and The facility failed to provide care and services to Resident #1 after he had sustained significant facial injuries, as well as 2nd and 3rd degree burns. Resident #1 was unresponsive and was wheeled outside slumped over in his wheelchair. No attempts were made to maintain an open airway or assess the resident for nursing or medical needs. On [DATE], shortly before 3AM, Resident #1 was noted in doorway of his room as the Night Shift Supervisor was coming down the hall. She could see that smoke was coming from the room. She began to call his name and as she approached him, she could see his hair was singed. As she got closer, she called his name, and he did not answer as his head was down. She pushed his head up and back and noted his face was melted off referring to his burned face. She immediately closed his door given the smoke detector was sounding and there was visible smoke, rescued him from danger to the nurses station, immediately pulled the fire alarm and called 911 for Emergency Medical Services (EMS) and Fire Rescue at 2:56am. While on the phone with 911, the Night Shift Supervisor assessed respirations and pulse and provided the information to dispatch as instructed. The 911 dispatcher asked her to get him to the front of the building to await pickup. The Night Shift Supervisor instructed the certified nurse aide (CNA) to take him to the front of the building to await EMS at the request of the 911 dispatch. In the meantime, the Night Shift Supervisor was asked to stay on the phone with the dispatcher. However, the nurse did not provide instruction to the certified nurse aide as to what to do for this resident; she didn't assess what the resident needed and failed to render emergency care to maintain Resident # 1's airway. During the wait for EMS to arrive, the CNA states she and other staff watched him, took his pulse, and she and other staff continued to speak to him and touch him to reassure him knowing he was unresponsive. His body was severely slumped over in the chair at his torso. The CNA notes on interview that she and other staff handed him off to EMS upon their arrival at 3:02am. They dismissed themselves when EMS took over. In review of this incident, the nurse and staff assigned to him after he left the unit failed to monitor and assess Resident #1 who had been through a traumatic event suffering multiple burns, did not assess him fully to know what nursing and medical needs he had, did not position the resident to promote breathing, did not cover the resident in 30 degree weather outside, and did not provide basic necessary services until EMS arrived. The nurse further sent him to the lobby with an unlicensed staff member who was unable to monitor him which was required per policy. All residents are at risk for neglect. 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 completed. Education began for nursing staff to include licensed nurses and nursing assistants on [DATE], by the DON or designee. Education included Nursing policy 1110-Emergecy First Aide, and other information noted below. Education included: Provision of emergency first aide as indicated by the situation to anyone in the center experiencing an accident or incident. A licensed nurse will assess injured persons, obtain vitals, monitor patient for changes. Obtain vital signs, pulse ox etc. as condition warrants. In the case of burn, protect airway, such as positioning, rescue breathing, CPR, emergency oxygen Providing emergency first aide for other accidents/incidents as needed-CPR, Rescue breathing, control bleeding, emergency oxygen, cleansing wounds/applying dressing, immobilizing fractures. Notification to physician/Next of Kin as soon as possible. Contacting EMS Assuring that licensed staff attend resident until EMS arrives, continue to monitor, assess and intervene as needed Completion of documentation related to the incident Education began for all staff on abuse and neglect began on [DATE] by staff development coordinator. Education included information regarding types of abuse and neglect as referenced in administrative policy 704. Any nursing staff member that did not receive education on [DATE] will receive education by the beginning of the next shift by the DON or designee. The Staff Development Coordinator will be responsible for tracking staff that still require education. Any staff that has not received education will not be allowed to work until education is received. All new hire licensed staff will be educated by the Staff Development Coordinator on this policy. This education will be added to the orientation process. Staff Development was notified of this responsibility on [DATE]. The DON or designee will verify the understanding of the education through oral discussion and feedback with all staff and notate this on a tracking tool. The SDC will also do this in orientation. Nursing staff will complete a post- test based on the education provided. Staff Development Coordinator is responsible for the post test and monitoring the post test results. The post test is initiated on [DATE]. Date of immediate jeopardy removal is [DATE] Person responsible for implementation the plan is the Administrator On [DATE], the facility's credible allegation for immediate jeopardy removal was validated by record review of the in-services and sign in sheet which discussed the Nursing Policy - 1110 Emergency First Aid, first aid, and abuse/neglect; multiple staff interviews which indicated education was provided by the Director of Nursing which discussed accidents/incidents (including in case of burns), assessments, notification of physician, cardiopulmonary resuscitation (CPR), emergency oxygen, and effective communication; and an interview with the Administrator which indicated the Director of Nursing and Staff Development Coordinator provided mandatory education for all nursing staff. The immediate jeopardy removal date of [DATE] was confirmed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of video surveillance footage and Emergency Medical Service (EMS) report and staff, paramedic and hospital staff interviews, the facility failed to identify the seriousness of 3rd degree facial burns when staff did not provide continuous monitoring of Resident #1's vital signs or assess the resident to determine the need for nursing or medical interventions until EMS arrived. Resident #1 sustained second- and third-degree flame burns to both sides of his face, both ears, left chest, left upper arm, left forearm, and back of left hand. Additionally, the low outdoor temperature on [DATE] was recorded as 29-degrees Fahrenheit, and Resident #1 was only wearing thin pajama pants and a short sleeve shirt while outside. Resident #1 was described by EMS records as being slouched/slumped over in his wheelchair when they arrived, and he was pulseless and not breathing. EMS personnel immediately began cardiopulmonary resuscitation (CPR) once inside the ambulance. Resident #1 went into cardiac arrest twice, required intubation, and became comatose due to his injuries. Resident #1 expired on [DATE]. This deficient practice occurred for 1 of 3 residents reviewed for supervision to prevent accidents. Immediate jeopardy began on [DATE] when the facility failed to provide continuous monitoring by staff or assess the resident to determine the need for nursing or medical interventions until Emergency Medical Services arrived. Immediate jeopardy was removed on [DATE] when the facility provided an acceptable credible allegation for immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level of D (No actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure completion of education and monitoring systems put into place are effective. The findings included: Resident #1 was admitted to the facility on [DATE] with multiple diagnoses which included Chronic Obstructive Pulmonary Disease, respiratory failure, peripheral vascular disease, heart failure, and tobacco use. A physician's order dated [DATE] indicated Resident #1 was to receive oxygen at 4 liters per minute via nasal cannula every day and night shift. The admission nursing assessment dated [DATE] revealed Resident #1 was cognitively intact and required supervision with chair/bed-to-transfers. Resident #1 was designated to be a Full Code. There was no documentation of vital signs recorded in Resident #1's electronic medical chart for [DATE]. The nursing note written by the Night Shift Supervisor in the electronic medical record of Resident #1 dated [DATE] at 3:15 AM stated, Resident found unresponsive and breathing in front of room door in W/C [wheelchair] with burns to face and hair. Transferred to nurses' station and called 911. Instructed by 911 to bring resident to front of building by EMS and transferred care to EMS. An interview was conducted with the Night Shift Supervisor on [DATE] at 10:30 AM. Night Shift Supervisor stated at about 3:00 AM on [DATE] she was sitting at the nurses' station when she heard an annoying beeping sound, which she later discovered it was the room's smoke detector going off. She got up to investigate the noise. As she walked down the hall, she saw and smelled gray smoke coming from Resident #1's room. She yelled I know you're not smoking! to Resident #1. When she reached Resident #1, she saw him in the doorway of his room, sitting upright, with his head down. She lifted his head and noticed Resident #1's face and hair severely burned, he was breathing, and unresponsive. She described his facial burns as it was like his face melted off. She immediately brought Resident #1 into the hallway via his wheelchair and closed the door. She pushed him to the nurses' station, pulled the fire alarm, and called 911. She stated she was instructed by 911 to escort Resident #1 to the front of the building and to stay on the phone. She instructed Nursing Assistant #1 (NA) to push Resident #1 to the front of the building. She stated she had checked Resident #1 for a pulse and respirations but could not remember the rate. She stated his pulse was strong, and his breathing was normal. She stated she did not indicate to other staff to stay with Resident #1 because she was worried about evacuating the other residents. A review of the video surveillance footage on [DATE] revealed Resident #1 was being assisted outside by three staff members. Resident #1 was in a wheelchair, slouched, with his chest to his knees, and arms dangling off the sides of the wheelchair, limp, with no movement. Once outside, two of the staff members stepped away. One staff member remained behind Resident #1. One staff member who stepped to the side, returned to Resident #1. She crouched down, looked at Resident #1's face, stood up, and intermittently touched him. Four additional staff members exited the building and walked past Resident #1. Resident #1 remained sitting in the wheelchair, slouched, with his chest to his knees, and arms dangling off the sides of the wheelchair, limp, with no movement until EMS arrived. He did not have a blanket or jacket to provide protection from the 29-degree Fahrenheit temperature. According to www.accuweather.com, the low temperature was 29-degrees Fahrenheit on [DATE] in [NAME]. An interview with NA #1 on [DATE] at 3:36 PM revealed she was not assigned to work with Resident #1 on [DATE]. She responded to the fire alarm sound and when she arrived at the nurses' station, she was instructed by the Night Shift Supervisor to bring Resident #1 to the outside front of the building. She indicated she saw Resident #1's injuries and described them as his skin was peeled off his face and his hair was burned on the side. She indicated she was not given other instructions from the Night Shift Supervisor regarding providing aid to Resident #1. She further stated she could not remember if she provided Resident #1 with a covering to protect him from the 29-degree Fahrenheit temperature. Nurse #1 was interviewed on [DATE] at 2:58 PM. She indicated she was assigned to work with Resident #1 on [DATE] and knew Resident #1 was dependent on oxygen. She indicated she was not on the floor when the incident occurred. She went to the front of the building because she was notified by other staff members Resident #1 had burned himself while smoking a cigarette. When she had arrived at the front of the building, EMS had already arrived. She indicated when she saw Resident #1, his head was down, and he was unresponsive. She did not assess Resident #1 because EMS had already arrived. Later in the interview, she stated the first time she checked Resident #1 for a pulse and respirations was when he was outside front of the building. She took his pulse and respirations manually and noted his breathing was shallow and his pulse was strong and within normal range. She stated she could not remember the pulse or respiration rates. She indicated she was not provided any instructions regarding providing aid to Resident #1 and did not indicate why she had not stayed with Resident #1. NA #3 was interviewed on [DATE] at 10:25 AM. She indicated she was assigned to work with Resident #1 on [DATE], was familiar with his care needs, and knew he was oxygen dependent. She stated she had checked 10 to 15 minutes prior to the incident. She indicated she was outside of the building and was not on the floor when the incident occurred. The first time she saw Resident #1 after the incident was when he was outside on the stretcher with EMS. Documentation of the Emergency Medical Services (EMS) report dated [DATE] revealed at 3:01 AM, EMS arrived on scene. Resident #1 was sitting in a wheelchair outside of the front door of the facility. Resident #1 was noted to be slouched/slumped over in the wheelchair. Staff was immediately asked if the resident was breathing and if the resident had a pulse. The nursing staff responded, he's unconscious. EMS personnel, again, asked if the resident was breathing and if he had a pulse, to which the nursing staff did not check the patient. EMS noted all nursing staff had no hands on the resident, the resident was not being assessed, nor was treatment administered by nursing staff prior to EMS arrival. EMS personnel quickly assessed the resident. The resident was found to not be breathing or have a pulse. EMS personnel asked the nursing staff about Resident #1's information and paperwork, and the staff responded with we don't know anything about the patient, and there is a fire, so we can not [sic] get you that information. It was noted that nursing staff continued to enter and exit the front doors of the facility. An interview was conducted with the responding Paramedic on [DATE] at 12:29 PM. The Paramedic stated when he arrived, he saw Resident #1 slumped over in a wheelchair outside in front of the facility. Resident #1 did not look like he was breathing. There were staff members around Resident #1; however, no staff member hand their hands on Resident #1. He stated staff members were either on their phones or walking around. He further indicated staff members could not report if Resident #1 was breathing or had a pulse. He also stated facility staff was not able to provide him Resident #1's name, date of birth , or medical conditions. When he assessed Resident #1 it was determined Resident #1 did not have a pulse or respirations. Resident #1 was assessed to the stretcher via 2-person manual lift and cardiopulmonary resuscitation (CPR) was started in the ambulance. The emergency room hospital records indicated presented to the hospital with partial-thickness burns covering Resident #1's face and neck as well as clavicle and shoulder, approximately 10% of body surface area, and soot in the nostrils. The emergency room physician noted EMS reported Resident #1 was sitting in wheelchair with oxygen on via nasal cannula when he subsequently lit a cigarette that exploded in his face causing severe burns to the face, neck, shoulders, and clavicle. Resident #1 was noted to be unresponsive, without a pulse so CPR was initiated by EMS. CPR was performed for 30 minutes then his pulse and blood pressure returned. Resident #1 went into cardiac arrest again for several minutes and was intubated after his pulse and blood pressure returned for the second time. Due to his significant burns, the hospital initiated transfer to a local burn unit. A review of the Burn Attending Intensive Care Unit (ICU) hospital note dated [DATE] revealed Resident #1 was critically ill and sustained second- and third-degree flame burns to both sides of his face, both ears, left chest, left upper arm, left forearm, and back of left hand to 5.5% of his body. It was noted that he also went into cardiac arrest twice as well has having acute respiratory failure secondary to pulmonary edema (excess fluid in the lungs) and aspiration. An interview with the ICU Nurse #1 was conducted on [DATE] at 3:02 PM. She indicated Resident #1 was comatose, intubated, unable to speak, and had an anoxic brain injury (a brain injury caused by a complete lack of oxygen to the brain). Resident #1's code status was switched from Full Code to Do Not Resuscitate (DNR). The ICU Physician Assistant was interviewed on [DATE] at 12:32 PM. She indicated it was reported to her that Resident #1 was smoking at the facility and caught fire. He was found to be unresponsive and remained unresponsive since admission to the ICU burn unit. She stated his injuries were consistent with smoking while on oxygen. The ICU Attending Physician was interviewed on [DATE] at 9:39 AM via phone revealed at the time of the call, Resident #1 had an anoxic brain injury (brain injury which occurs due to lack of oxygen to the brain) and had a poor prognosis. He was intubated, in critical condition, and unresponsive. She indicated she did not expect a full recovery and a palliative care consult would be placed due to Resident #1's poor prognosis. An interview with ICU Nurse #2 was conducted on [DATE] at 3:51 PM. She indicated Resident #1 remained in critical condition. Resident #1 was placed on comfort care with no aggressive treatment. He was not expected to recover, and death was imminent. On [DATE] at 12:34 PM the ICU Receptionist was interviewed. She indicated Resident #1 died on [DATE] at 5:15 PM. The Director of Nursing (DON) was interviewed on [DATE] at 1:57 PM. She stated she received a call from a staff member around 3:00 AM on [DATE] notifying her of Resident #1 sustaining injuries from lighting a cigarette while on oxygen. She indicated she did not see Resident #1 when she arrived at the facility as he had already been taken by ambulance; therefore, she was unable to assess Resident #1. She indicated she felt the staff responded appropriately to the emergency. The Administrator was notified of immediate jeopardy on [DATE], at 7:35 PM. The facility provided the following credible allegation for immediate jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; and On [DATE], shortly before 3AM, Resident #1 was noted in doorway of his room as the Night Shift Supervisor was coming down the hall. She could see that smoke was coming from the room. She began to call his name and as she approached him, she could see his hair was singed. As she got closer, she called his name, and he did not answer as his head was down. She pushed his head up and back and noted his face was melted off referring to his burned face. She immediately closed his door given the smoke detector was sounding and there was visible smoke, rescued him from danger to the nurses station, immediately pulled the fire alarm and called 911 for Emergency Medical Services (EMS) and Fire Rescue at 2:56am. While on the phone with 911, the Night Shift Supervisor assessed respirations and pulse and provided the information to dispatch as instructed. The 911 dispatcher asked her to get him to the front of the building to await pickup. The Night Shift Supervisor instructed the certified nurse aide (CNA) to take him to the front of the building to await EMS at the request of the 911 dispatch. In the meantime, the Night Shift Supervisor was asked to stay on the phone with the dispatcher. However, the nurse did not provide instruction to the certified nurse aide as to what to do for this resident; she didn't assess what the resident needed and failed to render emergency care to maintain Resident # 1's airway. During the wait for EMS to arrive, the CNA states she and other staff watched him, took his pulse, and she and other staff continued to speak to him and touch him to reassure him knowing he was unresponsive. His body was severely slumped over in the chair at his torso. The CNA notes on interview that she and other staff handed him off to EMS upon their arrival at 3:02am. They dismissed themselves when EMS took over. In review of this incident, the nurse and staff assigned to him after he left the unit failed to monitor and assess Resident #1 who had been through a traumatic event suffering multiple burns, did not assess him fully to know what nursing and medical needs he had, did not position the resident to promote breathing, did not cover the resident in 30 degree weather outside, and did not provide basic necessary services until EMS arrived. The nurse further sent him to the lobby with an unlicensed staff member who was unable to monitor him which was required per policy. 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 completed. Education began for nursing staff to include licensed nurses and nursing assistants on [DATE], by the DON or designee. Education included Nursing policy 1110-Emergency First Aide, and other information noted below. Education included: o Provision of emergency first aide as indicated by the situation to anyone in the center experiencing an accident or incident. o A licensed nurse will assess injured persons, obtain vitals, monitor patient for changes. Obtain vital signs, pulse ox etc. as condition warrants. o In the case of burn, protect airway, such as positioning, rescue breathing, CPR, emergency oxygen o Providing emergency first aide for other accidents/incidents as needed-CPR, Rescue breathing, control bleeding, emergency oxygen, cleansing wounds/applying dressing, immobilizing fractures. o Notification to physician/Next of Kin as soon as possible. o Contacting EMS o Assuring that licensed staff attend resident until EMS arrives, continue to monitor, assess and intervene as needed o Completion of documentation related to the incident Any nursing staff member that did not receive education on [DATE] will receive education by the beginning of the next shift by the DON or designee. The Staff Development Coordinator will be responsible for tracking staff that still require education. Any staff that has not received education will not be allowed to work until education is received. All new hire licensed staff will be educated by the Staff Development Coordinator on this policy. This education will be added to the orientation process. Staff Development was notified of this responsibility on [DATE]. The DON or designee will verify the understanding of the education through oral discussion and feedback with all staff and notate this on a tracking tool. The SDC will also do this in orientation. Nursing staff will complete a post- test based on the education provided. Staff Development Coordinator is responsible for the post test and monitoring the post test results. The post test is initiated on [DATE]. Date of immediate jeopardy removal is [DATE] Person responsible for implementation the plan is the Administrator On [DATE], the facility's credible allegation for immediate jeopardy removal was validated by record review of in-services; multiple interviews with facility staff revealed they received education on the facility's Nursing Policy - 1110 Emergency First Aid and education on situation of accidents including the case of burns, assessment, notification, and effective communication; and interview with the Administrator affirming the education was provided by the Director of Nursing and Staff Development Coordinator. Immediate jeopardy was removed on [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, fire department report review, Emergency Medical Services report review, and staff, facility's contracted transportation driver, facility's contracted transportation company's owner, fire department Captain, hospital staff, and Paramedic interviews, the contracted facility transportation company failed to notify the facility Resident #1 was observed to be smoking with an oxygen tank on his wheelchair, was in possession of cigarettes, a lighter, and repeatedly asked the driver to stop for cigarettes and coffee while en route to a physician's appointment. On [DATE] Resident #1 lit a cigarette in his room with oxygen in use and sustained second- and third-degree flame burns to both sides of his face, both ears, left chest, left upper arm, left forearm, and back of left hand. EMS personnel immediately began cardiopulmonary resuscitation (CPR) once inside the ambulance. He went into cardiac arrest twice, was intubated, and became comatose. Resident #1 expired on [DATE]. This is evidenced for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #1). In addition, the facility continued to assess a resident as safe to smoke without supervision after he was non-compliant with the facility's smoking policy for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #2). Immediate jeopardy began on [DATE] when the contracted facility transportation company failed to notify the facility Resident #1 was smoking with an oxygen tank on the back of his wheelchair, was in possession of cigarettes, a lighter, and was repeatedly asking the driver to stop for coffee and cigarettes while en route to a physician's appointment. Immediate jeopardy was removed on [DATE] when the facility provided an acceptable credible allegation for immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level of D (No actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure completion of education and monitoring systems put into place are effective. Example #2 for Resident #2 was cited at a scope and severity of D. The findings included: 1. The hospital Discharge summary dated [DATE] revealed Resident #1 is to place one 21 milligram (mg) Nicotine patch on the skin daily (reason unspecified) as well as to utilize oxygen at 4 liters continuously was also ordered (reason unspecified). Resident #1 was admitted to the facility on [DATE] with multiple diagnoses which included Chronic Obstructive Pulmonary Disease, respiratory failure, peripheral vascular disease, heart failure, and tobacco use. Resident #1 was admitted to and remained in a private room. A physician's order dated [DATE] revealed Resident #1 to utilize oxygen at 4 liters per minute via nasal cannula every day and night shift. A physician's order dated [DATE] staff is to pipe oxygen into Resident #1's BiPAP machine (a device that helps with breathing which pushes air into the lungs) every night shift and as needed for low oxygen saturation levels and shortness of breath. A physician's order dated [DATE] stated apply one 24-hour 21 milligrams Nicotine patch transdermal (on the skin) one time a day for nicotine cessation for 6 weeks and remove per schedule. A physician's order dated [DATE] stated apply one 24- hour 14 milligrams Nicotine patch transdermal (on the skin) one time a day for smoking cessation for 2 weeks and remove per schedule. A physician's order dated [DATE] stated apply one 24-hour 7 milligrams Nicotine patch transdermal (on the skin) one time a day for smoking cessation for 2 weeks and remove per schedule. The admission nursing assessment dated [DATE] revealed Resident #1 was cognitively intact and required supervision with chair/bed-to-transfers. The Smoking Safety Screen dated [DATE] completed by the Unit Manager revealed Resident #1 did not smoke. A nursing note written by the Unit Manager on [DATE] at 4:10 PM stated Resident stated that he has not had a cigarette in 2 months and did not have the urge to smoke. Writer made resident aware that he will be on nicotine patches. Resident #1's care plan dated [DATE] indicated Resident #1 is at risk for respiratory complications due to Chronic Obstructive Pulmonary Disease, respiratory failure, supplementary oxygen requirement and Bilevel Positive Airway Pressure machine (a machine used to help push air into lungs and opens airway). The goal was for Resident #1 to be free from respiratory complications through the review period. Interventions included: administer medications as ordered; administer nebulizer treatments as ordered; administer oxygen as ordered; BiPAP as ordered; observe for signs and symptoms of respiratory complications; and vitals as needed. The Unit Manager was interviewed on [DATE] at 12:30 PM. She indicated she completed Resident #1's admission on [DATE] and was familiar with him. Resident #1 was admitted directly from the hospital. Resident #1 was cognitively intact during her assessment. She completed the Smoking Safety Screen and indicated Resident #1 does not smoke. She stated Resident #1 indicated he did not want to smoke and had no desire to smoke while at the facility. She reviewed the facility's smoking policy and Resident #1 voiced understanding. While completing his admission, she did not notice any smoking materials in Resident #1's possessions. She did not recall Resident #1 ever having friends or family visit him while at the facility. She indicated she was aware of the facility's smoking policy that all smoking materials are to be kept at the nurses' station until ready to be used and smoking materials should not be kept in resident's rooms. An interview with the facility's contracted transportation driver on [DATE] at 4:43 PM revealed he picked Resident #1 up in the morning on [DATE] to transport him to a physician's appointment. Resident #1 frequently asked for the driver to stop at a store to purchase coffee and cigarettes while he was transporting Resident #1 to his physician's appointment. He told Resident #1 he could not stop and proceeded to drive to the physician's office. He stated when picking up Resident #1 after his physician's appointment, Resident #1 was outside of the physician's office, on an elevator lift, and smoking a cigarette with an oxygen tank on the back of his wheelchair. He told Resident #1 he could not smoke while on oxygen or while in the transportation van. He requested Resident #1 to put the cigarette out. Resident #1 agreed to stop smoking and threw the cigarette off the side of the elevator lift (The lift is a platform that is used to raise clients in wheelchairs to the level of the parking lot). On the way back to the facility, Resident #1 only asked to stop for a cup of coffee. He reminded Resident #1 that he could not make any additional stops. He stated he reported his observations to the owner of the facility's contracted transportation company. During a follow up interview on [DATE] at 1:21 PM the facility's contracted transportation driver reiterated Resident #1 was on the outside elevator lift when he arrived. Resident #1 had a lit cigarette in his hand. The cigarette was about half-way gone. He told Resident #1 that he could not smoke in the van or while on oxygen. Resident #1 agreed and put the cigarette out by throwing it over the side of the elevator lift. An additional interview with facility's contracted transportation driver was conducted on [DATE] at 9:24 AM. He, again, stated when he arrived to pick Resident #1 from his physician's appointment Resident #1 was smoking a lit cigarette with an oxygen tank on the back of his wheelchair. Resident #1 had a package of cigarettes and a lighter in his hands. He told Resident #1 that he could not smoke with oxygen on or smoke in the transportation van. He stated Resident #1 voiced understanding and put the cigarette out. On [DATE] at 11:34 AM with the owner of the facility's contracted transportation company revealed the driver did not notify him of his observations of Resident #1 smoking or asking for cigarettes until after the nursing home facility started their investigation on [DATE]. He stated if the driver had notified him of the observations, he would have notified the facility. An interview with the Scheduler at the physician's office was conducted on [DATE] at 2:15 PM. She stated Resident #1 sat in the lobby until transportation came. She assisted Resident #1 on the outside elevator then the transportation driver helped him onto the transportation van. She stated she could not recall Resident #1 having a cigarette or lighter visible when she assisted Resident #1 outside. The nursing note written by the Night Shift Supervisor in the electronic medical record of Resident #1 dated [DATE] at 3:15 AM stated, Resident found unresponsive and breathing in front of room door in W/C [wheelchair] with burns to face and hair. Transferred to nurses' station and called 911. Instructed by 911 to bring resident to front of building by EMS and transferred care to EMS. An interview was conducted with the Night Shift Supervisor on [DATE] at 10:30 AM. Night Shift Supervisor stated at about 3:00 AM on [DATE] she was sitting at the nurses' station when she heard an annoying beeping sound, which she later discovered was from the room's smoke detector. She got up to investigate the noise. As she walked down the hall, she saw and smelled gray smoke coming from Resident #1's room. She yelled I know you're not smoking! to Resident #1. When she reached Resident #1, she saw him in the doorway of his room, sitting upright, with his head down. She lifted his head and noticed Resident #1's face and hair severely burned, he was breathing, and unresponsive. She described his facial burns as it was like his face melted off. She immediately brought Resident #1 into the hallway via his wheelchair and closed the door. She pushed him to the nurses' station, pulled the fire alarm, and called 911. She stated she was instructed to escort Resident #1 to the front of the building and to stay on the phone. She indicated she did not know Resident #1 smoked. She stated she never saw smoking materials in his room and Resident #1 never asked about smoking. Additional interview with the Night Shift Supervisor was conducted on [DATE] at 10:44 AM. Resident #1 was not on fire and there was not a fire actively burning. She stated Resident #1 was wearing clothes when the incident had started, and a gray burned shirt was found on the floor. When she approached Resident #1, she could smell burned flesh and hair. His long hair and long beard were burned unevenly including all the way up to one of his ears. She could not remember which ear was burned. An interview with NA #1 on [DATE] at 3:36 PM revealed she was not assigned to work with Resident #1 on [DATE]. She further indicated she was not familiar with Resident #1 and had never worked with him. She was responding to the fire alarm when she was instructed by the Night Shift Supervisor to take Resident #1 to the front. Documentation of the Emergency Medical Services (EMS) report dated [DATE] revealed at 3:01 AM, EMS arrived on scene. Resident #1 was sitting in a wheelchair outside of the front door of the facility. Resident #1 was noted to be slouched/slumped over in the wheelchair. Staff was immediately asked if the resident was breathing and if the resident had a pulse. The nursing staff responded, he's unconscious. EMS personnel, again, asked if the resident was breathing and if he had a pulse, to which the nursing staff did not check the patient. It was noted that all nursing staff had no hands on the resident, the resident was not being assessed, nor was treatment administered by nursing staff prior to EMS arrival. EMS personnel quickly assessed the resident. The resident was found to not be breathing or have a pulse. EMS personnel asked the nursing staff about Resident #1's information and paperwork, and the staff responded with we don't know anything about the patient, and there is a fire, so we can not [sic] get you that information. It was noted that nursing staff continued to enter and exit the front doors of the facility. An interview was conducted with the responding paramedic on [DATE] at 12:29 PM. The Paramedic stated when he arrived, he saw Resident #1 slumped over in a wheelchair outside front of the facility building. Resident #1 did not look like he was breathing. There were staff members around Resident #1; however, no staff member hand their hands on Resident #1. He stated staff members were either on their phones or walking around. He further indicated staff members could not report if Resident #1 was breathing or had a pulse. He also stated facility staff was not able to provide him Resident #1's name, date of birth , or medical conditions. When he assessed Resident #1 it was determined Resident #1 did not have a pulse or respirations. Resident #1 was assessed to the stretcher via 2-person manual lift and cardiopulmonary resuscitation (CPR) was started in the ambulance. He further indicated Resident #1's eyes were swollen and not opened as well has had third degree burns on face and charring on his nose. Documentation of the Fire Department report dated [DATE] revealed at 3:03 AM the fire department arrived on scene. The location of the incident was Resident #1's room. Upon arrival to the room, they found the door was shut and inside of the room was light to moderate smoke and found no fire. After gathering information from the facility staff and investigating, it was determined the incident occurred due to Resident #1 was attempting to smoke a cigarette while on oxygen. The factor which contributed to ignition was misuse of material. An interview was conducted with the responding Fire Department Captain on [DATE] at 10:42 AM. He stated EMS was on scene upon his arrival and was attending to Resident #1. When he investigated the fire, the room was filled with residual smoke as well as powder from a fire extinguisher. He noticed a gray shirt on the floor with burns. He further indicated there was melted oxygen tubing located on the floor as well. He stated it was determined Resident #1 had a history of smoking and was attempting to smoke while on oxygen. The emergency room hospital records dated [DATE] indicated Resident #1 presented to the hospital with partial-thickness burns covering Resident #1's face and neck as well as clavicle and shoulder, approximately 10% of body surface area, and soot in the nostrils. The emergency room physician noted EMS reported Resident #1 was sitting in wheelchair with oxygen on via nasal cannula when he subsequently lit a cigarette that exploded in his face causing severe burns to the face, neck, shoulders, and clavicle. Resident #1 was noted to be unresponsive, without a pulse so CPR was initiated by EMS. CPR was performed for 30 minutes then his pulse and blood pressure returned. Resident #1 went into cardiac arrest again for several minutes and was intubated after his pulse and blood pressure returned for the second time. Due to his significant burns, the hospital initiated a transfer to a local burn unit. A review of the Burn Attending Intensive Care Unit (ICU) hospital note dated [DATE] revealed Resident #1 was critically ill and sustained second- and third-degree flame burns to both sides of his face, both ears, left chest, left upper arm, left forearm, and back of left hand to 5.5% of his body. It was noted that he also went into cardiac arrest twice as well has having acute respiratory failure secondary to pulmonary edema (excess fluid in the lungs) and aspiration. An interview with ICU Nurse #1 was conducted on [DATE] at 3:02 PM. She indicated Resident #1 was comatose, intubated, unable to speak, and had an anoxic brain injury (a brain injury caused by a complete lack of oxygen to the brain). Resident #1's code status was switched from Full Code to Do Not Resuscitate (DNR). The ICU Physician Assistant was interviewed on [DATE] at 12:32 PM. She indicated it was reported to her that Resident #1 was smoking at the facility and caught fire. He was found to be unresponsive and remained unresponsive since admission to the ICU burn unit. She stated his injuries were consistent with smoking while on oxygen. The ICU Attending Physician was interviewed on [DATE] at 9:39 AM via phone revealed at the time of the call, Resident #1 had an anoxic brain injury (brain injury which occurs due to lack of oxygen to the brain) and had a poor prognosis. He was intubated, in critical condition, and unresponsive. She indicated she did not expect a full recovery and a palliative care consult would be placed due to Resident #1's poor prognosis. An interview with ICU Nurse #2 was conducted on [DATE] at 3:51 PM. She indicated Resident #1 remained in critical condition. Resident #1 was placed on comfort care with no aggressive treatment. He was not expected to recover, and death was imminent. On [DATE] at 12:34 PM the ICU Receptionist was interviewed. She indicated Resident #1 died on [DATE] at 5:15 PM. An observation of Resident #1's room on [DATE] at 9:30 AM revealed 5 permanent dark brown burn marks on the linoleum tile floor on the left side of the bed, which was located near the window. One burn mark was approximately 5 (inches) x 2; one was approximately 4 x 3, one was approximately 4 x 2, and two were approximately 1 x 1. The areas felt rough to the touch. NA #2 was interviewed on [DATE] at 10:25 AM. She indicated she was assigned to work with Resident #1 on [DATE], was familiar with his care needs, and knew he was oxygen dependent. She stated she did not know Resident #1 smoked. He never asked for cigarettes, lighters, matches, or to go outside to smoke. She stated she had checked 10 to 15 minutes prior to the incident and did not notice anything abnormal. An interview with NA #3 on [DATE] at 11:40 AM revealed she had only worked with Resident #1 one time. While working with Resident #1, she never saw cigarettes or lighters in his room or in his possession. She further stated Resident #1 never asked her about smoking. An interview with Housekeeper #1 on [DATE] at 1:11 PM revealed she frequently cleaned Resident #1's room. She stated she did not know Resident #1 smoked. She never saw smoking materials in his room, and he never asked her about smoking while she cleaned his room. The Social Worker was interviewed on [DATE] at 2:15 PM. He stated he was familiar with Resident #1. He introduced himself to Resident #1 a week before the incident. He asked Resident #1 if he was a smoker, and Resident #1 denied being a smoker. He stated Resident #1 knew about the smoking policy. He further provided education to Resident #1 regarding oxygen safety which included safe mobility in the room while wearing oxygen and smoking while on oxygen. This education is provided to all residents who utilize oxygen. The Director of Nursing (DON) was interviewed on [DATE] at 1:57 PM. She stated she received a call from a staff member around 3:00 AM on [DATE] notifying her of Resident #1 sustaining injuries from lighting a cigarette while on oxygen. She indicated she did not see Resident #1 when she arrived at the facility as he had already been taken by ambulance; therefore, she was unable to assess Resident #1. She indicated she felt the staff responded appropriately to the emergency. When she investigated the room, she noticed a gray burned shirt on the floor as well as 5 burned marks on linoleum tile flooring. Additionally, she saw approximately 6 to 10 feet of melted oxygen tubing. There was a lighter located under the window's Packaged Terminal Air Conditioner (PTAC) unit and a package of cigarettes hidden in an animal cracker package with one cigarette missing. She threw the gray shirt away as well as the oxygen tubing. She did not indicate why she had thrown these items away. She stated the Smoking Safety Screens were completed at admission, quarterly, and whenever a residents changed their mind about smoking. She indicated the charge nurse or the unit manager completes the Smoking Safety Screen. The Unit Manager completed Resident #1's Smoking Safety Screen. She did not know where Resident #1 obtained smoking materials. The Administrator was notified of immediate jeopardy on [DATE], at 5:43 PM. The facility provided the following credible allegation for immediate jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; and Resident # 1 was taken to an appointment by a transportation company on [DATE]th. The transportation driver failed to communicate with the facility that Resident # 1 was observed by the transportation driver smoking with an oxygen tank present on his wheelchair and was observed in possession of smoking materials. The transportation driver failed to notify the facility that Resident #1 had requested numerous times during the transportation to stop and purchase smoking materials. As a result, on [DATE], shortly before 3AM, resident #1 was noted in doorway of his room as the Night Shift Supervisor was coming down the hall. She could see that smoke was coming from the room. She began to call his name and as she approached him, she could see his hair was singed. As she got closer, she called his name, and he did not answer as his head was down. She pushed his head up and back and noted his face was melted off referring to his burned face. All residents that are transported to appointments by a transport company and residents that are not compliant with smoking policy have the potential to be affected by this deficient practice. 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 completed. Education began on [DATE], for all staff in all departments by Staff Development Coordinator Education included: The smoking policy, including but not limited to: o Those patients currently assessed as deemed independent vs supervised for safety for smoking and supervised smoking times as indicated on the updated smoking list which was revised on [DATE] and is available at all nursing stations. The Director of Nursing was responsible for updating the list of supervised smokers on [DATE] and will update smoking list as necessary. o Monitoring patient behavior and activity in room related to having combustible materials on self and reporting it to the charge nurse and/or supervisor for follow-up. o Monitoring changes in the condition of patients that previously were non-smoking in the center, but who may express a desire to smoke, and reporting this to the charge nurse and/or supervisor for follow-up. o Immediately notifying administrator and/or Director of Nursing at the time of occurrence for any resident caught smoking out of the designated times and area. Consequences of smoking with oxygen on can result in serious injury. o Nurse management (director of nursing, assistant director of nursing, unit managers and/or staff development coordinator) will remove any employee that did not receive the education from the schedule until education is completed. The staff development coordinator is responsible for tracking that staff have received the required training prior to working their next shift. All future employees will be educated by staff development coordinator on the above in-services during new hire orientation. Current staff have received this education. The Staff Development Coordinator is tracking this information to ensure no staff works that have not received the education. o Education began on [DATE] for all nurses, discharge planners and IDT on completion of the smoking assessment and discussion of the smoking acknowledgement with all new admissions by the DON, SDC or designee, including discussions with patients who state they are not a current smoker but have a history of smoking, and education to patients desiring to smoke but who wear oxygen. This education will be done by the SDC, DON or designee. All disciplines were educated on their responsibility on [DATE]. All new admissions will be discussed during morning clinical meeting with the disciplines and updates on progress of assigned task. Anyone working after [DATE] who has not received the education will not be allowed to work. This education will also be done in orientation beginning of [DATE], for all new hire nurses and new hire members of the IDT. Staff Development Coordinator will track and ensure education is provided. Staff Development Coordinator was notified of this responsibility on [DATE]. o All smoking assessments and care plans for current smokers were reviewed and updated by the Interdisciplinary Team (IDT) to assure appropriateness of supervised vs. unsupervised smoking status. This was completed by the Director of Nursing or designee on [DATE]. o All new admissions for the last 30 days will be reviewed for evidence of a smoking assessment and their completion, as well as the care plan for anyone desiring to smoke by [DATE] by the DON or designee. o On [DATE] all residents' POC Kardex were updated to reflect smoking designation as supervised smoker, unsupervised smoker, or history of smoking. The resident Point of Care Kardex is seen on the Certified Nursing Assistance kiosk where daily resident review and documentation is done by the certified nursing assistants each shift. Education began on [DATE], for all staff in all departments by Staff Development Coordinator Education included: All current patients that smoke received re-education of the smoking policy, smoking acknowledgements for all current smokers and all new admits were re-reviewed and completed on [DATE] by the discharge planning director or designee. The smoking policy states smoking materials will not be kept in the patient room. For all current smokers and all new admissions, the discharge planner or designee will educate responsible parties/emergency contacts on proper providing and delivery of smoking materials to the charge nurse for safe keeping. The discharge planner performs this task by going over the smoking policy and having the resident or resident representative sign the smoking acknowledgement. Any new admission that arrives with smoking materials will have their smoking materials taken and properly stored in secure area by the discharge planners. Discharge planners contacted all emergency contacts/responsible parties and provided verbal education on smoking policy specifically delivery of smoking materials and storage. This will be completed on [DATE]. To ensure that smoking materials are returned for all smokers, residents are assisted from smoking patio by staff and smoking materials are placed in the designated locked and secured location. A smoking attendant is assigned to monitor the smoking area 8a-8p and will be noted on the daily nursing staffing sheets to communicate what staff member is assigned. The facility scheduler will be responsible for assuring that the assignment sheet notates what staff is assigned each shift as smoking attendant. The smoking attendant will collect smoking material when they return inside from the smoking area. The smoking attendant will distribute the smoking material when the resident goes to smoke. Between the hours of 8p-8a, if a resident, who is deemed a safe smoker would like to smoke a smoking attendant will be assigned individually as needed to distribute the resident their smoking materials and at the end of the smoking session retrieve smoking materials to be returned to proper storage location. All current safe/unsupervised smokers will be educated on this process by the Director of Nursing or designee beginning on [DATE] and this education will be tracked by the Staff Development Coordinator. The smoking attendant will supervise all unsupervised smokers and distribute and collect their smoking materials. Education began to all staff on the new smoking process by the Director of Nursing or designee on [DATE] on the responsibilities of the smoking attendant, location of assignment sheet, and appropriate storage of smoking materials. Any staff that have not received this education will not be allowed to work until they have received the required education. On [DATE] all smoking residents' rooms and persons were searched with consent by Director of Nursing and Unit manager and all smoking materials were confiscated and placed behind locked doors. Unit manager provided education to smokers on risks of having smoking materials in room and on person. Unsupervised smokers verbalized understanding of this policy. The Staff Development Coordinator will provide the education in writing to the third-party vendor on [DATE] who will then communicate the written education to the two transportation companies utilized by the facility and all drivers assigned to drive for the facility. Education will be provided by our third-party entity who provides administrative oversite for all transportation vendors for Alamance Nursing and Rehabilitation. Any driver not educated will not be allowed to transport residents from the center until education has been received. The third-party entity will communicate with the center that the transportation companies have been educated. This education will be tracked by the Staff Development Coordinator. Drivers that did not complete the education on [DATE], will not be allowed to transport for the center until education is received. The Staff Development Coordinator or designee will educate all service ambassadors and the in-house transportation coordinator on the written education received by the transportation companies and responsibilities for verifying and providing education on [DATE]. The service ambassadors and in-house transportation scheduler, located at the front desk will verify with any driver that reports to pick up a resident has received the required education by asking the driver when they enter the facility. Transportation drivers are required come into the facility to check out the resident for the transport. When a new transportation driver is hired by the company verification of education will be forwarded from the third-party entity to the facility for tracking of required education. The service ambassadors and facility appointment scheduler will be educated on [DATE] on the same items as the transportation company drivers by the Staff Development Coordinator. Education to the transportation drivers; service ambassadors, facility appointment scheduler will include. Safety concerns would include but not be limited to unbuckling, attempts to stand, attempts to smoke, known smoking or vaping. o Type of concerns to report-behaviors, unusual requests for stops, noncompliance with safety directions during transport. This will be part of the ongoing orientation process for the transportation vendors to use in their orientation process. o Returning the resident to facility and drop off procedure to include reporting concerns to Service Ambassador. The service ambassador is located at the front desk at the front door. The service ambassador is located at the front desk from the hours 8am- 8pm. If the transportation driver returns when the service ambassador is not available, the charge nurse for the patient will