**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, staff, Responsible Party text communication (RP), Nurse Practitioner (NP), physician (MD), and Urology Physician Assistant (PA) interviews, the facility failed to implement the Urology Physician's orders dated 6/9/23 for prophylactic antibiotic treatment for recurrent urinary tract infections (UTI) and to discontinue a medication to treat an overactive bladder. The facility also failed to ensure staff were trained on the correct procedure to collect a urine specimen and ensure the laboratory was notified there was a specimen for pick up. The deficient practice affected 1 of 3 residents reviewed for urinary tract infections (Resident #1). Resident #1 was sent to the emergency department on 7/13/23 due to being found unresponsive, upon examination in the emergency room Resident #1 required hospital admission in the intensive care unit (ICU) for sepsis (a life-threatening emergency to the body's response to an infection) secondary to a Urinary Tract Infection. The immediate jeopardy began on 6/9/23 when a medical provider (PA) ordered antibiotic therapy was not started and the medication for an overactive bladder was not discontinued per physician order for Resident #1. The immediate jeopardy was removed on 8/5/23 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at lower scope and severity E (no actual harm that is immediate jeopardy) to ensure monitoring systems are put into place are effective. Findings included: Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 was cognitively intact and had no rejection of care. The assessment indicated she was totally dependent for toileting and personal hygiene and was frequently incontinent of bowel and bladder. According to the MDS assessment, Resident #1 did not have a catheter, had no behaviors or delusions, and did not receive any antibiotic therapy during the review period. A review of a nurse's note dated 5/26/23 at 6:47 PM written by Nurse #1 revealed Resident #1 was transferred to the emergency room at the request of Resident #1's RP for signs and symptoms of a UTI. Review of the hospital Discharge summary dated [DATE] revealed Resident #1 had a urinalysis that was turbid (unclear and murky in clarity) in appearance and positive for protein and white blood cells during her hospitalization; however, had no bacterial growth on culture. During her hospitalization, she was treated with intravenous Cefazolin 2000 mg in the emergency room and then on Cipro IV, however, when the urine culture showed no growth, the antibiotics were discontinued, and Resident #1 was anticipated to return to baseline as her Blood Urea Nitrogen (BUN) and creatinine (kidney function labs) had returned to normal and she was tolerating a nutritional diet. Discharge instructions included the following: An indwelling catheter was placed on 5/26/23 and left intact to Resident #1's bladder on discharge, fluids were encouraged and Resident #1's urology appointment was to be rescheduled by Resident #1's RP due to original appointment was cancelled due to hospitalization. A physician's order dated 5/29/23 indicated Resident #1 was to have an indwelling catheter for a neurogenic bladder related to a disease of the brain and spinal cord and change it monthly and as needed for occlusion, obstruction, or obstruction closed system compromise. A nurse progress note dated 6/2/23 at 2:20 AM written by Nurse #7 indicated the nurse had gone into the room to administer medication for Resident #1 around 9:00 PM on 6/1/23 and the catheter was pulled out with the bulb was still intact. The on-call provider gave orders to leave the catheter out of the bladder that shift due to the bulb being intact when it was pulled out then re-insert. A nurse progress note dated 6/2/23 at 10:47AM written by the Director of Nursing (DON) indicated the in-house NP gave instructions that Resident #1's catheter could remain out until her urology appointment on 6/9/23 if she was voiding without difficulty. The note also indicated Oxybutynin, medication to treat overactive bladder, was to be discontinued at that time. A review of the Medication Administration Record dated June 2023 revealed Oxybutynin was discontinued on 6/2/23. Review of the quarterly MDS assessment dated [DATE] indicated Resident #1 was moderately impaired for cognition and had no rejection of care. The assessment indicated she was totally dependent for toileting and personal hygiene and was always incontinent of bowel and bladder. It further indicated Resident #1 had no rejection of care, no delusions, or hallucinations, and received no antibiotics during the review period. The MDS assessment referenced Resident #1 had a catheter intact during the reference period. A review of the Medication Administration Record dated June 2023 indicated Oxybutynin 5 mg TID (3 times a day) was restarted on the evening of 6/5/23 for overactive bladder. Resident #1's urinary care plan dated 6/7/23 revealed the following interventions: Resident #1 had an indwelling catheter intact and at risk for infection with interventions that included: observe for signs and symptoms of UTI: fever, flank pain, nausea, vomiting, dysuria, hematuria, change in color, consistency, and odor with notification of the physician as indicated. It also included obtain labs as ordered and notify the physician of abnormal findings. A telephone interview with Resident #1's RP on 7/24/23 at 3:00 PM revealed she scheduled an appointment for Resident #1 for a follow-up with the urology office on 6/9/23. A review of Urology office notes dated 6/9/23 indicated Resident #1 was seen by the Urology PA for a UTI without hematuria, blood in the urine, and urinary retention. The note indicated: Since Resident #1 was non-ambulatory and voided (elimination of urine) in a brief, the plan would be to rotate prophylaxis antibiotic treatment every 6 months and consider stopping the course should a time occur where Resident #1 regained her ability to ambulate to the bathroom. It further indicated a scan of Resident #1's bladder indicated she retained 211 cubic centimeters (cc) of urine and felt the urge when she needed to void. Details of the note included: Resident #1 was alert and oriented x 4 and had previously been under the care of a different urology provider where she was on a yearlong course of prophylaxis antibiotics which aided her in no recurrent UTIs while on the 1-year treatment course. The note indicated an order was placed for the following: Urine test using a dipstick to determine pH, nitrate, protein, glucose, ketones, leucocytes, and blood in the urine. A review of the Urology Consultation Report form dated 6/9/23 revealed Resident #1 was seen by the local Urology office for recurrent UTI's with encephalopathy which included orders provided by the physician to: Continue holding Oxybutynin and start Macrobid 50 milligrams (mg) daily for 6 months. The consult form did not indicate it was reviewed by a nurse or a medical provider. A review of Resident #1's physician's orders dated June 2023 revealed Macrobid 50 mg was not transcribed on 6/9/23. It further revealed no orders transcribed for Oxybutynin to be discontinued or held on 6/9/23. Resident #1's Medication Administration Record (MAR) dated June 2023 revealed Macrobid was not provided daily beginning on 6/9/23 as ordered. It further revealed an order for Oxybutynin dated 6/5/23 was not held nor discontinued on 6/9/23 and Resident #1 continued to receive Oxybutynin the remainder of the month of June. A review of the nurses' shift to shift report sheet dated 6/9/23 indicated Resident #1 had an appointment with the urology office at 8:15 AM but no further details were contained related to Resident #1. A telephone interview with Nurse #1 conducted on 8/2/23 at 9:59 AM revealed he was an agency nurse who had been employed to work the 500 hall on day shift (7A-7P) on 6/9/23. Nurse #1 stated he was familiar with Resident #1 and recalled she had been prone to recurrent UTI's, did have an indwelling catheter, but it was discontinued in June. Nurse #1 stated he recalled Resident #1 returning from her urology appointment on 6/9/23 with a consult form returned; however, he could not recall if he reviewed the orders provided by the urology office on that date. Nurse #1 stated he placed the consultation form in the box designated for the Director of Nursing (DON) and Assistant Director of Nursing (ADON) for review. Nurse #1 stated he could not recall if he provided report of the orders from the urology appointment to the oncoming nurse that evening and was unsure if the DON or ADON carried out the orders listed on the consultation form. Nurse #1 stated he had been taught how to enter orders into the electronic medical record but had not been taught to transcribe orders from consultation forms before approved by the in-house medical provider. An interview with the ADON on 8/2/23 at 10:22 AM revealed she was not aware Resident #1's physician's orders had not been transcribed on Friday 6/9/23 per a urology consult sheet until a complete chart review was conducted from 7/25/23 through 8/1/23 which revealed Resident #1 had not received her prophylaxis antibiotic treatment and her Oxybutynin had not been discontinued. The ADON stated she or the DON obtain consultation forms from the box at the nurses' station daily (Monday- Friday) and they were reviewed during morning clinical meetings. She indicated all orders should have been transcribed by Nurse #1 when they were received on 6/9/23. She reported she was not certain how review of this consultation report for Resident #1 dated 6/9/23 was overlooked during clinical review and orders were not transcribed as recommended. An interview with NA #1 on 7/25/23 at 11:51 AM revealed she worked on the 500 hall from 7:00 PM-7:00 AM and explained Resident #1 had incontinence of her bowel and bladder and during the last month she was in the facility, she frequently reported Resident #1's increase in odor and mucous in her urine visualized during incontinence care to the nurses. NA #1 indicated she had reported the hallucinations to Nurse #2 and was told not to be concerned the hallucinations were because of Resident #1 having recurrent UTIs. She was unable to verify what dates she had made reports to Nurse #2, but verified she worked on the 500 hall unit with Nurse #2 on the following dates: 6/14, 6/18, 6/19, 6/27, 6/28, 7/1, 7/3, 7/11, and 7/12. NA #1 stated prior to her hospitalization in May 2023, Resident #1 was able to make all her needs known and actively engage in decision making. A telephone interview with NA #2 on 7/25/23 at 1:11 PM revealed she worked the 500 hall from 7:00 PM-7:00 AM. NA #2 stated when she started in June 2023, Resident #1 would communicate most of her needs with staff and had no abnormal behaviors; however, within a couple week of working with Resident #1, her ability to communicate her needs clearly had declined and she was reaching for things or people not present. NA #2 indicated she had notified Nurse #2 and another nurses (she could not recall name or specific dates reported) about the changes in behaviors but was told Resident #1 was having the hallucinations due to a UTI. A telephone interview with Nurse #2 conducted on 7/26/23 at 5:00 PM revealed she was the routine nurse who worked on the 500 hall on night shift (7:00 PM -7:0 AM). Nurse #2 verified she worked on the night of 6/9/23. Nurse #2 stated she recalled Resident #1 was followed by urology but was unable to recall if Nurse #1 reported the recommendations provided by urology on 6/9/23 and she was unaware Resident #1 did not receive medications as recommended by the urology office following that visit. Nurse #2 stated Resident #1 was alert and oriented x 2, had been able to make her needs known at that time, and was able to assist in some of her activities of daily living (ADLs) at the time, she did not recall Resident #1 having any hallucinations or complaints of symptoms of UTI on that shift. Nurse #2 also indicated she could not recall if NA #1 and NA #2 notified her of Resident #1's hallucinations, increase urine odor or the discharge and mucous observed during incontinence care. A provider progress note written by the NP dated 6/15/23 indicated Resident #1 was assessed to be alert, oriented with some confusion. The note further indicated recent urology notes were reviewed and per urology oxybutynin was to be discontinued and Macrobid 50mg daily for 6 months due to recurrent UTI's was ordered. A telephone interview with the NP on 7/27/23 at 10:30 AM revealed she had seen Resident #1 and reviewed her medical record on 6/15/23; however, she was unaware the recommendations by urology had not been transcribed into her medical record and were not implemented. The NP stated the orders provided on the urology consultation should have been initiated on the day of the appointment. A telephone interview with Resident #1's RP on 7/24/23 at 3:00 PM revealed she notified the facility through text message communication on 6/23/23 that Resident #1 had been experiencing hallucinations by seeing cats and dogs on the ceiling. Resident #1's RP stated she did not get a response back from the ADON at the time and was not sure until several days later that Resident #1 had a UTI and was started on antibiotic therapy on 6/29/23. A review of photographed text messages between Resident #1's Responsible Party (RP) and the ADON which included date and time stamps revealed on 6/23/23 at 2:47 PM, Resident #1's RP made the facility aware Resident #1 was hallucinating by seeing dogs and cats on the ceiling and requested she be assessed for a UTI. An interview with the ADON on 7/25/23 at 3:45 PM revealed she frequently engaged in communication via text with Resident #1's RP, but no longer kept the text communication feed on her cellphone. The ADON stated she did recall being made aware Resident #1 had experienced hallucinations and she contacted the provider (she could not recall if she spoke with the MD or NP on that date). The ADON indicated she received orders to obtain a urine specimen for a urinalysis with culture and sensitivity for Resident #1 on 6/23/23 and entered the orders into the medical record. The ADON stated the hall nurse was made aware of the new orders at the time. A review of the physician's orders revealed the following orders: A physician's order dated 6/23/23 indicated obtain a urinalysis with culture and sensitivity x 1 without a reason indicated. A review of the nurses' shift to shift report sheet dated 6/23/23 indicated Resident #1 had a urine specimen located in the fridge. A telephone interview with Nurse #3 on 8/4/23 at 11:29 AM revealed she was an agency nurse employed by the facility to work on day shift (7A-7P) on the 500 hall on 6/23/23. Nurse #3 stated she was notified of the new orders for urinalysis for Resident #1. Nurse #3 indicated Resident #1 was up in her chair at the time and she requested staff place her back to bed to obtain the specimen. Nurse #3 explained she had the NA's (names unknown) place Resident #1 on a bed pain to void. She then, transferred the collected urine from the used bed pan into a cup and from that into a vacuum sealed tube available at the facility. Nurse #3 stated she placed the specimen in the fridge but did not contact the laboratory to make them aware the urine needed to be picked up. She stated she did not know the lab did not pick up specimens on the weekend without being notified. Nurse #3 explained when she obtained the specimen on 6/23/23, she noticed the specimen appeared abnormal and the urine had a strong odor and was a yellowish-white thick substance and contained mucous but did not contact the medical provider for further orders. A laboratory report revealed a urinalysis was collected on 6/23/23 at an unknown time and received by the laboratory company on 6/26/23 at 12:23 PM. It further revealed the results were sent to the facility on 6/29/23 which indicated the specimen contained 2 bacteria which included: enterococcus faecalis and streptococcus anginous. A review of the physician's order revealed an additional order dated 6/26/23 that indicated obtain a urinalysis with culture and sensitivity x 1 for urinary retention. A telephone interview with Nurse #3 on 8/4/23 at 11:29 AM revealed she was made aware when she returned to work on 6/26/23 that the urine specimen she collected on 6/23/23 had not been picked up by the lab and was collected using the incorrect collection method and therefore had to be recollected on 6/26/23. Nurse #2 explained she recalled NAs on the unit alerting her that Resident #1 had visual hallucinations and would begin talking to things that weren't seen by staff, but she had assessed her to have confusion and therefore did not alert the medical provider of the reported hallucinations. A review of the physician's order revealed an order dated 6/29/23 that indicated Resident #1 was to receive Macrobid 100 mg twice daily for 7 days for a UTI. A provider note written by the facility MD dated 6/29/23 indicated urology notes were noted and the plan was to continue with urology and urology orders. A review of the MAR dated June and July 2023 revealed Resident #1 received Macrobid 100 mg twice daily which began on the evening of 6/29/23 and was completed on the morning of 7/6/23. An appointment was scheduled by Resident #1's RP for a follow-up with the urology office on 7/12/23. A review of the Urology Report of Consultation form dated 7/12/23 revealed Resident #1 was seen by the local Urology office for Altered Mental Status (AMS) and returned the form to the facility with recommendations which indicated: Catheter sample, collect tonight and fax results to the urology office. Start Ciprofloxacin (Cipro) 500 mg twice daily for 10 days. Following Cipro, start Macrobid 50 mg daily and stop Oxybutynin. The consult form additionally revealed a clarification was made by Nurse #4 for a stop date for the Macrobid. A fax written order from the Urology office dated 7/12/23 at 2:58 PM was attached which included a prescription for the Cipro 500 mg twice daily. A review of Urology office notes dated 7/12/23 indicated Resident #1 was seen by the PA for recurrent UTI's and significant AMS with a plan to start antibiotic treatment and request and I&O (in and out) catheterization to collect the urine sample. It further detailed review of the medication reconciliation revealed Resident #1 had continued Oxybutynin and had not started on prophylaxis antibiotic therapy for recurrent UTI's as previously ordered. Additional orders were placed for Ciprofloxacin 500 mg twice daily for 10 days then resume prophylaxis antibiotic therapy Macrobid 50 mg daily for 6 months and discontinue Oxybutynin. An interview with Nurse #4 on 7/25/23 at 12:20 PM revealed she worked the 500 hall on 7/12/23 from 7:00 AM-7:00 PM shift. Nurse #4 recalled Resident #1 returning from a urology appointment on 7/12/23 with new orders to obtain a urine specimen for a culture and sensitivity and medication changes to include an antibiotic and stop Oxybutynin. Nurse #4 stated she called the urology office for clarification of the antibiotic order because it did not include a stop date; however, she did not collect the urine specimen on her shift nor start the antibiotics as ordered. Nurse #4 explained she reported the new orders to the night shift nurse (Nurse #2) at the change of shift. A telephone interview with Nurse #2 on 7/26/23 at 5:00 PM revealed she worked on the 500 hall on 7/12/23 to 7/13/23 on the 7:00 PM-7:00 AM shift. Nurse #2 indicated she collected the urine specimen around 9:00 - to 11:00 PM on 7/12/23 and placed it in the refrigerator for pick-up by the lab for the next morning. Nurse #2 stated she obtained the urine specimen via I &O catheterization. A nurses note written by Nurse #2 dated 7/12/23 at 9:52 PM indicated a urine specimen was collected from Resident #1 and sent to the laboratory. The specimen was described as white, thick, and contained mucous. A review of the MAR dated July 2023 revealed Resident #1 received one dose of oral Ciprofloxacin 500 mg on 7/12/23 at 8:00 PM. A telephone interview with Nurse #5 on 7/25/23 at 12:50 PM revealed she was an agency nurse who was assigned to work the 500 hall on 7/13/23 during day shift (7:00 AM-7:00 PM). Nurse #5 stated she obtained shift report from Nurse #2 who had not indicated any concerns with Resident #1 and began administering her morning medications as usual. Nurse #5 stated around 8:30 AM on the morning of 7/13/23, she entered Resident #1's room to administer her medications and found her to be unresponsive to verbal or tactile stimuli. Nurse #5 stated Resident #1's breathing was sporadic (8-10 breaths per minute), and her skin was slightly pale with her mouth being cyanotic, blue, and her tongue being very dry in nature. She attempted to obtain vital signs and perform a sternal rub without success. Nurse #5 explained she continued to attempt to obtain vital signs and an oxygen saturation and called for the assistance of staff to come to the room for assistance. After a few minutes, the ADON and Medication Aide #1 arrived to the unit to assist Nurse #5. Nurse #5 stated when she obtained an oxygen saturation in the 70 % range, MA #1 retrieved an oxygen tank and a rebreather mask and the ADON began a facetime call with the NP who provided orders to send Resident #1 to the hospital via EMS for further evaluation. Nurse #5 stated Resident #1 had not shown any responsiveness when paramedics arrived and was transported to the local hospital. An interview with MA #1 on 7/25/23 at 2:25 PM revealed he arrived to the 500 hall unit to assist Nurse #5 and was asked to retrieve an oxygen tank and a rebreather mask for Resident #1. He stated he could not recall if he attempted to obtain vitals on Resident #1 on the morning of 7/13/23, but explained he took the robo- nurse (portable multi-use machine used to obtain vital signs) and a manual blood pressure cuff and stethoscope to Nurse #5 and printed out discharge/transfer paperwork for Resident #1's discharge with EMS. MA #1 said he could not recall Resident #1's appearance on the morning of 7/13/23 other than her being unresponsive. An interview with the ADON on 7/25/23 at 3:45 PM revealed she was called to the room of Resident #1 on the morning of 7/13/23 in the early morning although she could not recall a time. The ADON stated when she arrived, Resident #1 was unresponsive to verbal and tactile stimuli according to Nurse #5 who was at the bedside. The ADON stated she immediately facetimed the NP who assessed Resident #1 and provided orders to transfer her to the hospital for evaluation. The ADON stated she notified Resident #1's RP via telephone and then Resident #1 was discharged with EMS. A telephone interview with the NP on 7/31/23 at 10:48 AM revealed she was familiar with Resident #1 and aware she had a diagnosis of recurrent UTI's. The NP indicated she was aware Resident #1 had been seen by urology and was aware of the mediation changes but had not been made aware the orders were not initiated on 6/9/23. The NP stated all orders from the consult sheets were expected to be transcribed and started as ordered. The NP further explained that she became aware of changes in condition for Resident #1 on 6/23/23 by the ADON and provided orders to obtain a urine specimen for culture and sensitivity. She was not aware the specimen was not sent to the lab until 6/26/23 and therefore delayed treatment for Resident #1 until 6/29/23. The NP also explained that she would expect a provider to be notified immediately if there was a delay in collection of a lab, delay in processing, and of any abnormalities of the urine specimen that were obvious on collection. A telephone interview with the MD on 7/31/23 at 10:15 AM revealed he was somewhat familiar with Resident #1. The MD indicated most concerns related to Resident #1 were handled through the NP. He stated he was not made aware orders were not transcribed from the urology consult sheet and initiated as ordered nor was he made aware of the delays in collection and processing of the urine specimen collected on 6/23/23 which delayed treatment of a UTI. The MD stated he would expect to be notified immediately of all changes in a resident's medical condition and expected orders to be carried out as prescribed. Due to being unable to interview by phone, the Urology PA provided the following documentation for the surveyor: By the facility not following recommendations to collect a urine specimen and begin treatment Resident #1 incurred risk of untreated UTI's which included worsening infection to the point of urosepsis and significant decline in health with possible mortality. A review of emergency room notes dated 7/13/23 revealed Resident #1 arrived at the hospital via EMS after she had presented with Altered Mental Status (AMS) status and unresponsiveness, low oxygen saturation of 79% which required 15 liters oxygen via nasal cannula to stabilize, and hypotensive with systolic blood pressure in the 80's. Resident #1 was febrile with a temperature of 101.8 degrees Fahrenheit. Resident #1 required hospital admission in the ICU due to the medical providers evaluation which indicated a high probability of imminent or life-threatening deterioration due to coma and lactic acidosis. The note also read admitted due to severe sepsis believed to be secondary to UTI, acute kidney injury, hypercalcemia, and AMS. The Administrator, Assistant Director of Nursing, and Regional Nurse Consultant were notified of the immediate jeopardy on 8/3/23 @ 11:15 AM. The facility provided the following plan for IJ removal. Recipients who have suffered or are likely to suffer a serious adverse outcome as a result of the non-compliance. Resident #1 was alert with moderately impaired cognition. Diagnoses include encephalopathy, altered mental status, history of urinary tract infections (UTIs), neuromuscular dysfunction of the bladder, multiple sclerosis, muscle weakness, generalized anxiety, and major depressive disorder. On 6/9/23, Resident #1 was seen by the urologist with a new order to start Macrobid 50 mg once a day for 6 months and continue holding oxybutynin. When the resident returned to the facility from the appointment, the assigned nurse (Nurse #1) did not review the consult sheet and was not aware of the new orders from the urologist. The Macrobid 50 mg was never started, and the oxybutynin was not put on hold due to Nurse #1 not understanding the process for checking consult sheets. On 6/23/23, the resident's sister notified the Assistant Director of Nursing (ADON) that Resident #1 was hallucinating. The ADON contacted the Nurse Practitioner (NP), and a new order was received for a urinalysis (UA) and culture and sensitivity (C&S). The resident's urine was collected on 6/23/23, but the nurse did not notify the lab company that the UA was collected. The lab company picked up the urine on 6/26/23 and it resulted on 6/29/23. The NP reviewed the results on 6/29/23, and Macrobid was ordered and administered for 7 days. On 7/12/23, the resident attended a urology appointment scheduled by her sister. Per the urology consult sheet on 7/12/23, the resident was experiencing altered mental status. Resident #1 was sent back to the facility from the urology appointment with new orders for a UA, start Cipro 500 mg bid x 10 days, start Macrobid 50 mg daily after the Cipro is completed and stop the oxybutynin. The Cipro was started on 7/12/23 at 8:00 pm, the oxybutynin was discontinued, and the UA was collected per the provider's order. On 7/13/23, Resident #1 was unresponsive, had decreased blood pressure and heart rate, and was sent to the emergency room per physician's order, where she was diagnosed with severe sepsis secondary to UTI. All residents could be affected by the deficient practice. On 8/3/23, the Staff Development Coordinator (SDC) conducted education with all alert and oriented residents with a BIMs of 13 and higher regarding signs and symptoms of a UTI, reporting signs and symptoms of a UTI, and prevention of UTIs. On 8/3/23, the Unit Manager (UM) will assess all residents with a history of UTIs to ensure all residents with active signs and symptoms are being treated per the physician's order. The nurse will contact the physician, carry out any new orders received, notify the resident representative, and document any identified areas of concern in the clinical record. The UM will provide oversight to ensure new orders received from the audit are carried out. The audit will be completed by 8/4/23. On 8/3/23, the SDC will interview all nurses and nursing assistants, in person or via telephone, regarding residents with a change in condition to include signs and symptoms of a UTI. After 8/4/23, anyone that has not been interviewed will be educated prior to the next scheduled shift. The purpose of the interviews is to ensure all residents with a change in condition, including a UTI, have been identified with notification to the physician. The nurse will contact the physician, carry out any new orders received, notify the resident representative, and document any identified areas of concern in the clinical record. The UM will provide oversight to ensure new orders received from the audit are carried out. The audit will be completed by 8/4/23. On 8/3/23, the Facility Nurse Consultant (FNC) will review all resident's progress notes in the past 30 days for documented signs and symptoms of UTIs. The purpose of the audit is to ensure the physician was contacted and orders were followed for all residents identified with UTI symptoms. The nurse will contact the physician, carry out any new orders received, notify the resident representative, and document any identified areas of concern in the clinical record. The Assistant Director of Nursing will provide oversight to ensure new orders received from the audit are carried out. The audit will be completed by 8/4/23. On 8/1/23, the FNC began an audit of all consults x 30 days, the UM will complete the review of all consult sheets, including urology consults for the past 30 days, to ensure new orders received, including antibiotics, are processed, and implemented as ordered by the consulting physician. The UM will contact the provider for any identified orders that were not implemented. The audit will be completed by 8/4/23. On 8/3/23, the Assistant Director of Nursing (ADON) and Unit Manager (UM) will review all lab orders, including urinalysis for the past 30 days to ensure the lab was collected, picked up by the lab company, and results received timely. The ADON and UM will contact the provider for any identified delays in labs noted. The audit will be completed by 8/4/23. Actions taken to alter the process or system failure to prevent a serious adverse outcome for occurring or recurring. On 8/3/23, the Staff Development Coordinator initiated an in-service with all nursing assistants, nurses, and agency staff, regarding: 1. Signs and symptoms of UTIs include but are not limited to urinary urgency, burning urination, frequent urinating, cloudy urine, red, bright pink, or cola-colored urine, strong-smelling urine, or pelvic pain. 2. In the elderly, signs and symptoms of UTI can be any subtle change. It is important to recognize and report all acute changes in condition observed to prevent the risk of severe symptoms. 3. Signs and symptoms of sepsis include but are not limited to changes in mental status, shivering, shallow breathing, decrease in blood pressure, and lethargy. 4. Prevention of UT[TRUNCATED]