**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview, staff interview, nurse practitioner interview, physician interview, pharmacist, and psychiatry nurse practitioner interview the facility failed to administer 6 doses of a required antipsychotic medication for one (Resident #11) of one resident reviewed for significant medication errors. Resident #11 had an acute psychotic event after missing 6 doses of his antipsychotic medication resulting in a fall with a broken shoulder and hip that required surgical repair, acute blood loss and acute pain. Resident #11 has been bedbound since the incident. Findings included: Resident #11 was admitted to the facility on [DATE] with a diagnosis of paranoid schizophrenia. Resident #11 had a physician's order for 200 milligrams (mg) Clozapine, an antipsychotic, to be administered as one tablet by mouth two times a day for paranoid schizophrenia initiated on 7/9/2024. The administration times listed were 8:00 AM and 8:00 PM. Documentation in the manufacturer's label for Clozapine revealed the average elimination half-life of Clozapine after a singe 75 mg dose, was 8 hours with a range of 4 to 12 hours, while the average elimination half-life after achieving a steady state with 100 mg twice a day dose, of 12 hours. Half-life is the time it takes for the amount of a drug's active substance in the body to reduce by half. Anemia and vitamin B12 deficiency can be a rare side effect of the medication Clozapine. The abrupt stopping of Clozapine has been associated with agitation and a rapid onset of psychosis. Documentation in the assessment and plan portion of a psychiatry progress note date 9/19/2024 revealed Resident #11's paranoid schizophrenia was chronic and stable. The documentation also indicated Resident #11 was adhering to his medication regimen and indicated a stable mental state. Documentation on a quarterly Minimum Data Set assessment dated [DATE] coded Resident #11 as cognitively intact with no moods or behaviors. Resident #11 was coded as requiring set up/cleanup for eating and personal hygiene, but was dependent for toileting, showers/bathing, personal hygiene, and dressing. Resident #11 was coded as requiring substantial assistance with mobility. Resident #11 had a physician's order dated as initiated on 9/19/2024 for blood to be drawn for a complete blood count (CBC) and a complete metabolic panel (CMP) on the night shift every 30 days for anemias and vitamin deficiencies to be completed on 10/19/2024 at 7:00 PM. The pharmacy requires blood tests every 30 days for a resident on the medication Clozapine to monitor the neutrophil counts in the blood. There was no evidence in the electronic medical record of the CBC and CMP test results dated 10/19/2024. Resident #11 had an additional physician's order written by Nurse Practitioner (NP) #1 dated 10/22/2024 at 11:17 AM for the medication Clozapine to be held for 2 days until 10/24/2024. Documentation in a progress note written by NP #1 on 10/22/2024 at 7:55 PM revealed in part, [Resident #11's] schizophrenia appears controlled with current therapy. Will order lab work as indicated and continue with therapy as prescribed. Obtain STAT (immediate) CBC (complete blood count) and CMP (comprehensive metabolic panel). Documentation on a lab results report for Resident #11 revealed the collection date was 10/23/2024 at 10:31 AM, received at 10/23/2024 at 10:31 AM, and reported to the physician on 10/23/2024 at 11:15 AM. Documentation on the October Medication Administration Record (MAR) indicated Resident #11 had the medication Clozapine on hold by the practitioner for the 8:00 PM dose on 10/22/2024, the 8:00 AM dose on 10/23/2024, the 8:00 PM dose on 10/23/2024, and the 8:00 AM dose on 10/24/2024. Documentation on the same MAR indicated Resident #11 did not receive the scheduled Clozapine for the 8:00 PM dose on 10/24/2024, and the 8:00 AM dose on 10/25/2024 indicating an explanation would be in the progress notes. Documentation in the electronic medication administration record (e-MAR) administration notes dated 10/24/2024 at 9:01 PM indicated the medication Clozapine was on order for Resident #11. Documentation in the e-MAR administration notes dated 10/25/2024 at 9:23 AM had no explanation for why the Clozapine dose was not administered to Resident #11. Medication Aide (Med Aide) #1 was interviewed on 11/26/2024 at 9:04 AM. Med Aide #1 confirmed she was assigned to administer medications to Resident #11 on 10/24/2024 and 10/25/2024 on the evening shift. Med Aide #1 recalled that the medication Clozapine was held at one point and then was not available when she was administering medications on the evening shift on 10/24/2024 and 10/25/2024. Med Aide #1 recalled that on the evening shift on 10/24/2024, Resident #11 did not have a good night in that he was acting out with behaviors that made him seem like he was possessed. Med Aide #1 stated she was aware the medication Clozapine required laboratory values monthly and was a very important medication for Resident #11 to take. Med Aide #1 thought she had reported the absence of the medication Clozapine for Resident #11 to a nurse, but she could not remember which nurse or the details of the conversation. Nurse #6 was interviewed on 11/25/2024 at 11:36 AM. Nurse #6 confirmed she was the nurse assigned to administer medication to Resident #11 on the morning of 10/25/2024. Nurse #6 stated she did inform the unit manager (Nurse #5) that the Clozapine for Resident #11 was not available on the morning of 10/25/2024. Nurse #6 stated Nurse #5 contacted the pharmacy and sent the required laboratory report to the pharmacy so that the medication Clozapine would be sent to the facility for Resident #11. NP #1 was interviewed on 11/22/2024 at 9:52 AM. NP #1 revealed the following information. NP #1 was in the facility Monday through Friday as an onsite practitioner. NP #1 explained the reason the Clozapine was put on hold for Resident #11 on 10/22/2024 was because the pharmacy needed laboratory values to be sent to them prior to filling another 30-day supply of the medication to Resident #11. The requirement for the laboratory values to be sent to the pharmacy prior to filling the Clozapine for Resident #11 was well known to the facility and there was a reoccurring order for blood to be drawn from Resident #11 for laboratory values each month. The problem, as explained by NP #1, was that the laboratory tests for Resident #11 were not drawn as ordered on 10/19/2024 and were then not faxed to the pharmacy. NP #1 explained on 10/22/2024 she entered an additional order for a CBC (complete blood count) with differential for Resident #11 to be completed STAT (immediately). (A CBC with differential measures the number and types of cells in your blood to help diagnose a variety of conditions to include anemia, infection, or immunodeficiencies.) Documentation in a physician's progress note for Resident #11 dated 10/25/2024 at 1:00 PM written by Medical Doctor (MD) #1 stated in part, Today, he was quite ornery. He is having acute psychosis event at this point. Very difficult to reconcile, redirect and calm down. He was actually verbally offensive and abusive to many of the staff members as well as me and other residents. The patient became very angry while at the nursing station. Attempted to get out of his wheelchair and I suspect probably attempted to take a swing at a staff member when he fell backward and fell on the ground. We did not move him, but I did assess him the best I could on the floor. He denies complaints at this point. However, I am concerned about his ongoing injury from his fall. He did not strike his head. Neurologically, he had no changes from his fall at this point. Neurological assessment otherwise is his baseline other than psychosis. Brief orthopedic assessment could not be completed after a fall secondary to the patient being stabilized on the ground awaiting EMS (Emergency Medical Services). His vital signs otherwise are stable at this point. Approximately 15 minutes earlier, he received an IM (intermuscular) injection of Benadryl in his arm to calm him down I believe. Benadryl is an antihistamine that can have a sedative effect. An interview was conducted with the physician for Resident #11, MD #1, on 11/22/2024 at 1:23 PM. MD #1 explained that Resident #11 was rolling around in his wheelchair acting very verbally abusively threatening staff, other residents, and MD #1 on 10/25/2024. MD #1 explained Resident #11 was yelling, cussing, speaking in tongues, and acting in a way he had never seen before for this resident. MD #1 explained that Resident #11 rose up out of his wheelchair and what looked like to him attempted to take a swing at one of the staff members nearby, when he fell hard on the ground. MD #1 explained that Resident #11 did periodically have verbal behaviors but this was something else. MD #1 stated he could not definitively say Resident #11 missing the six doses of Clozapine at the time of the incident and fall on 10/25/2024 was a direct cause of the accident because he was unsure of the half-life of the medication. (The half-life provides an accurate indication of the length of time that the effect of the drug persists in an individual.) MD #1 confirmed there was no reason Resident #11 should have missed getting the required lab work completed and missed doses of Clozapine. Documentation in the nursing progress notes dated 10/25/2024 at 1:46 PM written by Nurse #5 revealed, Nurse called pharmacy to check status of resident's Clozapine oral tablet 200 mg. Pharmacist requested to have copy of labs. Nurse [#5] faxed lab per request. [NP #1] made aware. Nurse #5 was interviewed on 11/25/2024 at 9:52 AM. Nurse #5 stated she was the unit manager, and she was in the office adjacent to the nursing station with NP #1 when Resident #11 fell. Nurse #5 revealed Resident #11 usually had a calm demeanor when he received his medication Clozapine, but when he did not receive his antipsychotic medication, he became almost demonic. Nurse #5 explained that the medication Clozapine required lab work to be completed prior to the pharmacy filling the medication. Nurse #5 further explained the nurses working at the facility should know Resident #11 required the medication Clozapine and that the lab work must be sent to the pharmacy for him to obtain it from the pharmacy. Nurse #5 stated the nurses who were working on the medication cart should know to call the pharmacy if Resident #11 did not have his Clozapine and the pharmacy would have readily told the nurse the laboratory report was needed. Nurse #5 stated when she saw the manic state Resident #11 was in on 10/25/2024 she called the pharmacy because she surmised, he probably had not received his antipsychotic medication. Nurse #5 indicated after the pharmacy notified her the laboratory report was needed, she immediately faxed the results to the pharmacy, and the pharmacy sent the Clozapine to the facility. Resident #11 had a physician's order dated 10/25/2024 initiated at 1:46 PM for 50 mg of Benadryl to be injected intramuscularly one time only for agitation for one day and may repeat in one hour if needed. Documentation on a transfer form dated as initiated on 10/25/2024 at 1:57 PM written by Nurse #5 indicated Resident #11 was sent to the hospital because, Resident threw himself on the floor. Documentation on the MAR revealed Resident #11 was administered the ordered dose of Benadryl on 10/25/2024 at 2:30 PM by Nurse #6. Documentation on a SBAR (Situation, Background, Assessment, and Recommendation) communication form and progress note dated 10/25/2024 initiated at 3:15 PM written by Nurse #6 revealed in the nursing assessment, Resident having outburst with behavior toward staff. Documentation in the nursing progress notes dated 10/25/2024 at 3:21 PM written by Nurse #6 stated, Resident up and down the hall in wheel[chair] with noted behavior fussing at staff and other residents. Resident talking to self, having out [bursts] toward others. Resident attempted to stand up to hit at staff when resident fell at nursing station. Resident complained of pain, refused help from staff, [Primary Care Physician] onsite, EMS/Police called to escort resident to ER (emergency room). Resident family aware/unit manager aware. Nurse #6 was interviewed on 11/25/2024 at 11:36 AM. Nurse #6 explained she was an agency nurse and was not very familiar with Resident #11, but she did recall the day he fell at the nurses' station. Nurse #6 stated Resident #11 was rolling all around the facility in a wheelchair in a very agitated state cursing at everybody he encountered. Nurse #6 confirmed that prior to Resident #11 falling at the nurses' station, she had administered Benadryl to him with an order obtained from NP #1. Nurse #6 stated, in addition she went to the unit manager, Nurse #5, to let her know Resident #11 did not have any more Clozapine for administration. Nurse #6 revealed Resident #11 was cursing at MD #1 when he rose up out of his wheelchair and attempted to hit either MD #1 or herself. Nurse #6 stated Resident #11 fell, but was in such a state he would not allow anyone to assess him or for EMS to transport him to the hospital so, the police were called. Documentation on the October MAR indicated Resident #11 did not receive the scheduled Clozapine for the 8:00 PM dose on 10/25/2024 indicating an explanation would be in the progress notes. Documentation in the e-MAR administration notes dated 10/25/2024 at 10:24 PM indicated the medication Clozapine was on order for Resident #11. Record review of an emergency room visit on 10/25/2024 for Resident #11 revealed resident was uncooperative for an x-ray of his left shoulder with continuous refusals. Resident #11 was administered medications intramuscularly to calm him down enough to perform an x-ray of the left shoulder. The x-ray of the shoulder revealed Resident #11 had a fracture of the long bone, between the shoulder and the elbow. Resident #11 was transferred back to the facility with a long-arm splint and sling for support with the recommendation to follow-up with orthopedics the first of the next week. NP #1 was interviewed on 11/22/2024 at 9:52 AM and additional information was provided. NP #1 revealed the CBC with differential was completed as ordered on 10/23/2024, but the results were not faxed to the pharmacy until 10/25/2024, resulting in Resident #11 missing seven doses of his Clozapine until the pharmacy sent another 30- day supply on 10/26/2024. NP #1 indicated the medication Clozapine did not make Resident #11 lucid but did make him manageable, so he was not hollering and yelling all the time. NP #1 stated she was in her office near the nursing station on 10/25/2024 when Resident #11 started yelling obscenities and could be heard threatening everyone around him. NP #1 stated she saw MD #1 step back away from Resident #11, but she did not actually see Resident #11 fall. NP #1 stated Resident #11 hit the ground so hard it could be heard by everyone. NP #1 explained MD #1 immediately ordered for 911 to be called as Resident #11 needed to be sent out. NP #1 indicated Emergency Medical Services (EMS) arrived very quickly but Resident #11 was so belligerent the police had to be called to assist the EMS workers. An interview was conducted with a pharmacist from the facility's pharmacy on 11/22/2024 at 10:25 AM. The Pharmacist revealed the following information. According to the pharmacy records, Resident #11 ran out of the ordered medication Clozapine on 10/22/2024. The Pharmacist called the facility on 10/22/2024 and notified them a new prescription for the Clozapine and a CBC differential for Resident #11 needed to be faxed to the pharmacy so that another 30-day supply of the medication could be sent to the facility. The Pharmacist did not have any record of who she spoke to at the facility. The pharmacist explained the neutrophil count was the value the Pharmacist was monitoring because residents on Clozapine had an increased risk for infection. (Neutrophils are a type of white blood cell that help the body fight infection and heal from injury.) On 11/22/2024 at 11:20 AM a new prescription for Resident #11 for the Clozapine was sent to pharmacy. The required CBC with differential for Resident #11 was not sent to the pharmacy on 10/22/2024. The pharmacy received the CBC with differential dated 10/23/2024 for Resident #11 on 10/25/2024. The pharmacy sent a 30-day supply of the Clozapine to the facility on the morning of 10/26/2024. The Pharmacist stated if the medication Clozapine, used for paranoid schizophrenia, was abruptly stopped there was usually rebound psychosis and increase in behaviors related to Clozapine's short duration of action. Documentation in the Nursing Progress notes dated 10/25/2024 at 5:30 PM written by Nurse #6 revealed, [Resident #11] return from hospital with a [diagnosis] of closed displaced fracture of the surgical neck of the left humerus (the long bone that runs from upper shoulder to the elbow), unspecified fracture morphology. (Unspecified fracture morphology means the doctor does not have enough information to describe the exact shape or pattern of a bone fracture.) New order to go to Orthopedics in 3 days. Sling to left arm noted. Documentation in the nursing progress notes dated 10/30/2024 at 9:10 AM written by the Director of Nursing revealed Resident #11 was transferred to another hospital after a diagnosis of a hip fracture was obtained in a local emergency room. The note further went on to explain the responsible party for Resident #11 was contacted to update health information regarding Resident #11 and discuss the likelihood of Resident #11 sustaining the hip fracture when he fell on [DATE] because Resident #11 had not had any other falls. Documentation in a discharge summary from the hospital revealed Resident #11 had a hospitalization from 10/29/2024 to 11/6/2024 for surgical repair of a left hip fracture. Additionally, while in the hospital Resident #11 had the problem areas and procedures of acute blood loss with transfusion of 2 units of blood and acute pain due to trauma. An interview was conducted with a Nurse Aide (NA) #5 on 11/22/2024 at 12:14 PM. NA #5 revealed she worked on the first (7:00 AM to 3:00 PM) and second (3:00 PM to 11:00 PM) shift routinely. NA #5 indicated she knew the care needs of Resident #11 well. NA #5 stated Resident #11 would occasionally get out of bed with a one person stand and pivot to the wheelchair prior to his fall. NA #5 stated that Resident #11 was a completely different person now and would require a mechanical lift to get out of bed, but he no longer wants to get out of bed. NA #5 stated she knew Resident #11 did not like the mechanical lift. Resident #11 was observed on 11/22/2024 to be asleep in bed laying on his right side 9:46 AM, 11:10 AM, and 1:04 PM. An observation and interview were conducted with Resident #11 on 11/22/2024 at 4:29 PM. Resident #11 was laying on his right side in bed with a sling on his left arm. Resident #11 stated he had consistent pain in his hip, and he longer felt like he could get out of bed. An interview was conducted with MD #1 on 10/25/2024 at 11:22 AM. MD #1 stated he visited with Resident #11 on 11/22/2024 to encourage him to work with therapy. MD #1 stated the mentation of Resident #11 was to just stay in bed and not move at this point. Documentation in a psychiatry progress note dated 11/14/2024 written by NP #2 revealed under the history of present illness portion in part, Patient ran out of his Clozapine a few days ago, which led to a resurgence of his delusions and hallucinations. This incident escalated to the point where he attempted to physically confront a doctor, resulting in a fall. Since resuming his medication, his symptoms have subsided, and he is reported to be doing well again. The goal is to prevent such an occurrence in the future by ensuring consistent access to his medication. His current medication regimen will be continued without changes, with a follow-up planned in a few weeks. NP #2 was interviewed on 11/22/2024 at 1:43 PM. NP #2 stated it was hard to say if the behaviors of Resident #11 on 10/25/2024 were due to him missing 6 doses of Clozapine over two and a half days. NP #2 stated the half-life of Clozapine was 26 to 36 hours. NP #2 revealed she visited the facility every two weeks and usually the facility staff reported occasional verbal behaviors from Resident #11 and never reported physical behaviors. The Director of Nursing was interviewed on 10/22/2024 at 10:45 AM. The Director of Nursing acknowledged the facility initially failed to obtain the needed laboratory report required by the pharmacy for the dispensing of the medication Clozapine on 10/19/2024. The DON also acknowledged NP #1 failed to give a separate order for the faxing of the laboratory report to the pharmacy after it was obtained on 10/23/2024, further delaying the dispensing of the medication Clozapine to Resident #11. The facility was notified of the immediate jeopardy on 11/22/2024 at 3:39 PM. The facility submitted the following corrective action plan on 11/23/2024: Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 10/22/24 at 8:00 pm. Resident #11's medication could not be administered as ordered by the provider due to it not being available. When the nurse notified the pharmacy of the medication not being available to administer the pharmacy stated the medication required lab work to be completed and faxed to the pharmacy prior to dispensing the medication. On 10/22/24 the provider was notified, and an order was obtained to draw stat lab work on 10/22/24. The results of the labs were received on 10/23/24 in the morning and the provider failed to place a physician order to fax the results to the pharmacy so the medication could be dispensed. On 10/25/24 at 1:26 pm the nurse notified the pharmacy the medication was not available to administer. Upon notifying the pharmacy the pharmacy stated they had not received the lab results to dispense the medication. The provider was notified and stated the lab work had been completed and needed to be faxed to the pharmacy. The lab results were faxed to the pharmacy and received by the pharmacy at 1:42PM. The pharmacy dispensed the medication at 1:59pm. The facility received Resident #11's medication on 10/26/24 at 2:00 am. On 10/26/24 Resident #11's medication of Clozapine was administered at 8:00am to the resident as ordered by the provider. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: An audit of all current residents was completed by the Director of Nursing on 10/23/24 to determine if any other residents required lab work previous to medication distribution from pharmacy. No other residents required lab work prior to medication distribution indicating that there were no other residents affected by the deficient practice of significant medication errors. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: Licensed nurses were educated on the new process that the provider will enter a physician order for lab work. The order will be on the Medication Administration Record. The Licensed Nurse will ensure a lab form is completed and placed in the lab book for the lab to be drawn. Results of the lab are integrated with the electronic medical records system and once the results are received the provider is notified to review. When applicable, a separate order will be placed on the medication administration record when a lab is required to be faxed to the pharmacy for medication distribution. The providers were educated on 11/8/24 of the new process by the Director of Nursing. When the order appears on the Medication Administration record the licensed nurse will ensure the lab results are faxed to the pharmacy. Education was provided by the Director of Nursing to licensed staff and licensed agency staff on 11/12/24 to 11/13/24 that the provider will enter a physician order for lab work. The order will be on the Medication Administration Record. The Licensed Nurse will ensure a lab form is completed and placed in the lab book for the lab to be drawn. Results of the lab are integrated with the electronic medical records system and once the results are received the provider when applicable will order for lab results to be faxed to the pharmacy. The order will be placed on the medication administration record when a lab is required to be faxed to the pharmacy for medication distribution. When the order appears on the medication administration record the licensed nurse will ensure the lab results are faxed to the pharmacy. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: On 11/4/24 the Quality Assurance team (Administrator, Director of Nursing, Assistant Director of Nursing, nurse practitioner, Medical Director, social services director, admissions director and therapy director) met and a decision was made that the Director of Nursing or Designee will audit that includes the following: the provider entered a physician order for lab work; the order was placed on the Medication Administration Record; a lab form was completed and placed in the lab book for the lab to be drawn; an order was placed to fax the results to pharmacy for medication distribution when applicable; the results were received and faxed to pharmacy when applicable; and the medication is administered as ordered by the provider to prevent a significant medication error; and when the order appears on the Medication administration record the licensed nurse will ensure the lab results are faxed to the pharmacy. All ordered lab work will be reviewed from the previous day to ensure results have been reviewed by the provider and as applicable faxed to the pharmacy timely to prevent a significant medication error on Monday through Friday with ordered lab work through the weekend reviewed Monday for two weeks and then weekly for ten weeks. Results of these audits will be presented by the Director of Nursing or Designee to the facility Quality Assurance and Performance Improvement (QAPI) Committee monthly for three months for review and, if warranted, further action. Alleged date of immediate jeopardy removal date and compliance date: 11/14/2024 The corrective action plan was validated on 11/26/24. Interviews were conducted with a sample of nurses to verify education was conducted for nurses regarding processing lab results and pharmacy notification of lab results. Documentation of in-service records were reviewed. The initial audit was verified as well as the ongoing monitoring audits to identify residents that required labs for medication administration were verified to be completed. In an interview with the Director of Nursing on 11/26/24 at 12:00 pm, she stated that nurses, had been educated on the process for physician orders for medications that required lab monitoring and the completion of labs, to include to fax results to the pharmacy where indicated. The providers were also educated on the new process. Resident #11's medical record revealed the resident had received all prescribed doses of Clozapine from 11/14/24 through present. He had an order for labs and a separate order to fax lab results related to the medication, clozapine to the pharmacy every 28 days. The facility's immediate jeopardy removal date and compliance date of 11/14/24 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview, staff interview, nurse practitioner interview, physician interview, pharmacist interview, and psychiatry nurse practitioner interview the facility failed to obtain laboratory tests as ordered and provide laboratory results to the pharmacy as required for antipsychotic medication monitoring for one (Resident #11) of one resident reviewed for laboratory services. Resident #11 had an acute psychotic event after laboratory results were not obtained and faxed to the pharmacy for the renewal of his antipsychotic medication. Resident #11 suffered a fall with a broken shoulder and hip that required surgical repair, acute blood loss and acute pain. Resident #11 has been bedbound since the incident. Abrupt withdrawal from the medication can cause rebound psychosis (sudden return of psychotic symptoms). Findings included: Resident #11 was admitted to the facility on [DATE] with a diagnosis of paranoid schizophrenia. Resident #11 had a physician's order for 200 milligrams (mg) Clozapine, an antipsychotic, to be administered as one tablet by mouth two times a day for paranoid schizophrenia initiated on 7/9/2024. The administration times listed were 8:00 AM and 8:00 PM. Documentation in the manufacturer's label for Clozapine revealed the average elimination half-life of Clozapine after a singe 75 mg dose was 8 hours with a range of 4 to 12 hours, while the average elimination half-life after achieving a steady state with 100 mg twice a day dose, of 12 hours. The abrupt stopping of Clozapine has been associated with agitation and a rapid onset of psychosis. Documentation in the assessment and plan portion of a psychiatry progress note date 9/19/2024 revealed Resident #11's paranoid schizophrenia was chronic and stable. The documentation also indicated Resident #11 was adhering to his medication regimen and indicated a stable mental state. Resident #11 had a physician's order dated as initiated on 9/19/2024 for blood to be drawn for a complete blood count (CBC) and a complete metabolic panel (CMP) on the night shift every 30 days for anemias and vitamin deficiencies to be completed on 10/19/2024 at 7:00 PM. Anemia and vitamin B12 deficiency can be a rare side effect of the medication Clozapine. Documentation on a quarterly Minimum Data Set assessment dated [DATE] coded Resident #11 as cognitively intact with no mood issues or behaviors. Resident #11 was coded as requiring substantial assistance with mobility and transfers. Documentation on the October Medication Administration Record (MAR) revealed on 10/19/2024 at 7:00 PM Nurse #2 completed the order for a CBC and a CMP for Resident #11. There was no evidence in the electronic medical record for Resident #11 of the CBC and CMP laboratory results from 10/19/2024. Nurse #2 was interviewed on 11/22/2024 at 11:01 AM. Nurse #2 explained she worked in the facility on the 7:00 PM to 7:00 AM shift. Nurse #2 acknowledged she checked off on the MAR that Resident #11's CBC and CMP were completed on 10/19/2024, but it was not completed. Nurse #2 further explained the order for laboratory services for Resident #11 involved the nursing staff putting the necessary paperwork into a laboratory book so that when the phlebotomist came to draw blood between midnight and 5:00 AM, they would have the necessary information to do so. Nurse #2 stated that usually the orders for laboratory services for the residents were acknowledged and the information for the laboratory book was completed by the day shift nursing staff. Nurse #2 stated she must have been distracted or just forgot on 10/19/2024 to put the required information into the laboratory book for the phlebotomist who comes to the facility to draw the blood for Resident #11. Nurse #2 stated she did understand the system and process for residents to obtain laboratory services, but she thought this was the first time she had to obtain laboratory services for Resident #11. Resident #11 had an additional physician's order written by Nurse Practitioner (NP) #1 dated 10/22/2024 at 11:17 AM for the medication Clozapine to be held for two days until 10/24/2024 at 11:17 AM. NP #1 was interviewed on 11/22/2024 at 9:52 AM. NP #1 revealed the following information. NP #1 explained the reason the Clozapine was put on hold for Resident #11 on 10/22/2024 was because the pharmacy needed laboratory tests to be sent to them prior to filling another 30-day supply of the medication to Resident #11. The pharmacy requires the CBC because Clozapine puts a resident at higher risk for infections. The requirement for the laboratory tests to be sent to the pharmacy prior to filling the Clozapine for Resident #11 was well known to the facility and there was a reoccurring order for blood to be drawn from Resident #11 for laboratory tests each month ahead of time prior to Resident #11 running out of Clozapine. The problem, as explained by NP #1, was that the laboratory tests for Resident #11 were not drawn as ordered on 10/19/2024 and were then not faxed to the pharmacy. NP #1 explained on 10/22/2024 she entered an additional order for a CBC with differential for Resident #11 to be completed STAT (immediately) when she was notified Resident #11 ran out of his Clozapine. (A CBC with differential measures the number and types of cells in your blood to help diagnose a variety of conditions to include infection.) An interview was conducted with a Pharmacist from the facility's pharmacy on 11/22/2024 at 10:25 AM. The Pharmacist revealed that because of the required laboratory tests, the medication Clozapine was not available for the nurses to remove from an electronic medication dispensing cabinet for Resident #11. The Pharmacist explained the laboratory tests were required before the medication could be dispensed from the pharmacy and there was no other way of obtaining the medication for Resident #11. Documentation in a progress note written by NP #1 on 10/22/2024 at 7:55 PM revealed in part, [Resident #11's] schizophrenia appears controlled with current therapy. Will order lab work as indicated and continue with therapy as prescribed. Obtain STAT (immediate) CBC and CMP. (A CBC and CMP measure the number and types of cells in your blood to help diagnose a variety of conditions to include infection.) Documentation on a lab results report for Resident #11 revealed the collection date was 10/23/2024 at 10:31 AM, received at 10/23/2024 at 10:31 AM, and reported to the physician on 10/23/2024 at 11:15 AM. Documentation on the October Medication Administration Record (MAR) indicated Resident #11 had the medication Clozapine on hold by the practitioner for the 8:00 PM dose on 10/22/2024, the 8:00 AM dose on 10/23/2024, the 8:00 PM dose on 10/23/2024, and the 8:00 AM dose on 10/24/2024. Documentation on the same MAR indicated Resident #11 did not receive the scheduled Clozapine for the 8:00 PM dose on 10/24/2024, the 8:00 AM dose on 10/25/2024, and the 8:00 PM dose on 10/25/2024. Documentation in a physician's progress note for Resident #11 dated 10/25/2024 at 1:00 PM written by Medical Doctor (MD) #1 stated in part, Today, he was quite ornery. He is having acute psychosis event at this point. Very difficult to reconcile, redirect and calm down. He was actually verbally offensive and abusive to many of the staff members as well as me and other residents. The patient became very angry while at the nursing station. Attempted to get out of his wheelchair and I suspect probably attempted to take a swing at a staff member when he fell backward and fell on the ground. We did not move him, but I did assess him the best I could on the floor. He denies complaints at this point. However, I am concerned about his ongoing injury from his fall. He did not strike his head. Neurologically, he had no changes from his fall at this point. Neurological assessment otherwise is his baseline other than psychosis. Brief orthopedic assessment could not be completed after a fall secondary to the patient being stabilized on the ground awaiting EMS [Emergency Medical Services]. His vital signs otherwise are stable at this point. Approximately 15 minutes earlier, he received an IM [intramuscular] injection of Benadryl in his arm to calm him down I believe. Benadryl is an antihistamine that can have a sedative effect. An interview was conducted with the physician for Resident #11, MD #1, on 11/22/2024 at 1:23 PM. MD #1 explained that Resident #11 was rolling around in his wheelchair acting very verbally abusively threatening staff, other residents, and MD #1 on 10/25/2024. MD #1 explained Resident #11 was yelling, cussing, and speaking in tongues and acting in a way he had never seen before for this resident. MD #1 explained that Resident #11 rose up out of his wheelchair and what looked like to him attempted to take a swing at one of the staff members nearby, when he fell hard on the ground. MD #1 explained that Resident #11 did periodically have verbal behaviors but this was something else. MD #1 stated he could not definitively say missing the six doses of Clozapine at the time of the incident and fall on 10/25/2024 was a direct cause of the accident because he was unsure of the half- life of the medication. (The half-life provides an accurate indication of the length of time that the effect of the drug persists in an individual.) MD #1 confirmed there was no reason Resident #11 should have missed getting the required lab work completed and missed doses of Clozapine. Documentation in the nursing progress notes dated 10/25/2024 at 1:46 PM written by Nurse #5 revealed, Nurse called pharmacy to check status of resident's Clozapine oral tablet 200 mg. Pharmacist requested to have copy of labs. Nurse [#5] faxed lab per request. [NP #1] made aware. Nurse #5 was interviewed on 11/25/2024 at 9:52 AM. Nurse #5 stated she was the unit manager, and she was in the office adjacent to the nursing station with NP #1 when Resident #11 fell. Nurse #5 revealed Resident #11 usually had a calm demeanor when he received his medication Clozapine, but when he did not receive his antipsychotic medication, he became almost demonic. Nurse #5 explained that the medication Clozapine required laboratory tests to be completed prior to the pharmacy filling the medication. Nurse #5 further explained the nurses working at the facility should have known Resident #11 required the medication Clozapine and that the laboratory tests must be sent to the pharmacy for the medication to be obtained from the pharmacy. Nurse #5 stated the nurses who were working on the medication cart should have known to call the pharmacy if Resident #11 did not have his Clozapine and the pharmacy would have readily told the nurse the laboratory report was needed. Nurse #5 stated when she saw the manic state Resident #11 was in on 10/25/2024 she called the pharmacy because she surmised, he probably had not received his antipsychotic medication. Nurse #5 indicated after the pharmacy notified her the laboratory report was needed, she immediately faxed the results to the pharmacy, and the pharmacy sent the Clozapine to the facility. Documentation on a SBAR (Situation, Background, Assessment, and Recommendation) communication form and progress note dated 10/25/2024 initiated at 3:15 PM written by Nurse #6 revealed in the nursing assessment, Resident having outburst with behavior toward staff. Documentation in the nursing progress notes dated 10/25/2024 at 3:21 PM written by Nurse #6 stated, Resident up and down the hall in wheel[chair] with noted behavior fussing at staff and other residents. Resident talking to self, having out [bursts] toward others. Resident attempted to stand up to hit at staff when resident fell at nursing station. Resident complained of pain, refused help from staff, [Primary Care Physician] onsite, EMS/Police called to escort resident to [emergency room]. Resident family aware/unit manager aware. Nurse #6 was interviewed on 11/25/2024 at 11:36 AM. Nurse #6 revealed she was an agency nurse who only periodically worked at the facility. Nurse #6 stated that Resident #11 was in an agitated state rolling around the facility in a wheelchair swearing at everyone around him on 10/25/2024. Nurse #6 indicated she notified the charge nurse, Nurse #5, when during her medication pass administration, she noted Resident #11 did not have his antipsychotic medication, Clozapine. Nurse #6 stated Nurse #5 contacted the pharmacy and was told Resident #11 required laboratory tests to be sent to the pharmacy prior to the distribution of the medication by the pharmacy. Record review of an emergency room visit on 10/25/2024 for Resident #11 revealed resident was uncooperative for an x-ray of his left shoulder with continuous refusals. Resident #11 was administered medications intramuscularly to calm him down enough to perform an x-ray of the left shoulder. The x-ray of the shoulder revealed Resident #11 had a fracture of the long bone, between the shoulder and the elbow. Resident #11 was transferred back to the facility with a long-arm splint and sling for support with the recommendation to follow-up with orthopedics the first of the next week. NP #1 was interviewed on 11/22/2024 at 9:52 AM and the following additional information was provided. NP #1 revealed the CBC with differential was completed as ordered on 10/23/2024, but the results were not faxed to the pharmacy until 10/25/2024, resulting in Resident #11 missing seven doses of his Clozapine until the pharmacy sent another 30- day supply on 10/26/2024. NP #1 indicated the medication Clozapine did not make Resident #11 lucid but did make him manageable, so he was not hollering and yelling all the time. NP #1 stated she was in her office near the nursing station on 10/25/2024 when Resident #11 started yelling obscenities and could be heard threatening everyone around him. NP #1 stated she saw MD #1 step back away from Resident #11, but she did not actually see him fall. NP #1 stated Resident #11 hit the ground so hard it could be heard by everyone. NP #1 explained MD #1 immediately ordered for 911 to be called as Resident #11 needed to be sent out. NP #1 indicated Emergency Medical Services (EMS) arrived very quickly but Resident #11 was so belligerent the police had to be called to assist the EMS workers. NP #1 indicated that after the incident on 10/25/2024 she questioned if the results of the CBC from 10/23/2024 were ever faxed to the pharmacy because Resident #11 was acting like he was not on his psychoactive medication. NP #1 stated at that point someone called the pharmacy to check if they received the laboratory results for Resident #11. An interview was conducted with a pharmacist from the facility's pharmacy on 11/22/2024 at 10:25 AM. The Pharmacist revealed the following information. According to the pharmacy records, Resident #11 ran out of the ordered medication Clozapine on 10/22/2024. The Pharmacist called the facility on 10/22/2024 and notified them of a need for a CBC differential for Resident #11 to be faxed to the pharmacy so that another 30-day supply of the medication could be sent to the facility. The Pharmacist did not have any record of who she spoke to at the facility. The Pharmacist explained the pharmacy requires the blood test CBC with differential every 30 days for a resident on the medication Clozapine to monitor the neutrophil counts in the blood. Residents taking Clozapine can develop dangerously low neutrophil counts. Neutrophils are the cells that fight off infection in the body and if someone had very low levels of neutrophils; he or she can be vulnerable to infections. The required CBC with differential for Resident #11 was not sent to the pharmacy on 10/22/2024. The pharmacy received the CBC with differential dated 10/23/2024 for Resident #11 on 10/25/2024. The pharmacy sent a 30-day supply of the Clozapine to the facility on the morning of 10/26/2024. The Pharmacist stated if the medication Clozapine, used for paranoid schizophrenia, was abruptly stopped there was usually rebound psychosis and increase in behaviors related to Clozapine's short duration of action. Documentation in the Nursing Progress notes dated 10/25/2024 at 5:30 PM written by Nurse #6 revealed, [Resident #11] return from hospital with a [diagnosis] of closed displaced fracture of the surgical neck of the left humerus, unspecified fracture morphology. New order to go to Orthopedics in 3 days. Sling to left arm noted. The humerus is the long bone that runs from the upper shoulder to the elbow. Unspecified fracture morphology means the doctor does not have enough information to describe the exact shape or pattern of a bone fracture. Documentation in a nursing progress note dated 10/29/2024 at 6:07 PM revealed that Resident #11 was sent to the emergency room for a difference in legs and swelling to his knee. Documentation in a discharge summary from the hospital revealed Resident #11 had a hospitalization from 10/29/2024 to 11/6/2024 for surgical repair of a left hip fracture. Additionally, while in the hospital Resident #11 had the additional problem areas and procedures of acute blood loss with transfusion of 2 units of blood and acute pain due to trauma. An interview was conducted with a Nurse Aide (NA) #5 on 11/22/2024 at 12:14 PM. NA #5 revealed she worked on the first (7:00 AM to 3:00 PM) and second (3:00 PM to 11:00 PM) shift routinely. NA #5 indicated she knew the care needs of Resident #11 well. NA #5 stated Resident #11 would occasionally get out of bed with a one person stand and pivot to the wheelchair prior to his fall. NA #5 stated that Resident #11 was a completely different person now and required a mechanical lift to get out of bed, but he no longer wants to get out of bed. NA #5 stated she knew Resident #11 did not like the mechanical lift. Resident #11 was observed on 11/22/2024 to be asleep in bed laying on his right side at 9:46 AM, 11:10 AM, and 1:04 PM. An observation and interview were conducted with Resident #11 on 11/22/2024 at 4:29 PM. Resident #11 was laying on his right side in bed with a sling on his left arm. Resident #11 stated he had consistent pain in his hip, and he longer felt like he could get out of bed. An interview was conducted with MD #1 on 10/25/2024 at 11:22 AM. MD #1 stated he visited with Resident #11 on 11/22/2024 to encourage him to work with therapy. MD #1 stated the mentation of Resident #11 was to just stay in bed and not move at this point. Documentation in a psychiatry progress note dated 11/14/2024 written by NP #2 revealed under the history of present illness portion in part, Patient ran out of his clozapine a few days ago, which led to a resurgence of his delusions and hallucinations. This incident escalated to the point where he attempted to physically confront a doctor, resulting in a fall. Since resuming his medication, his symptoms have subsided, and he is reported to be doing well again. The goal is to prevent such an occurrence in the future by ensuring consistent access to his medication. His current medication regimen will be continued without changes, with a follow-up planned in a few weeks. NP #2 was interviewed on 11/22/2024 at 1:43 PM. NP #2 explained that Clozapine had side effects with one of them being the possibility of a severe decrease in white blood cell counts, although rare was a possibility. NP #2 further explained the pharmacy was required to monitor the neutrophils by receiving the laboratory values of Resident #11 monthly prior to sending the Clozapine to the facility to make sure he was not having any adverse side effects. NP #2 stated it was hard to say if the behaviors of Resident #11 on 10/25/2024 were due to him missing 6 doses of Clozapine over two and a half days. NP #2 stated the half-life of Clozapine was 26 to 36 hours. NP #2 revealed she visited the facility every two weeks and usually the facility staff reported occasional verbal behaviors from Resident #11 and never reported physical behaviors. The Director of Nursing (DON) was interviewed on 10/22/2024 at 10:45 AM. The DON stated she felt the root cause of the failure to obtain the Clozapine medication for Resident #11 began with Nurse #2 not following the physician order and not putting the required information in the laboratory book for the laboratory order to be carried out. The DON stated she felt like an additional root cause was the failure of NP #1 to separate out the orders so that one order was to obtain the laboratory services for Resident #1 and then a second order should have been written to fax the results to the pharmacy. The facility was notified of the immediate jeopardy on 11/22/2024 at 3:39 PM. The facility submitted the following corrective action plan on 11/23/2024: Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 10/22/24 at 8:00 pm, Resident #11's medication could not be administered as ordered by the provider due to it not being available. When the nurse notified the pharmacy of the medication not being available to administer the pharmacy stated the medication required lab work to be completed and faxed to the pharmacy prior to dispensing the medication. On 10/22/24 the provider was notified, and an order was obtained to draw stat lab work on 10/22/24. The results of the labs were received on 10/23/24 in the morning and the provider failed to place a physician order to fax the results to the pharmacy so the medication could be dispensed. On 10/25/24 at 1:26 pm the nurse notified the pharmacy the medication was not available to administer. Upon notifying the pharmacy the pharmacy stated they had not received the lab results to dispense the medication. The provider was notified and stated the lab work had been completed and needed to be faxed to the pharmacy. The lab results were faxed to the pharmacy and received by the pharmacy at 1:42PM. The pharmacy dispensed the medication at 1:59pm. The facility received Resident #11's medication on 10/26/24 at 2:00 am. On 10/26/24 Resident #11's medication of Clozapine was administered at 8:00am to the resident as ordered by the provider. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: An audit of all current residents was completed by the Director of Nursing on 10/23/24 to determine if any other residents required lab work previous to medication distribution from pharmacy. No other residents required lab work prior to medication distribution indicating that there were no other residents affected by the deficient practice of not obtaining lab services as ordered by the provider. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: Licensed nurses were educated on the new process that the provider will enter a physician order for lab work. The order will be on the Medication Administration Record. The Licensed Nurse will ensure a lab form is completed and placed in the lab book for the lab to be drawn. Results of the lab are integrated with the electronic medical records system and once the results are received the provider is notified to review. When applicable, a separate order will be placed on the medication administration record when a lab is required to be faxed to the pharmacy for medication distribution. The providers were educated on 11/8/24 of the new process by the Director of Nursing. When the order appears on the Medication Administration record the licensed nurse will ensure the lab results are faxed to the pharmacy. Education was provided by the Director of Nursing to licensed staff and licensed agency staff on 11/12/24 to 11/13/24 that the provider will enter a physician order for lab work. The order will be on the Medication Administration Record. The Licensed Nurse will ensure a lab form is completed and placed in the lab book for the lab to be drawn. Results of the lab are integrated with the electronic medical records system and once the results are received the provider when applicable will order for lab results to be faxed to the pharmacy. The order will be placed on the medication administration record when a lab is required to be faxed to the pharmacy for medication distribution. When the order appears on the medication administration record the licensed nurse will ensure the lab results are faxed to the pharmacy. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: On 11/4/24 the Quality Assurance team (Administrator, Director of Nursing, Assistant Director of Nursing, nurse practitioner, Medical Director, social services director, admissions director and therapy director) met and a decision was made that the Director of Nursing or Designee will audit that includes the following: the provider entered a physician order for lab work; the order was placed on the Medication Administration Record; a lab form was completed and placed in the lab book for the lab to be drawn; an order was placed to fax the results to pharmacy for medication distribution when applicable; when the order appears on the medication administration record the licensed nurse ensured the lab results were faxed to the pharmacy, and the results were received and faxed to pharmacy when applicable. All ordered lab work will be reviewed from the previous day to ensure results have been reviewed by the provider and as applicable faxed to the pharmacy timely to prevent an omission of ordered lab services on Monday through Friday with ordered lab work through the weekend reviewed Monday for two weeks and then weekly for ten weeks. Results of these audits will be presented by the Director of Nursing or Designee to the facility Quality Assurance and Performance Improvement (QAPI) Committee monthly for three months for review and, if warranted, further action. Alleged date of immediate jeopardy removal date and compliance date: 11/14/2024 The facility's correction action plan was validated on 11/26/24. Interviews were conducted with a sample of nurses to verify education was conducted for nurses regarding processing lab results and pharmacy notification of lab results. Documentation of in-service records were reviewed. The initial audit was verified as well as ongoing monitoring audits to ensure labs were obtained were verified to be completed. In an interview with the Director of Nursing on 11/26/24 at 12:00 pm, she stated that nurses had been educated on the process for physician orders for medications that required lab monitoring and the completion of labs, to include to faxing results to the pharmacy where indicated. The providers were also educated on the new process. Resident #11's medical record revealed the resident had received all prescribed doses of Clozapine from 11/14/24 through present. He had an order for labs and a separate order to fax lab results related to the medication, clozapine to the pharmacy every 28 days. The facility's immediate jeopardy removal date and compliance date of 11/14/24 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews with resident, staff and the Physician, the facility failed to protect the residents' right to be free from resident to resident abuse for 3 of 5 residents reviewed for abuse (Resident #222, Resident #61, and Resident #41). On 10/19/23 Resident #2, a male resident, entered Resident #222's room (a female resident) and punched her in her legs multiple times with a closed fist as she was sitting on her bed. On 6/22/24 Resident #2 punched Resident #61 (a female resident) in the face multiple times with a closed fist at the nurse's station due to the belief that she was cheating on him. Resident #222 and Resident #61 were vulnerable and were unable to protect themselves. The physical abuse had a high likelihood of resulting in serious physical and psychosocial harm. A reasonable person expects to be protected from physical abuse in their home and would suffer trauma such as feelings of fear, anxiety, and intimidation. Additionally, the facility failed to protect Resident #41 from verbal abuse perpetrated by Resident #6 when he verbally threatened Resident #41 stating he was going to kill her and everyone else in the facility. Immediate jeopardy began on 10/19/23 when Resident #2 punched Resident #222 multiple times in the legs with a closed fist. Immediate jeopardy was removed on 10/11/24 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity D to ensure education is completed and monitoring systems put in place are effective. Example #2 for Resident #41 was cited at scope and severity D. Findings included: 1. Resident #2 was admitted to the facility on [DATE] with diagnoses that included non-traumatic intracranial hemorrhage (stroke) and hemiplegia (weakness on one side of the body) and hemiparesis (paralysis on one side of the body), schizophrenia and dementia. Review of the care plan for Resident #2 initiated on 4/7/23, identified problems of: Behaviors including swinging at staff, yelling, history of throwing himself on the floor for attention, kicking and hitting at staff, wandering in and out of other resident's rooms, resident to resident altercation and pushing equipment forcefully. The goal was the resident would have no negative outcomes related to behaviors through the next review. Interventions included administer medications as ordered and observe for side effects and effectiveness. Anticipate and meet the resident's needs, explain all procedures to the resident before starting and allow the resident time to adjust to changes. If reasonable, discuss the behavior with the resident and explain/reinforce why the behavior is inappropriate and/or unacceptable. Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner, divert attention and remove from the situation and take to an alternate location as needed. Monitor behavior episodes and attempt to determine underlying causes considering location, time of day, persons involved and situations. Document behavior and potential causes. The quarterly Minimum Data Set, dated [DATE] revealed Resident #2 was severely cognitively impaired and required supervision or touching assistance with wheelchair mobility. He was coded as having no hallucinations or delusions and receiving antipsychotic, antianxiety and antidepressant medications. He was coded as having had other behavioral symptoms not directed toward others. The active physician's orders for Resident #2 on 10/19/23 included the following psychotropic medications: - Fluoxetine (antidepressant medication) 10 milligrams (mg) once daily - Olanzapine (antipsychotic medication) 7.5 mg once daily - Ativan (antianxiety medication) 0.5 mg twice daily - Trazodone (antidepressant used for sleep) 75 mg once daily - Depakote (mood stabilizer) 375 mg twice daily - Buspirone (antianxiety medication) 5 mg twice daily. Review of a progress note written by Nurse #2 on 10/19/23 at 2:14 AM stated Resident #2 was going in and out of other residents' rooms. He was cursing at Nurse #2 and became combative when she tried to remove him. Review of a progress note written by Nurse #2 on 10/19/23 at 4:50 AM stated Resident #2 was in the employee break room, removing items from the refrigerator and throwing them on the floor. The note further stated Resident #2 was verbally abusive and physically combative. Nurse #2 indicated they were unable to redirect him. a. Resident #222 was admitted to the facility on [DATE] with diagnoses that included reduced mobility and moderate intellectual disabilities. The admission MDS dated [DATE] revealed Resident #222 was severely cognitively impaired with no behaviors. It further revealed she had no impairment of upper or lower extremities and needed substantial assistance with activities of daily living. A review of Resident #222's comprehensive care plan revealed no care plan for behaviors. A nurse's note written by Nurse #1 on 10/19/23 at 8:23 PM stated she was notified by the Physical Therapist (PT) that Resident #2 hit Resident #222 with a closed fist. The note further stated Resident #2 was fighting and kicking the PT and Nurse Aide (NA) #2 while they removed him from the room. Resident #2 was holding onto the handrails in the hall trying to get back into the room, attempted to hit NA #2 and Nurse #1 in the face with a closed fist. DON #2 attempted to calm Resident #2 but was unsuccessful. Nurse #1 notified Nurse Practitioner #1 and received a one-time order for antipsychotic medication which they gave with no effect. Emergency Medical Services (EMS) and the Sheriff were notified. They arrived at the facility and transported Resident #2 to the hospital. A review of Resident #2's record revealed an order dated 10/19/23 for 2.5 milliliters (ml) of Haldol (antipsychotic medication) injection solution 5 mg/1 ml to be given intramuscularly (injected into a muscle) one time only for behaviors. An interview with the PT who witnessed the resident abuse on 10/19/23 was interviewed on 10/11/24 at 9:40 AM. He stated he heard yelling coming from the room of Resident #222 and went to investigate. When the PT entered the room, he observed Resident #222 sitting on the edge of her bed. Resident #2 had come into her room in his wheelchair and was punching her on the legs repeatedly with a closed fist. Resident #222 was not physically responding. The PT immediately removed Resident #2 from Resident #222's room. The PT further stated Resident #2 held onto furniture and the handrail outside the room when he removed him from the situation. When the PT got Resident #2 into the hall he yelled to Nurse #1 and NA #3 to help. He told them what he had witnessed and immediately went and reported the incident to the Therapy Department Manager. The PT revealed Resident #222 looked surprised but not upset or crying. The PT revealed he was familiar with Resident #2 and he was not surprised he struck another resident as he often hit staff. He further revealed that Resident #2 was unpredictable in his actions and often struck without notice. NA #2 was not available for interview. Nurse #1 was not available for interview. A nurse's note written by DON #2 on 10/19/23 at 8:21 PM revealed she was called to the hallway outside of Resident #222's room at approximately 6:50 PM to help with Resident #2 who was striking and kicking staff and attempting to get back into the room of Resident #222. The note further revealed she brought him in his wheelchair to the nurse's station to attempt to redirect him but was unsuccessful. Resident #222 was taken to the hospital by EMS at approximately 7:10 PM due to his behaviors and being a danger to himself and others. An interview was conducted with DON #2 on 10/9/24 at 3:24 PM. She stated she was called to the hallway outside the room of Resident #222 at approximately 6:50 PM on 10/19/23 because Nurse #1 and NA #3 needed help with Resident #2 who was fighting with staff. When she arrived, Resident #2 was holding onto the handrails in the hall while the PT, Nurse #1 and NA #3 were attempting to have him let go. Resident #2 did let go of the handrail, but then tried to punch DON #2, NA #3 and the PT. DON #2 was able to take him to the nurse's station where she attempted to calm him without success. DON #2 further stated Nurse #1 called Nurse Practitioner (NP) #1 and received a one-time order for a psychotropic medication (Haldol injection) to help calm him without effect. Nurse #1 then called EMS who sent the Sheriff and an ambulance. Resident #2 was then taken to the hospital. He returned to the facility the same evening. DON #2 revealed she assessed Resident #222 approximately 30 minutes after the incident and she was free of physical injury such as bruising or scratches. She further revealed Resident #222 did not recall the incident at that time. DON #2 indicated Resident #222 was not able to defend herself due to her cognitive status. She also indicated staff were afraid of Resident #2 as he was strong enough to push medication, treatment and food carts into them, sometimes backing them into a corner. He also hit, kicked and screamed at staff without warning. NA #3 was not available for interview. Police report dated 10/19/23 indicated that when he responded to the call Resident #2 was at the nurse's station with staff and was calm. It further indicated that Resident #2 was transported to the hospital by EMS. An emergency room note dated 10/19/23 stated Resident #2 was brought to the hospital by ambulance after a combative episode at the facility. He was not combative with hospital staff. The note further stated Resident #2 was given Trazodone and Ativan to help him sleep and basic blood and urine tests were performed to rule out dehydration and infection. The tests were unremarkable. Resident #2 was transported back to the facility the same day with no new orders. A Nurse's note written by Nurse #2 on 10/19/23 revealed Resident #2 returned to facility at 11:35 PM accompanied by two ambulance attendants. He was alert, awake and calm when returned to the facility. Physician's orders dated 10/20/23 indicated Resident #2's olanzapine was changed from 7.5 mg once daily to 5 mg twice daily and clonazepam (antianxiety medication) 0.25 mg three times a day was initiated. A psychiatric note completed by Nurse Practitioner (FNP) #2 on 10/30/23 revealed: Recent medication changes have had mild improvements in his behaviors and DON feels this is the best combination he has been on so far, but there are still concerns about how his behaviors are affecting the safety of himself, other residents and staff. He has impulsivity with rage and loves to terrorize. He reportedly went after a pregnant staff member. He was noted to push medication carts with his wheelchair until staff were backed into a corner or until he hit them with the cart. Staff felt he has no problem hitting or punching people. This has created issues providing care to him as staff were scared of him when he became agitated. The facility has had to involve law enforcement due to his behaviors. He was sneaking into the staff breakroom and will get into whatever is in there and he has been stealing food off other residents' trays. Facility noises appeared to overstimulate him and his behaviors got notably worse at shift change around 4 pm. The note further stated Resident #2 was not a danger to himself or others at that time. Interventions included changes to his psychotropic medication regime and a referral to psychotherapy. NP #2 was unavailable for interview. A telephone interview with the Physician on 10/14/24 at 10:25 AM revealed he did not recall the 10/19/23 incident, and he did not see mention of it in his progress note. The Physician stated Resident #2 was capable of striking other residents in October of 2023 but did not feel he was capable recently due to a decline in function. He further stated the resident has had psychiatric services involved throughout his stay at the facility. b. Resident #61 was admitted to the facility on [DATE] with diagnoses that included encephalopathy (alteration in brain function), decreased renal function and the need for dialysis. A review of the admission MDS dated [DATE] revealed Resident #61 was severely cognitively impaired with no behaviors. She was able to walk less than 10 feet with a walker and substantial assistance. Resident #61's comprehensive care plan revealed she was not care planned for behaviors. A nurse's note completed by Nurse #3 on 6/22/24 at 6:52 PM stated Resident #61 was punched in the face twice by Resident #2 at the nurse's station. Resident #61 was pulled to safety by staff. Resident #2 was still trying to hit the staff. NP #3 was called and ordered a one time dose of a psychotropic medication that was given with no effectiveness. EMS was called and the ambulance and Sheriff arrived. Resident #2 attempted to hit and kick the Sheriff and ambulance crew. He was taken to the hospital for evaluation. Skin check sheet for Resident #61 dated 6/22/24 was completed by Nurse #3 and it revealed there were no injuries to Resident #61. A review of Resident #2's record revealed an order dated 6/22/24 for 2.5 ml of Haldol injection solution 5 mg/1 ml to be given intramuscularly one time only for behaviors. In a telephone interview with Nurse #3 on 10/9/24 at 9:07 AM she stated on 6/22/24 she witnessed Resident #2 wheel his wheelchair to the nurse's station where Resident #61 was sitting in her wheelchair, yelled at her that she had been cheating on him (they were not a couple) and punched her in the nose twice. Resident #2 was removed from the area by an NA and she (Nurse #3) attended to Resident #61. She stated Resident #61 was upset but not crying. Resident #61 had no physical injuries at that time. She further stated Resident #61 was not able to protect herself from an attack due to age and debility. Nurse #3 revealed Resident #2 was unpredictable and volatile at baseline. She stated he would lash out at staff, trying to punch or kick them, go into other residents' rooms, get into the staff break room and throw stuff around and push medication and food carts into staff. Nurse #3 further revealed that many staff were afraid of being, or have been, hurt by him. A nurse's note written by DON #3 on 6/22/24 at 8:56 PM revealed he assessed Resident #61 for bruising or swelling of the nasal area and the area was clear of obvious injury. The police report for 6/22/24 was requested and law enforcement indicated there was no police report. The hospital emergency room visit note dated 6/22/24 revealed Resident #2 was calm and did not recall assaulting Resident #61, staff or the Sheriff. It further stated he appeared to have cognitive deficits and could not hold a full conversation but could answer yes/no questions. Basic labs were run and were reported as unremarkable. No changes or recommendations were made. Resident #2 returned to the facility on 6/23/24. An interview with Resident #61 was conducted on 10/7/24 at 3:00 PM. She did not recall being punched by Resident # 2 on 6/22/24. In a telephone interview with DON #3 on 10/10/24 at 11:16 AM he stated he was not in the building at the time of the 6/22/24 incident but came in and filed a report with the State Agency, Adult Protective Services (APS) and local police. He further stated staff reported Resident #2 came up to Resident #61 at the nurse's station and punched her in the nose twice. DON #3 revealed Resident #2 was unpredictable in his actions such as screaming, kicking out or attempting to strike staff. DON #3 had not known Resident #2 to strike out at other residents, but he had only worked there for less than two weeks at the time of the incident. Resident #2 was observed on 10/7/24 at 9:10 AM lying quietly in his bed. A second observation was conducted on 10/10/24 at 10:15 AM. Resident #2 was sitting up in his wheelchair in his room screaming. When spoken to, he stopped screaming, smiled and waved. Resident #2 continued screaming afterward. An interview with the Physician on 10/14/24 at 10:25 AM revealed he did not recall the incident on 6/22/24 as he was out of the country at the time. The Physician stated Resident #2 was capable of striking other residents in June of 2024 but did not feel he was capable at this time due to a decline in function. He further stated the resident has had Psychiatric services involved throughout his stay at the facility. Administrator #1 was notified of Immediate Jeopardy on 10/10/24 at 9:25 AM. The facility implemented the following credible allegation of immediate jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: On 10/19/23 Resident #2 was in Resident #222's room when a staff member heard residents talking. The staff member went into Resident #222's room and observed Resident #222 hitting Resident #2 with a closed fist. Staff immediately removed Resident #222 from the resident's room. Residents were assessed for injuries by the staff nurse on 10/19/23. No injuries were noted. Resident #2 and Resident #222 were unable to recall the events of the incident. Resident #2's physician was notified on 10/19/23. All attempts to calm Resident #2 were unsuccessful. Resident #2 was sent to the hospital emergency department on 10/19/23 for further evaluation. On 10/20/23 Social Services offered emotional support to Resident #222 and documented no signs of distress, discomfort or pain noted. Upon Resident #2 returning to the facility resident was placed on increased supervision and assessed by psychiatric nurse practitioner on 10/30/23. On 6/22/24 Resident #2 was observed punching Resident #61 in the nose with a closed fist twice while both were in their wheelchairs at nurses' station. Staff immediately separated the residents. Resident #2 was sent to emergency room for further evaluation. Resident #61 was assessed with no injuries noted. Resident #2 continues to reside at the facility under psychiatric care and services. Resident #2 continues to receive medications as ordered and has not had any further altercations. He has shown a decrease in overall aggressive behaviors. Resident #222 no longer resides in the facility. Resident #61 continues to reside in the facility without further concerns. All Staff were interviewed by the Scheduler and Administrative Assistant on 10/10/24. All residents that were able to participate in an interview were interviewed by the Social Services and Admissions Director on 10/10/24. The questions that they were asked were the following: Do you know about abuse? Do you know who to report abuse to? Do you feel safe in the facility? Do you have any concerns about abuse (physical, verbal, emotional, sexual, financial)? Any further allegations made will be investigated towards resolution by the Administrator and /or Director of Nurses. All residents were assessed by nurses via skin sweeps for suspicious injuries on 10/10/24. No suspicious injuries (those injuries that would be evident without a reasonable or rational explanation for the injury) were noted at those times. All residents were assessed by the Director of Nursing, Assistant Director of Nursing and Unit Manager for behaviors including verbal abuse, physical aggression to ensure appropriate care plans were in place to prevent resident to resident altercation. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. Education - All staff including nurses, certified nursing assistants, agency/contract staff, all ancillary staff, and all newly hired employees will be educated on the Abuse Prevention Policy. The policy describes the right for residents to be free from abuse, neglect, exploitation or mistreatment. Staff will receive education on managing residents who have aggressive behaviors. Staff will be educated on verbal and nonverbal signs of aggression such as increased agitation, yelling out and clenching of fists. Staff will be educated on techniques to de-escalate residents displaying increased agitation such as removing the residents from the trigger and providing a quiet place for de-escalation. Staff will be trained to use the behavioral monitoring forms to document any aggressive behavior, including what happened before, during, and after the incident. All education will be completed by the DON/ADON designee by 10/10/2024. This education will include 1:1, and group training sessions. The Administrator/designee will be the person who will ensure all licensed nurses, certified nursing assistants, agency/contract staff, all ancillary staff, and all newly hired employees will be educated. No staff will work after 10/10/2024 until education has been received. Alleged date of Immediate jeopardy removal: 10/11/24. Onsite validation of the immediate jeopardy removal plan was completed on 10/11/2024. Interviews confirmed that all staff working on 10/11/24 were educated on the Abuse Prevention Policy. Staff were also educated on managing residents who have aggressive behaviors, verbal and nonverbal signs of aggression such as increased agitation, yelling out and clenching of fists, as well as techniques to de-escalate residents displaying increased agitation such as removing the residents from the trigger and providing a quiet place for de-escalation. Nurses were trained to use behavioral monitoring forms to document any aggressive behavior, including what happened before, during, and after the incident. Nurse aides indicated they would notify the Nurse of any aggressive behaviors, abuse, or incidents involving residents. All other staff indicated they would report to the Nurse, Director of Nursing or Administrator. Verification was completed that all staff scheduled to work 10/11/24 were reeducated prior to returning to duty. The immediate jeopardy removal date of 10/11/24 was validated. 2. Resident #41 was admitted to the facility on [DATE]. Review of Resident #41's Minimum Data Set assessment dated [DATE] revealed she was assessed as cognitively intact. She had no behaviors documented and required supervision with locomotion on and off unit. Review of Resident #6's Minimum Data Set assessment dated [DATE] revealed he was assessed as cognitively intact. He had no behaviors documented. Resident #6's active care plan as of 11/28/23 revealed there was no care plan for behaviors. An investigational summary completed by Previous Director of Nursing #1 dated 12/5/23 revealed on 11/29/23 Resident #41 reported that Resident #6 was outside in the smoking area with her. Resident #6 rolled up to Resident #41 in the wheelchair, stood up getting in her face, and stated he would kill her and other people. She stated she felt threatened and was afraid of him at that moment. She reported this to a staff member who brought her directly to the Previous Director of Nursing #1. Facility staff interviewed both residents and Resident #6 was not able to recall specific details. Resident #41 was able to recite what happened and that Resident #41 immediately removed herself from the situation and told staff about the incident. During an interview on 10/7/24 at 1:57 PM Resident #6 stated he did not remember the incident. During an interview on 10/10/24 at 11:01 AM Resident #41 stated she remembered the incident with Resident #6 a long time ago. She stated she was in the smoking area and as far as she could remember it was just herself and Resident #6 out there. She stated Resident #6 rolled up to her while she was in her wheelchair, stood up in front of her, and yelled at her, I will kill you and everyone here! She stated Resident #6 had never done this to her before or since. She stated at that moment, it made her afraid and she turned around, entered the dining room, and was met by the Activities Director. She told the Activities Director what Resident #6 had said to her and the Activities Director ensured her safety and removed her from the situation. She stated she did not remember much else about the incident, it did not affect her daily life at the facility, and she was not traumatized by the incident. She concluded she was being followed by psychiatric services and the facility set up a psychiatric evaluation following the incident as well as getting her statement. During an interview on 10/10/24 at 11:25 AM the Activities Director stated on 11/29/23 she was in the dining room preparing an activity for the residents. From the dining room she could view the smoking area through the dining room windows. Resident #6 and Resident #41 were in the smoking area at that time. She stated Resident #6 rolled over to Resident #41 and was making gestures in her face. She did not recall him standing up but he was up very close and personal in a threatening manner. The Activities Director went to the door as Resident #41 turned to the door and motioned to the Activities Director to let her come inside. Once inside, Resident #41 told the Activities Director that Resident #6 had threatened to kill her and called her some vulgar names. The Activities Director immediately took the resident to administration at that time and let Resident #41 recount what happened as another staff member took Resident #6 to his room. During an interview on 10/10/24 at 11:41 AM Administrator #1 stated she started working at the facility on 7/29/24. She stated she was not at the facility during the time of the incident. She stated since she became the Administrator, Resident #41 had not indicated to her any concerns of being fearful of Resident #6. She concluded residents should not be verbally threatened to be killed in the facility.