**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of hospital records, review of hospice notes, review of a transportation report, observations, and review of facility policy, the facility failed to ensure one resident (Resident #87) did not experience neglect. This resulted in Immediate Jeopardy and the potential for serious harm, injury, and/or negative health outcomes when on 12/03/23 Resident #87, whose left hand was discolored and painful, did not receive an x-ray as ordered, was not medicated for pain, and was not assessed by a physician or appropriately assessed by a nurse. She was not seen by a physician, and the primary care physician was not made aware of her condition. There was no documentation that Resident #87's radial pulse or capillary refill was assessed for appropriate blood flow to her left hand. X-rays were ordered on 12/03/23 but not completed until 12/07/23. Pain medication was ordered on 12/03/23 but not given until 12/06/23. The hospice physician ordered Resident #87 to be sent to the emergency room (ER) on 12/07/23 at 2:30 P.M. for evaluation, but she was not transported until 5:30 P.M. when she went by non-emergent transport. After being assessed in the emergency room, Resident #87 was diagnosed having left limb ischemia and dry gangrene, and her hand may not be salvageable. This affected one (Resident #87) of three residents identified by the facility as having a significant change in condition. The facility census was 108. On 12/14/23 at 1:09 P.M., the Administrator, Director of Nursing (DON), and Regional Director of Clinical Operations #16 were notified Immediate Jeopardy began on 12/03/23 when Resident #87 was observed with a discolored left hand, which became swollen, more painful and darkened in color. Upon assessment at the hospital on [DATE] Resident #87's hand was found to be painful and cold, with no left radial pulse detected. Her left hand was flaccid. Resident #87 had a hemoglobin level of 4.5 requiring a transfusion of three units of packed red blood cells. After being assessed in the emergency room, Resident #87 was diagnosed having left limb ischemia and dry gangrene, and her hand may not be salvageable. The Immediate Jeopardy was removed on 12/15/23 when the facility implemented the following corrective actions: · On 12/07/23 at 5:30 P.M., Resident #87 was sent to the hospital by non-emergency transport. · On 12/13/23, the DON began immediate education with all nurses to educate on the following and to be completed by 12/15/23: a. Facility protocol of Episodic and Narrative Documentation and physician and responsible party notification. b. Physician Orders and timely implementation and follow-up. c. Pain Management Protocols d. Any nurse who was not scheduled or who could not be educated will receive education prior to working their next scheduled assignment. · On 12/14/23 at 1:10 P.M., the facility reviewed the 24-hour summary report up to 5:00 P.M. for current residents to verify that any other residents who had/may have had a change of condition that appropriate documentation, notification, and follow-up occurred. Two residents were identified with a change of condition and appropriate documentation and notification had occurred. · On 12/14/23, the DON had phone conversations with our other contracted Hospices to make them aware of our expectations of communication of injuries of unknown origin, communication of new orders, and physician notification. · On 12/14/23, the Licensed Nursing Home Administrator (LNHA) began immediate education for all current staff on the facility protocols for Abuse, Neglect, Misappropriation, and Injury of Unknown Origin. This will be completed by 12/15/23. Any staff member who was unable to be educated will be educated prior to their next scheduled assignment. · On 12/14/23, the Medical Director was notified of the Immediate Jeopardy once the facility was notified. · On 12/15/23, the facility will conduct ongoing monitoring for condition change and documentation during the daily clinical morning meeting by reading the 24-hour summary report in the Electronic Health Record (EHR) Monday through Friday, and the 72-hour report on Mondays for Friday through Sunday to verify appropriate assessment/documentation and notification has occurred and will follow up as indicated. The DON/Designee will complete a condition change audit tool daily Monday through Friday to verify that condition change protocols, notification and documentation have been followed. · On 12/15/23, the LNHA will query five random staff members daily Monday through Friday weekly times four weeks, and then three times per week for four weeks, and then weekly for two weeks. Results will be reviewed at the Quality Assurance and performance Improvement meetings. · On 12/18/23 from 3:15 P.M. to 3:32 P.M., interviews conducted with Licensed Practical Nurse (LPN) #93, LPN #106, State Tested Nursing Assistant (STNA) #10, and STNA #38 verified they had received in-servicing as specified in the corrective action plan. Although the Immediate Jeopardy was removed on 12/15/23, the facility remains out of compliance at a Severity Level 2 (the potential for more than minimal harm that is not Immediate Jeopardy) as the facility is in the process of implementing their corrective action and monitoring for effectiveness and on-going compliance. Findings include: Review of the medical record for Resident #87 revealed an admission date of 01/24/23 with diagnoses including Alzheimer's disease with late onset, muscle weakness, dementia without behavioral disturbance, protein-calorie malnutrition, adult failure to thrive, anorexia, and osteoarthritis. Resident #87 was transferred to the hospital on [DATE] at 5:30 P.M. Review of Resident #87's care plan dated 03/21/23 revealed Resident #87 had the potential for pain with a goal to be free of pain/discomfort. One of the interventions was to evaluate for non-verbal indicators of pain. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she had severe cognitive impairment and at that time she was assessed as not having pain. She was noted as being under hospice care. Review of a progress note dated 12/03/23 at 8:00 A.M., written by LPN #120, documented the aide advised me about (the) res (resident's) left hand being discolored. It noted the nurse called hospice and told the nurse who answered about Resident #87's hand. She asked if the resident had any pain medication ordered. The nurse charted that she looked up her Medication Administration Record (MAR) and saw that she did not. The nurse (Hospice Nurse #171) stated she would call the doctor and would give her a call back. A couple hours later Hospice Nurse #171 came to the facility and looked at Resident #87. She said she had called the doctor and was waiting for them to call her back to see what pain medicine he could prescribe. She stated she would call the facility when she had an order. The note documented Hospice Nurse #171 did not call back during the shift. The progress note revealed the nurse let the following nurse know that they were waiting for a return call from hospice to see what they suggested. Review of the hospice note dated 12/03/23 revealed Hospice Nurse #171 was in on 12/03/23 at 11:30 A.M. to 12:05 P.M. The pain medication order on the hospice file at that time was Acetaminophen 500 milligrams (mg) to give two tablets every morning as needed for pain that started on 06/21/23. The Acetaminophen order was not on the facility's MAR or in the resident's electronic record. The note said the visit was completed at that time and Resident #87 was in bed complaining of left hand pain. The facility staff reported that she had blue and purple fingers. The physician was notified, and hospice staff were awaiting directions. Review of the hospice case note dated 12/03/23 at 8:55 P.M. documented a return call was received from Hospice Physician #172. Hospice Nurse #171 reported to the physician that Resident #87's hand was discolored at the fingertips. Resident #87 was able to move her fingers at that time and complained of discomfort and some swelling. Hospice Physician #172 gave orders for Tylenol 325 mg every six hours as needed and Norco 5/325 mg every four to six hours as needed. The physician was requesting an anteroposterior (AP) and lateral x-ray of her hand. The orders were called to the facility. Hospice Physician #172 would sign and send the orders for medication to the pharmacy. The orders were called and faxed to the facility. Review of the hospice case note dated 12/04/23 at 9:10 A.M. revealed a call was made to the facility by Hospice Nurse #171 to receive the results of the X-ray per request of Hospice Physician #172. The floor nurse stated the results were still pending. The nurse reported the pain intervention was effective. Review of a progress note dated 12/04/23 at 3:39 P.M. written by LPN #118 documented Resident #87's left hand was swollen, and the fingers were discolored (dark bruising). It further documented hospice was notified, awaiting a return call. The note indicated she was told verbally that Hospice came out the day before (12/03/23) for an evaluation and there were no new orders. Review of a nursing progress note dated 12/04/23 at 11:56 P.M. revealed Resident #87 refused her evening medication. Review of the narcotic count sheet for Norco 5-325 mg revealed it was signed as being received by the facility on 12/04/23. Review of a change of condition note dated 12/05/23 at 5:00 P.M. revealed Resident #87's condition had gotten worse. Her weight had dropped from 72 pounds on 11/03/23 to 60 pounds on 12/02/23. She had increased confusion and decreased mobility. She had edema, but the location was not documented. She had discoloration to her left hand, and her intensity of pain was rated a nine on a zero to ten scale. She had called for Hospice Nurse #171 to come out and reevaluate her on 12/05/23 at 3:00 P.M. Resident #87's responsible party was notified of her decline and change to her left hand. Review of the hospice note dated 12/05/23 at 9:15 P.M. revealed that a call was made to Resident #87's responsible party due to his concern that she was refusing medication. He was advised the facility reported the patient was taking Norco on the previous day and that she had relief. Review of the MAR revealed on 12/05/23 night shift, Resident #87 had a pain rating score of six with no pain medication given. Review of a progress note dated 12/06/23 at 8:55 A.M. by LPN #93 revealed a call was placed to the hospice nurse requesting her to come and reevaluate Resident #87. Review of the hospice visit note dated 12/06/23 at 10:15 A.M. revealed Resident #87 was in her room with her hand elevated on a pillow. Her hand had previously been assessed with plus one edema (a 2 millimeter indentation that rebounds immediately), now non-pitting. Resident #87's hand was still hurting to touch. She said she just needed some sleep and was tired. The facility reported she was not eating at all except small snacks left in her room. The staff reported the X-ray was completed but are still awaiting results of the X-ray. It stated, Patient has decreased range of motion still able to move fingers, just painful. Review of the MAR revealed on 12/06/23 at 4:49 P.M., Resident #87 was given Norco 5-325 mg after she reported her pain was rated a seven. Review of Resident #87's order recap report revealed the order for a two-view X-ray of the hand was ordered on 12/07/23. During an observation on 12/07/23 at 10:54 A.M., Resident #87 was sitting in a reclining wheelchair in the dining room. Her hand appeared to have a dark bruise on her thumb and fingertips. During an interview at this time, Resident #87 stated she hit her hand on a door. When asked if it hurt, she said It hurts so bad! A nearby nurse said she had given Resident #87 pain medication that was ordered after her injury. Review of the progress note dated 12/07/23 at 11:50 A.M. by LPN #92 revealed Resident #87 had swelling to her left hand with discolored fingers (bluish black colored). Hospice was informed over the past weekend. Resident #87 had complaints of pain and the as needed Norco pain medication was given. The pain subsided for about an hour, but the pain came back, and Resident #87 wasn't due for more pain medication until 2:46 P.M. Her pain was rated a four out of ten but did not interfere with her activities of daily living at that time. A call was made to the hospice provider and the nurse would come out that day to re-evaluate Resident #87's hand. Review of the MAR revealed Resident #87 was medicated for pain on 12/07/23 at 8:44 A.M. after rating her pain a four. Review of the hospice skilled nursing visit note dated 12/07/23 at 1:10 P.M. revealed Resident #87 was present in a chair. Her fingers were more swollen than the previous visit with a slight change in color. Orders were given to the facility on Sunday evening (12/03/23), and no results and no orders were put in by the facility nurse. The DON ordered an X-ray at that time. She informed Hospice Physician #172 and he stated he did not want to wait for results and to send her to the hospital. The orders to send her to the hospital were given directly to the DON at that time. The DON demonstrated understanding. The responsible party was present and acknowledged understanding also. Review of the transport record revealed she was picked up on 12/07/23 at 5:30 P.M. by non-emergent transport. Review of Resident #87's two-view X-ray to her left hand dated 12/07/23 revealed the findings that the hand demonstrated slightly decreased bony ossification. There was no evidence of acute fracture, or dislocation. Diffuse arthritic changes were noted throughout the hands and digits. No significant soft tissue swelling was identified and there was no evidence of osteomyelitis. Review of the hospital records for Resident #87 revealed on 12/07/23 at 11:00 P.M. results from a computed tomography-angio of the upper extremity with and without hypoattenuation revealed she had severe 90 percent atherosclerotic stenosis of the left subclavian artery shortly after its origin with mural thrombus. It showed patent left axillary, brachial, and radial arteries. The left ulnar artery was patent at its origin and no longer visualized along the proximal to mid forearm. A vascular surgery consultation was recommended. Review of the medical intensive care unit history and physical, dated 12/08/23 at 1:22 A.M., documented the resident was admitted on [DATE] at 8:57 P.M. Her left hand was painful and cold. Her blood pressure was in the 120s/40s and she was tachycardic. Her hemoglobin was 4.6 (normal level for females 11.6 to 15 per Mayo Clinic). She had no left radial pulse detected. She was admitted to the Surgical Intensive Care Unit (SICU) for anemia in setting of limb ischemia. She had left limb ischemia and dry gangrene. Review of the SICU flow sheet dated 12/08/23 at 5:17 A.M. revealed she had complaints of pain at a level of eight in her left hand. Her hand was black at the fingertips and the patient was unable to perform fine motor skills. She had to be given as needed Haldol one time so staff could safely and effectively provide treatments. She had mitt restraints in place. Review of the hospital Vascular Surgery Daily Progress note dated 12/08/23 at 7:01 A.M. revealed her pulses were palpable at the left brachial only and absent in the radial and ulnar. Her left hand was flaccid. They could not perform surgery with her hemoglobin of 4.5 and her hand may not be salvageable. During an interview on 12/11/23 at 2:30 P.M., the DON said the resident went to the hospital on [DATE]. She spoke to Resident #87's responsible party who said he was going to meet her at the hospital. Non-emergency transport was called to take her and drop her off. She said the facility sent the X-ray results, face sheet, and orders. She stated the hospice nurse was out to see her on 12/04/23 at around 1:00 P.M. to 2:00 P.M. The hospice nurse told the responsible party and the nurse that there was nothing they could do. There were no new orders from hospice at that time. The DON said she went through the hospice notes finding there was an order for an X-ray. She spoke with the hospice nurse and she said she spoke with a nurse about the X-ray order. She was unable to provide the name of the nurse, but said it was requested from the day shift nurse. The DON saw that an order for an X-ray was not obtained until 12/03/23 at 8:30 P.M. She said the facility did not get the order and requested the resident be seen again on Tuesday and asked for the hospice notes. When she found the order, she called to have it done on 12/07/23. The results were that she did not have any fractures. During an interview on 12/11/23 at 4:36 P.M., LPN #120 stated she worked day shift on 12/03/23 and the aide told her she should look at Resident #87's hand. She stated Resident #87's hand was discolored, and when LPN #120 touched her hand, Resident #87 was in pain. She stated she called the physician and he said she had to contact hospice. She said she called the hospice provider and spoke with the nurse telling her that Resident #87's left hand fingers were discolored. Hospice Nurse #171 asked if Resident #87 had any as needed pain medication. LPN #120 looked at her orders and there were no orders for as needed pain medication. Hospice Nurse #171 said she would have to contact the doctor to see what they could do about it. About one and a half to two hours later, Hospice Nurse #171 came out to see Resident #87. She revealed Hospice Nurse #171 said yes it does look bad and told her she was waiting for the doctor to call back to see what she could prescribe. She believed Hospice Nurse #171 came out on 12/03/23 about 1:00 P.M. She said Resident #87 stayed in her room and did not want to come out. She stated Hospice Nurse #171 did not call back with a pain medication order during the shift. LPN #120 said she did not call the physician again but felt she should have. She revealed Resident #87 did not complain of pain anymore that shift. She said Hospice Nurse #171 did not say they were ordering an X-ray. She also stated the bruising was not reported to management, and she was not aware of the proper procedure regarding a bruise. During an interview on 12/13/23 at 12:57 P.M., LPN #119 stated she worked on the 200 unit that night and stated Resident #87 complained of pain when her left hand was touched or if she moved it. She said Resident #87's hand was turning blue. She was not aware of Hospice Nurse #171's visit and thought they were still waiting for her. She stated she did not receive a call for an order for an X-ray or pain medication. She stated when the State Tested Nursing Assistant (STNA) tried to move her hand she said it hurt. She said she tried to call hospice and did not get an answer. She said Resident #87 could move her arm, wiggle fingers, and had a pulse. She stated Resident #87 did not get any pain medicine but did not complain if her hand was not touched. She said Resident #87 slept through the night. She passed on to day shift that she did not hear from hospice. She said the supervisor was Registered Nurse (RN) #157. During an interview on 12/13/23 at 1:24 P.M., RN #157 said he was not aware of any concerns regarding Resident #87's left hand and did not receive a call from hospice. During an interview on 12/13/23 at 12:37 P.M., LPN #118 stated Resident #87's responsible party came in and got her. He said she was really complaining about her hand. She said the night shift nurse said they were not going to do an X-ray. She said she talked to LPN #93 and was told they were not going to do anything due to her being on hospice. She said she tried to contact the hospice by trying several numbers (due to one of the numbers not being a good contact number). The hospice staff did not know what to do and said they would send someone out. She revealed Resident #87 was in pain at that time. She said she looked to see if there was anything ordered for pain. She revealed they were supposed to get a prescription for her for pain medications, so she looked for a prescription and did not find one. She said Resident #87 was able to wiggle her fingers very little due to pain and Resident #87 told her she slammed it in the door. She stated the complaint of pain was after lunch. LPN #118 did not remember checking her wrist for a pulse. She said she did not hear from the hospice nurse and was taught that all orders were to go through hospice. During an interview on 12/13/23 at 12:28 P.M., LPN #88 stated she was told Hospice Nurse #171 had been called and she came to evaluate her. She said she did not send her out. She said she did not remember if Resident #87 complained of pain or not. She said one finger was discolored and swollen. She thought there was pain medication in the cart but did not administer any. She was not aware of any order for an X-ray. She did not remember Resident #87 having any changes out of the ordinary. She believed she checked her pulse but was not sure and the resident could move her hand and arm. During a telephone interview on 12/13/23 at 11:36 A.M., LPN #128 said the resident did not have pain medication on the MAR, but she did not remember her having pain. She revealed she did not check Resident #87's pulse, but her hand looked contracted with her fingers turning in. She said Resident #87 was moving the arm, but her fingers were discolored. The behavior that she observed was Resident #87 being agitated and refusing her medication. She said Resident #87 did not cry out in pain, she just wanted ice chips. During an interview on 12/13/23 at 10:22 A.M., LPN #92 said she worked on the 200 unit caring for Resident #87 often. She said Resident #87 was right-handed and was able to feed herself. She noticed the resident was declining to come to the dining room around the end of November. Resident #87 could use both hands but her appetite was poor. She said she did not see Resident #87's bruised hand until 12/05/23. She did a change of condition assessment on 12/05/23, taking her vitals but she did not check for a pulse in her left hand. She had said Resident #87 had edema, pain, and discoloration in her left hand. She revealed she called hospice on 12/05 and talked to Resident #87's responsible party. She was letting him know that Resident #87's appetite was poor, she had weight loss, and swelling in her hand. She stated she called hospice out to reevaluate her, and the on-call nurse said Hospice Nurse #171 would call her back or come out. She stated she did not get a call back on 12/05/23, so she called hospice again on 12/06/23. She revealed Resident #87 could use both hands at that time. She said Resident #87 said her left hand hurt but she did not recall the pain rating. She believed Resident #87 had Norco for pain. She said the prescription was not put on the MAR until 12/06/23. She said the hospice on call was not sure when, but the doctor had sent over the prescription for Norco. She revealed the orders were usually electronically sent directly to the pharmacy. She said Resident #87 did not have any pain medication from 12/03/23 to 12/05/23, but she did not think the hand looked worse. During an interview on 12/13/23 at 11:52 A.M., Hospice Nurse RN #171 said on Sunday 12/03/23 she came to see Resident #87. She said Resident #87's index and ring finger were a purplish color around the nail bed like a bruise. She had slight edema and complained of severe pain, wincing, and screaming when touched. She said Resident #87 did not have any pain medication ordered on file. She said usually Resident #87 did not like taking pain medications and would not take them. She revealed that evening (12/03/23) she received orders for Norco and Tylenol. There was also an order for an X-ray of the left hand that evening. She said she called the facility, and the orders were given to a nurse, but she didn't know her name. She said they do not call the pharmacy with orders. They use an application called Arcopia which goes straight to the pharmacy. Their physician signs for the narcotic and she was able to see this was done on the computer. She said she was in constant contact with the doctor. She revealed it would have been the night shift nurse that she talked to. She said at that time Resident #87 had a pulse in that hand and good capillary refill. She was able to flex her fingers, and she could lift her left arm. She called the next day (12/04/23) for the results of the x-ray and the facility staff nurse said they were waiting for the results. The nurse said they put in the orders, and she also said a pain pill was given and was effective. She did not see her 12/04/23, but on 12/05/23 Resident #87's responsible party told her the hand was about to fall off. He said the nursing home did not get in touch with him on Sunday. He was surprised and angry he was not informed. The responsible party was to come on Saturday, but she asked if he wanted to meet her on Wednesday. She said she came and saw Resident #87 on Wednesday 12/06/23 in the early morning. She said Resident #87 was asleep, not appearing to be in pain. She said Resident 87's left hand was not severely different than Sunday. She stated she did not see a change and was told the X-ray had not gotten back. She talked to third shift staff briefly, and there were no complaints. They said she slept all night. She stated she checked Resident #87's pulse and her capillary refill and vitals were within normal limits. On 12/07/23, facility staff called the responsible party and then called her saying her hand was black and falling off. She said she came to the facility and met with Resident #87's responsible party. She said Resident #87's left hand was not black but darker and more swollen. She said there was a pulse, and she was able to move arm, wrist, and elbow. Hospice Nurse #171 said Resident #87 appeared to be in pain when she came in. She revealed the DON pulled her aside and asked what happened on Sunday, telling her there was no documentation. She asked why she did not come in to facilitate the X-ray, but hospice would usually give orders for the facility to schedule the X-ray. She talked to the social worker and responsible party, who was saying the resident never talked to him about the resident. A facility nurse reported to Resident #87's responsible party that she was mottling, and he was beginning to get family together. She said Resident #87 was not mottling. She stated she called Hospice Physician #172 from the facility to ask if he wanted to wait for X-ray or send her to the hospital to make sure there was no deep vein thrombosis. His orders were to send her to the hospital on [DATE] at 2:30 P.M. She called the hospital at 8:30 P.M. to 9:00 P.M. The responsible party called and told her he had just left the hospital at about 8:45 P.M. She said the DON was calling report. She stated Resident #87 was admitted to the Intensive Care Unit (ICU) and she was taken off hospice service when admitted . During an interview on 12/13/23 at 3:01 P.M., Hospice Physician #172 stated on 12/03/23 Hospice Nurse #171 sent him a picture of Resident #87's left hand saying her hand was smashed in a door. The note said she could move her fingers, and the original treatment was to apply ice at first every 20 minutes and use Naproxen or Ibuprofen for pain. He ordered Norco due to Resident #87 not keeping the ice on. He said he also ordered an X-ray for her hand. Her pain level was rated 10. He sent a verbal order which the system notified him to sign. He stated he would sign for narcotics immediately, and the electronic prescription went to the pharmacy. He would later sign all other verbal orders, including the X-ray order, on Tuesdays. He received another call from Hospice Nurse #171 on 12/04/23 at 9:37 A.M. but did not recall the conversation. He said there was a picture sent to him by Hospice Nurse #171 on Thursday at 2:23 P.M. He said Resident #87's left hand looked swollen but wrinkled, not stretched, slightly curled fingers, showing her index finger having a darker color and a whitish nail bed. He compared the pictures from 12/03/23 and 12/07/23. He said Resident #87's left hand looked worse and due to not having anything else to go by, he ordered her be sent to the emergency room for evaluation on 12/07/23 at 2:23 P.M. During an interview on 12/14/23 at 11:00 A.M., the DON said Resident #87 went into the hospital where she was found to have a blockage on 12/07/23. She said the hospital tried to get in touch with her responsible party for options, but when they got in touch with him, he refused to have a stent placed to improve circulation to the arm. She said after two days, once the fingers developed dry gangrene they were talking about palliative care. She said Resident #87 was in the emergency room waiting area for several hours prior to being seen. She said Resident #87 was scheduled to return on 12/08/23, but the responsible party wanted more options done before sending her back. Review of the facility policy titled Abuse, Neglect, Misappropriation of Resident Property, and Injury of Unknown Origin, revised on 08/01/22 stated the facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation of resident/patient property by anyone including staff, family, friends, etc. This deficiency represents non-compliance found during the investigation of Complaint Number OH00148957.