**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review revealed Resident #19 was admitted to the facility on [DATE] with diagnoses including human immunodeficiency virus (HIV) disease, atrial fibrillation, type two diabetes mellitus with neuropathy, cardiomyopathy, peripheral vascular disease, anxiety disorder, major depressive disorder, and pulmonary embolism without acute cor pulmonale. Review of Resident #19's quarterly MDS assessment dated [DATE] revealed Resident #19 was cognitively impaired with a BIMS score of an eight out of 15 and required extensive assistance for mobility and general personal care. Resident #19 was on medication to thin the blood that put Resident #19 at risk for bruising and bleeding. Resident #19 was listed on the facility's quality improvement monitoring log indicating Resident #19 had lab work drawn on 10/09/23 and the physician was notified of results on 10/09/23 at 7:30 P.M. Resident # 19's electronic medical record indicated Resident #19 had a PT (prothrombin time)/INR (international normalized ratio) test results called to the physician 10/12/23 at 4:25 P.M. and 10/19/23 at 11:37 A.M. Resident #19's paper chart has a PT/INR listed as drawn 10/13/23 at 11:11 A.M. and resulted 10/13/23 at 6:21 P.M., with results listed as high outside the normal range, and a hand written note stating the physician was notified with no documented evidence of the date or time the notification occurred. Interview on 11/20/23 at 1:00 P.M. with Regional Director of Operations #224 confirmed the lab audit contained inconsistent information and the paper chart for Resident #19 was missing information. Review of the facility document Guidelines for Reporting Abnormal Test Results to Physician, revision date of 02/2014, revealed any PT/INR outside the therapeutic range requires immediate notification. Any results in the normal range are non-emergent and should be reported on the next office day. 3. Record review revealed Resident #24 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation, type two diabetes mellitus with neuropathy, peripheral vascular disease, vascular dementia, and a history of falls. Review of Resident #24's quarterly MDS dated [DATE] revealed Resident #24 mildly cognitively impaired with a BIMS score of 11 out of 15. Resident #24 was on medication to thin the blood that put Resident #24 at risk for bruising and bleeding. Resident #24 was listed on the facility's quality improvement monitoring log reflecting Resident #24 had lab work drawn on 10/13/23 and the physician was notified of results on 10/13/23 at 7:00 P.M. with results listed as highly outside the normal range. Resident #24's electronic medical record indicated Resident #19 had a PT/INR test results called to the physician 10/12/23 at 4:25 P.M. and 10/19/23 at 11:37 A.M. Resident #19's paper chart had a PT/INR listed as drawn 10/13/23 at 11:11 A.M. and resulted 10/13/23 at 6:21 P.M. with a handwritten note stating physician notified 10/13/23 with no documented evidence of the time the notification occurred. Interview on 11/20/23 at 1:00 P.M. with Regional Director of Operations #224 confirmed the lab audit contained inconsistent information and the paper chart for Resident #24 was missing information. Review of the facility document Guidelines for Reporting Abnormal Test Results to Physician, revision date of 02/2014, revealed any PT/INR outside the therapeutic range requires immediate notification. Any results in the normal range are non-emergent and should be reported on the next office day. 4. Record review revealed Resident #34 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, type two diabetes mellitus with neuropathy, congestive heart failure, cardiomyopathy, and peripheral vascular disease. Review of the annual MDS dated [DATE] revealed Resident #34 was cognitively intact with a BIMS score of 12 out of 15 and required supervision for mobility, general activities of daily living, and personal care. Resident #34 was on medication to thin the blood that put Resident #34 at risk for bruising and bleeding. Resident #34 was listed on the facility's quality improvement monitoring log stating Resident #34 had lab work drawn on 09/27/23 and the physician was notified of results on 09/28/23 at 1:00 A.M. Resident # 34's electronic medical record indicates Resident #34 had a PT/INR test results called to the physician 09/28/23 at 12:23 P.M. Review of Resident #34's paper chart revealed a PT/INR listed as drawn 09/27/23 at 8:26 P.M. and resulted 09/27/23 at 9:50 P.M. with no documented evidence of the time the notification occurred. Interview on 11/20/23 at 1:00 P.M. with Regional Director of Operations #224 confirmed the lab audit contained inconsistent information, and the paper chart for Resident #34 was missing information. Interview on 11/29/23 at 3:30 P.M. with Regional Director of Nursing #103 revealed not all notification of lab work reported to the physician was in the electronic medical record. The nurses may also document notification in the paper chart. Review of the facility document Guidelines for Reporting Abnormal Test Results to Physician, revision date of 02/2014, revealed any PT/INR outside the therapeutic range requires immediate notification. Any results in the normal range are non-emergent and should be reported on the next office day. Based on medical record review, interviews with facility staff, review of laboratory test results, review of hospital records, and review of facility policies, the facility failed to provide timely, adequate, and necessary care and treatment to Resident #74 following laboratory notification of a critically low potassium level. This resulted in Immediate Jeopardy and Actual Harm on 09/08/23 when a Basic Metabolic Panel (BMP) laboratory blood test showed a critically low potassium level of 2.7 milliequivalents (meq)/hour (hr) (normal 3.5 to 5.3 meq/hr), and the facility failed to notify the physician or provide treatment until 09/15/23. On 09/15/23 Resident #74 was assessed to be dehydrated and had increased confusion which had worsened over the previous week. From 09/15/23 to 09/19/23 the facility failed to ensure physician orders related to a fluid bolus were clarified and failed to ensure nursing staff adequately monitored the resident. On 09/19/23 the resident was transferred to the hospital and treated for ventricular tachycardia (VT) requiring one electric shock treatment before a return of spontaneous circulation (ROSC) was received as well as treatment for hypokalemia (low potassium). The resident was hospitalized until 09/22/23 and then admitted to Hospice care services on 09/27/23. Additionally, a concern that did not rise to an Immediate Jeopardy occurred when facility staff failed to timely notify the physician or accurately address abnormal laboratory testing for Resident #19, #24 and #34. This affected four residents (#19, #24, #34, and #74) of four residents reviewed for laboratory services, physician notification, and quality of care. The facility census was 84. On 11/28/23 at 4:10 P.M., the Administrator, Regional Director of Operations #224, Corporate Director of Nursing (CDON) #102, Director of Nursing (DON), [NAME] President of Clinical Services #230, and [NAME] President of Operations #231 were notified Immediate Jeopardy began on 09/08/23 at 2:55 P.M. when a critically low potassium level of 2.7 for Resident #74 was received and the facility failed to notify Physician #191 of the critical lab results or provide treatment until 09/15/23 (one week later). Additionally, on 09/15/23 the facility failed to ensure a complete physician's order was obtained for a bolus of fluids to treat Resident #74's dehydration. The facility failed to monitor Resident #74 every two hours as their policy stated while the resident received the fluids. The facility failed to develop and implement a comprehensive care plan for Resident #74 that addressed the resident's risk for low potassium levels. The resident required hospital treatment/intervention after being transferred from the facility to the hospital on [DATE]. The Immediate Jeopardy was removed on 11/29/23 when the facility completed the following actions: • On 09/19/23 at 9:00 A.M., an order was received to send Resident #74 to the hospital after reassessment due to altered mental status (AMS), lethargy and elevated blood pressure of 174/94. The resident was re-admitted to the facility on [DATE] at 5:43 P.M. • On 11/27/23 at 11:00 A.M. the facility subcutaneous (SQ) infusion policy was reviewed by [NAME] President of Clinical Services #230, [NAME] President of Operations ##231, Regional Director of Operations #224, and CDON #103 with no changes made to policy. • On 11/28/23 at 5:00 P.M., a whole house audit for any resident with any change in condition in the last seven days was completed to ensure care plans were in place and address specific interventions by the Minimum Data Set (MDS) Nurse Director #212. MDS Nurse Director #212 also audited all current residents with chronic clinical condition history to ensure care plans reflected monitoring. • On 11/28/23 at 5:00 P.M., a whole house audit was completed to ensure labs drawn in the last seven days had physician notifications for any critical results by CDON #103. • On 11/28/23 at 5:00 P.M., a whole house audit was completed to ensure any changes in condition in the last seven days had physician notification by CDON #103. • On 11/28/23 at 5:10 P.M., nursing management was educated on Change of Condition, Lab Services, and Notification per facility policy by CDON #103. Nursing managers included: ADON #105, DON, and Unit Manager #109. • On 11/28/23 at 5:44 P.M., an Ad Hoc Quality Assessment Performance Improvement (QAPI) meeting was conducted with the Administrator, ADON #105, CDON #103, Human Resources Director #204, Dietary Director #207, and Physician #191 (Medical Director), Therapy Director #225, Business Office Manager (BOM) #209, Housekeeping Director #232, MDS Nurse Director #212, Unit Manager #109, and Activities Director #214. The Immediate Jeopardy Notification was reviewed, policies on Change of Condition, Lab Services, and Notification were reviewed. Also, audits were implemented, and a plan for weekly QAPI to take place. Policies were reviewed at this time with no changes made. The facility would also hold weekly QAPl meetings times four weeks. • On 11/28/23 at 6:22 P.M., a whole house education was completed to all nurses (20 LPNs and seven RNs) by the DON, ADON #105, and Unit Manager #109. Change of Condition, Lab Services, and Notification were reviewed. At the time of the training, the facility identified they used no agency staff, and no current employees were on leave. • On 11/28/23, audits began and would be conducted five times weekly by the DON/designee to ensure any critical lab values had physician notification promptly times four weeks then weekly thereafter for eight weeks. • On 11/28/23, audits began and would be conducted five times weekly by the DON/designee to ensure any change in condition is reassessed 24 hours after the initial change in condition with physician notification, the care plan is updated after the initial change in condition, and that physician notification is completed with any discrepancies from reassessment and orders obtained if appropriate times four weeks, then weekly thereafter for eight weeks. • On 11/29/23 at 5:50 P.M., whole house education was completed to nursing managers including the ADON, Unit Manager (UM) #109, MDS Nurse Director #212, and the DON by CDON #103 related to infusion orders that included the SQ infusion policy and chronic clinical history care planning. Infusion education was to cover all forms of possible infusions. • On 11/29/23 at 6:32 P.M., whole house education was completed for all nurses (20 LPNs and seven RNs) by ADON #105, the DON, and Unit Manager (UM) #109 over infusion orders, SQ infusion policy, and chronic clinical history care planning. The facility has no agency nurses or staff on leave at the time of the training. For all newly hired nurses, the facility would complete education during orientation. The infusion education covered all forms of possible infusions. • On 11/29/23, audits were started and would be conducted five times weekly by the DON/designee to ensure any infusion orders had the correct rate, dose, amount, and time along with assessments of sites while infusions run times four weeks, then weekly thereafter for eight weeks. • All audits would be discussed/reviewed through QAPI weekly times four weeks. Any discrepancies will be addressed at that time. Although the Immediate Jeopardy was removed on 11/29/23, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: 1.Review of the medical record for Resident #74 revealed an admission date of 06/07/23 with medical diagnoses including cerebral infarction (stroke), type II diabetes mellitus, generalized muscle weakness, difficulty in walking, vascular dementia with behavioral disturbance, other abnormalities of gait and mobility, essential primary hypertension (high blood pressure), hypokalemia (added on 09/22/23) (low potassium level), paroxysmal atrial fibrillation, syncope and collapse, cardiac arrhythmia (added on 09/22/23), and congestive heart failure (added on 09/22/23). Review of Resident #74's laboratory testing result history from 03/15/22 through 10/27/23 revealed Resident #74's potassium levels ranged from 3.1 to 5.2 milliequivalents (meq)/hour (hr). The normal range for potassium level is 3.5 to 5.3 meq/hr. Review of the plan of care, dated 06/07/23 revealed Resident #74's risk for hypokalemia (low potassium levels) was not addressed in the resident's care plan. A diagnosis of hypokalemia was added to the care plan for cardiovascular status on 09/22/23. However, there were no specific interventions related to the hypokalemia diagnosis added to the care plan. Review of Physician #191's progress note dated 09/07/23 revealed the physician visited Resident #74 for a scheduled surveillance visit. Physician #191 was notified Resident #74 had experienced two falls that week and diarrhea for four days. Resident #74's blood glucose levels, blood pressures, and neurological checks were within normal limits. Physician #191 ordered orthostatic blood pressures, a Clostridium difficile (C. Diff) test, complete blood count (CBC) and basic metabolic panel (BMP) laboratory tests. Review of the corresponding physician's orders for September 2023 revealed on 09/07/23 orders for a CBC, BMP, and urinalysis (UA) laboratory tests. Review of the laboratory test results dated 09/08/23 revealed Resident #74 had a renal critically low (RCL) potassium level of 2.7 milliequivalents (meq)/hour (hr). Test results also show hypoglycemia with a low glucose level of 58, and a high creatinine level of 1.6 (normal range was listed as 0.6 to 1.2). The results were reported (from the lab to the facility) on 09/08/23 at 2:55 P.M. Review of the progress notes revealed there was no documented evidence the physician was notified of the critical lab results for Resident #74. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #74 had severely impaired cognition with a score of five out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #74 required supervision from one staff to complete bed mobility and limited assistance from one staff to complete transfers. Resident #74 required extensive assistance from one staff to complete dressing, toileting, and personal hygiene tasks. Resident #74 had not experienced any falls and did not receive any special services, including hospice services. Review of Physician #191's untimed progress note dated 09/15/23 (seven days after the laboratory results were obtained) revealed Resident #74 was seen for follow-up of abnormal lab results. Resident #74 was noted with dehydration, acute injury of the kidney most likely in setting of low perfusion (reduced peripheral blood flow) and dehydration, hypokalemia (low potassium level) with critically low potassium level of 2.7, worsened anemia without an obvious source of bleeding, and high creatinine level. Physician #191 ordered a STAT (immediate) CBC, BMP, and UA along with a potassium supplement (on 09/15/23). Physician #191 confirmed the facility did not notify her of Resident #74's critical lab results (on 09/08/23). Physician #191 was informed by the nurse at the time of the visit that Resident #74 had not had diarrhea during the shift but was unable to state when it had improved. Resident #74 had poor intakes for some time. Unit Manager (UM) #111 notified Physician #191 Resident #74 had been more confused than normal for over one week. The nurse notified Physician #191 later in the day (on 09/15/23) that the laboratory testing (ordered on this date) could not be completed as attempts to obtain blood from the resident were unsuccessful. Physician #191 ordered a subcutaneous (SQ) bolus of 500 milliliters (mL) of normal saline (NS) with labs to be repeated once fluids were administered. Physician #191 noted having a lengthy conversation with ADON #105, CDON #103, and UM #111 related to proper notification protocols of abnormal lab results. Review of additional physician's orders dated September 2023 revealed Resident #74 had an order for STAT CBC and BMP laboratory tests one time only for altered mental status dated 09/15/23 at 6:30 P.M. The tests were ordered by Physician #191 and had an end date on 09/16/23 at 6:29 P.M. Resident #74 had a physician's order for 500 mL of 0.9% NS bolus one time only for hydration dated 09/15/23. The order did not indicate a rate, end date, or end time. The order was made by Physician #191. Resident #74 had an order for Potassium Chloride Extended Release 20 meq with instructions to give two tablets one time only for hypokalemia (administer a total of 40 meq). The order was dated 09/15/23. Review of the progress note dated 09/15/23 at 6:23 P.M. by LPN #226 revealed a lab technician arrived to draw STAT CBC and BMP labs but was not able to obtain. Physician #191 was notified and gave orders to administer 500 mL bolus of 0.9% NS and 40 meq of potassium one time. Repeat STAT CBC and BMP after administration of fluids. The note did not specify a rate for the bolus or an end date or time. Review of the progress note dated 09/15/23 at 6:24 P.M. by LPN #226 revealed the nurse placed a SQ IV in Resident #74's lower left quadrant of her abdomen. Resident #74 tolerated the placement well. The IV line was patent and running. The note indicated LPN #226 would continue to monitor. Review of the Medication Administration Record (MAR) dated September 2023 revealed Resident #74 received potassium supplement and IV fluids as ordered. The bolus was signed off on the MAR on 09/15/23 at 09:16 P.M. by LPN #155. The STAT CBC and BMP lab order was signed off on 09/15/23 at 9:22 P.M. by LPN #155. Review of the lab results dated 09/16/23 revealed Resident #74 had a low potassium level of 3.0 millimoles per liter (mmol/L). The results were faxed to the facility on [DATE] at 7:45 P.M. There were no additional progress notes entered on Resident #74 until 09/17/23 at 11:32 A.M. (approximately 41 hours after the IV line was placed). Review of the progress note dated 09/17/23 at 11:32 A.M. (approximately 16 hours after the results were faxed to the facility) by LPN #176 revealed lab results were received and the on-call physician was notified. A new order for potassium 40 meq was received with instructions to administer twice daily for three days. LPN #176 would continue to monitor. Review of the physician orders dated September 2023 revealed Resident #74 had an order for potassium oral tablet with instructions to give 40 meq twice daily for supplement for three days until 09/20/23. The order was dated 09/17/23. Review of the MAR dated September 2023 revealed Resident #74 received the potassium supplement at 8:00 P.M. on 09/17/23 and on 09/18/23 at 8:00 A.M. and 8:00 P.M. Resident #74 was out of the facility on 09/19/23 at 8:00 A.M. The potassium was marked as administered on 09/19/23 at 8:00 P.M. but Resident #74 was out of the center on 09/20/23 at 8:00 A.M. according to the MAR. Review of the progress note dated 09/19/23 at 9:00 A.M. by RN #160 revealed Resident #74 was found lying down in bed very lethargic, unable to sit or stand. Resident #74 was not able to eat or drink breakfast. Resident #74's blood pressure was (elevated/hypertensive) 174/94, pulse was 71, respiratory rate was 20, and oxygen saturation was 95%. The nurse practitioner was notified and ordered Resident #74 to be sent to the emergency department. The DON and resident's family were notified. Resident #74 was hospitalized from [DATE] to 09/22/23. Resident #74's payer source was changed to a Hospice payer on 09/27/23. Review of the progress note dated 09/22/23 at 9:17 P.M. revealed Resident #74 returned to the facility from the hospital on [DATE] at 4:45 P.M. Review of hospital records dated 09/22/23 revealed Resident #74 was treated for an elevated troponin level (a protein released into the bloodstream during a heart attack and a sign of some damage to the heart), tachycardia (fast heart rate) with frequent premature ventricular contractions (PVCs), ventricular tachycardia (a condition caused by faulty heart signaling that triggers a fast heart rate in the lower heart chambers), hypertension, hypokalemia, and hypomagnesemia. Resident #74's blood pressure was 180/65 while lying down. Upon admission on [DATE], Resident #74 had a low potassium level of 3.3 and critically high troponin levels of 251 initially and 128 upon repeat. Review of the after-visit summary (AVS) dated 09/22/23 revealed Resident #74 was treated for ventricular tachycardia (VT) felt to be electrolyte related. Resident #74 experienced VT arrest with return of spontaneous circulation (ROSC) following a single defibrillation. Treatment for hypokalemia and hypomagnesemia (low magnesium level) included replacing electrolytes, maintaining potassium level above four, and maintaining a magnesium level over two. At discharge, Resident #74 would continue potassium and magnesium supplements. Review of the progress note dated 09/27/23 at 4:06 P.M. revealed Resident #74 was accepted to Hospice and palliative care. Interview on 11/22/23 at 5:15 P.M. with Regional Director of Operations #224 and Corporate Director of Nursing (CDON) #103 confirmed Resident #74's physician was not notified of the critical lab results that were received on 09/08/23 until 09/15/23 (one week later). CDON #103 stated Resident #74 received a potassium supplement and IV fluids on 09/15/23. Resident #74 was sent to the hospital on [DATE] for a change in condition. CDON #103 confirmed Resident #74 experienced VT in the hospital and confirmed the resident was treated for heart issues and low potassium. Interview via telephone on 11/27/23 at 10:02 A.M. with LPN #176 revealed she worked at the facility on the weekends and was familiar with Resident #74. LPN #176 stated if a resident had an order to receive SQ IV fluids, the order should include a rate and time frame for it to infuse over. If the order did not include these instructions, the nurse should clarify the order (with the physician). LPN #176 also stated the resident should be monitored while the fluids were administered to ensure the line was patent and flowing and that the resident was tolerating the treatment. The observations of the resident should be documented in the medical record. Interview via telephone on 11/27/23 at 11:44 A.M. with Physician #191 confirmed the facility failed to notify her of Resident #74's critical lab results on 09/08/23. Physician #191 stated she was at the facility for a regular visit on 09/15/23 and Resident #74 was not on her schedule to be seen that day. When she arrived on-site, she happened to find and reviewed Resident #74's lab results. At that time, Physician #191 decided to see Resident #74 on 09/15/23 to follow up. Physician #191 stated there were concerns Resident #74 was dehydrated based on the resident's appearance. The resident appeared dehydrated and had dry lips. Physician #191 stated she was told the DON would be available to monitor the bolus while the fluids were being administered. Physician #191 confirmed she could not confirm the rate at which the nurse was ordered to administer the fluids. Physician #191 stated the rate was determined based on the resident's weight and other factors. Physician #191 stated the bolus should have been administered at a rate less than 70 mL/hr. Physician #191 confirmed MedOne (the physician's group) received notification of the lab results completed on 09/16/23 on 09/17/23 at 11:41 A.M. Physician #191 stated she had considered sending Resident #74 to the hospital on [DATE] but the nursing staff reported the resident had been at baseline, looked okay, and vital signs were within normal limits. Physician #191 decided to treat Resident #74 at the facility. Physician #191 reported if a resident had low potassium levels, she would want to replace it as soon as possible because there would be concern for the resident's heart health. Interview on 11/27/23 at 2:13 P.M. with CDON #103 confirmed there was no documented evidence in the medical Resident #74 had been monitored every two hours. There was no documented evidence of any observations completed on Resident #74 except on 09/15/23 at 6:23 P.M. when the nurse placed the line for the SQ IV fluids and 09/15/23 at 9:16 P.M. when the night shift nurse signed off on the MAR. Interview via email on 11/27/23 at 5:40 P.M. with CDON #103 confirmed Resident #74's abnormal lab results were faxed to the facility on [DATE] at 7:45 P.M. and there was no documented evidence the physician was notified until 09/17/23 at approximately 11:30 A.M. Interview on 11/28/23 at 10:47 A.M. with LPN #226 confirmed she was the nurse who started the SQ IV fluids for Resident #74 on 09/15/23 ordered by Physician #191. LPN #226 confirmed Physician #191 did not provide a rate at which the fluids should have been administered. LPN #226 confirmed Resident #74 should have been observed/monitored at least every two hours to make sure the line was still in place, running without any issues, and the resident was tolerating the infusion without any adverse effects. LPN #226 stated she thought it was an open line. LPN #226 stated the nursing staff should notify the physician of any lab results regardless of whether the results were abnormal. Interview on 11/28/23 at 4:00 P.M. with CDON #103 confirmed Resident #74's care plan did not address the resident's risk for low potassium levels until Resident #74 returned from the hospital on [DATE] with that diagnosis. Interviews on 11/29/23 at 3:40 P.M. with RN #160 and Assistant Director of Nursing (ADON) #105 confirmed the physician should be notified immediately upon receipt of any lab results regardless of if the results were normal or abnormal. Both nurses confirmed this had always been the facility's process for the nursing staff. Both nurses confirmed all notifications should be documented in the electronic medical record. Review of the facility policy, Lab and Diagnostic Test Results-Clinical Protocol, revised 09/2012, revealed nursing staff would consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results: the result was something that should be conveyed to a physician regardless of other circumstances (the abnormal result is problematic regardless of any other factors), the resident's clinical status was unclear or worsening. Furthermore, if the resident had signs and symptoms of acute illness or condition change and he/she was not stable or improving, the nurse would notify the physician promptly to discuss the situation. Facility staff should document information about when, how, and to whom the information was provided and the response in the Progress Notes section of the medical record and not on the lab results report. Review of the facility policy, Guidelines for Reporting Abnormal Test Results to Physicians, revised 02/2014, revealed for a chemistry test, immediate notification should be completed if potassium level was less than 3.0. Review of the undated facility policy, Hypodermoclysis revealed hypodermoclysis was subcutaneous administration of fluid to correct dehydration. Infusion sites would be observed at least every two hours for redness, swelling, leaking, or discomfort. Document date and time of procedure, site assessment, patient response to procedure and/or medication, and patient teaching on appropriate nursing document. Review of the facility policy, Change in a Resident's condition or Status, revised 12/2016, revealed the nurse would notify the resident's Attending Physician or physician on call when there has been a significant change in the resident's physical/emotional/mental condition or need to alter the resident's medical treatment significantly. A significant change of condition was a major decline or improvement in the resident's status that would not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions. Review of the facility policy, Care Plans, Comprehensive Person-Centered, revised 12/2016, revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs was developed and implemented for each resident. The comprehensive, person-centered care plan would include measurable objectives and timeframes, describe the services that were to be furnished to attain or maintain the resident's highest physical, mental and psychosocial well-being, describe services that would otherwise be provided for the above, but were not provided due to the resident exercising his or her rights, including the right to refuse treatment, include the resident's stated goals upon admission and desired outcomes, incorporate identified problem areas, incorporate risk factors associated with identified problems, identify the professional services that are responsible for each element of care, and reflect currently recognized standards of practice for problem areas and conditions. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Review of the facility policy, Medication Orders, revised 11/2014, related to intravenous orders included when recording orders for IV solutions, specify the type of solution, rate of flow, and volume to be infused. Example: 1000 cc D5W I.V. at 50 cc/hr. Discontinue when infused.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review, hospital record review, review of Centers for Disease Control (CDC), National Health Institutes of Health, and National Pressure Injury Advisory Panel (NPIAP) information, review of the facility policy and procedure titled Prevention of Pressure Ulcers/Injuries, review of the facility policy and procedure titled Perineal Care, facility and staff interviews, the facility failed to implement a comprehensive and effective pressure ulcer treatment program to prevent the development of an avoidable pressure ulcer for one newly admitted resident, Resident #14, who was admitted with intact skin, assessed to be at risk for pressure ulcer development, incontinent of bowel and bladder and dependent on staff for bed mobility and personal care. This resulted in Immediate Jeopardy and serious life-threatening harm to Resident #14 on [DATE], when the resident was assessed to have an unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) pressure ulcer to the coccyx with deterioration of previously identified moisture associated skin damage (MASD) without evidence adequate interventions (including but not limited to turning and repositioning) had been implemented to prevent the development. Following the development, the ulcer continued to deteriorate and on [DATE] due to a change in responsiveness and vital signs the resident was transferred to the emergency room. The resident was admitted and subsequently diagnosed at the hospital with sepsis and necrotizing fasciitis. This affected one resident (#14) of three residents reviewed for pressure ulcers. The facility identified four current residents with pressure ulcers in a facility census of 87. On [DATE] at 5:24 P.M., Regional Director of Operations #800, the Director of Nursing (DON), the [NAME] President of Operations #801, the Regional Director of Clinical Services #802, and the [NAME] President of Clinical Services #803 were notified Immediate Jeopardy began on [DATE] when the facility failed to provide necessary interventions to prevent the development of an unstageable pressure ulcer to Resident #14. On [DATE], Resident #14 was found to have an unstageable pressure ulcer to the coccyx and the pressure ulcer was assessed to be 9.2 centimeter (cm) long and 10.4 cm wide. The wound base had 40-percent granulation tissue (a type of connective tissue that forms on a wound during healing) and 15-percent slough (yellow/white necrotic tissue). There were scatter open granular areas with one small, sloughed area over sacrum. The peri wound area appeared to be macerated. On [DATE], Resident #14 exhibited a change in condition, was hospitalized and admitted with sepsis and necrotizing fasciitis. Resident #14 did not return to the facility and expired on [DATE]. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: • On [DATE] at 2:00 P.M., the DON notified the Medical Director #950 that the facility created a new skin Quality Assurance Performance Improvement (QAPI). The skin QAPI plan is to address concerns with in-house pressure growth and the need for staff training due to turnover in management and nursing. • On [DATE], DON and ADON #603 completed a whole house skin audit with no unidentified areas observed. • On [DATE], all nurses, one registered nurse (RN) and 18 licensed practical nurses (LPNS), were in-serviced on preventative interventions to prevent skin breakdown by the DON. All 36 State Tested Nursing Assistants (STNA) in-serviced on turns and repositioning, and incontinence care by the DON. • On [DATE], all six residents with noted pressure areas were evaluated by the DON to ensure all preventative measures were appropriate and in place with no concerns noted. • On [DATE], Resident #14 was sent to the emergency room and did not return back to the facility. • On [DATE], the facility completed a QAPI meeting to discuss that the facility had a skin QAPI in place and the facility identified no further in house pressure ulcers developed. Medical Director #950, DON, Administrator, Medical Records and Central Supplies #615, Unit Manager #901, ADON #603, admission Coordinator #620, Activity Director #630, Housekeeping Supervisor #640, Maintenance Director #645, and Business Office Manager #650 were all in attendance at the QAPI meeting. • On [DATE] at 9:00 A.M., the DON completed a Braden risk assessment on all current residents to identify any high-risk residents. Changes were made in the resident's plan of cares who were identified at high risk and active pressure ulcers by the Minimum Data Set Nurse #900. The care plans were updated to reflect all preventative interventions. • On [DATE], Unit Manager #901 completed a skin assessment on all 88 current residents residing in the facility. No new skin areas or pressure ulcers were found. • On [DATE], the DON educated all 30 LPNs (no RN) on Prevention of Pressure Ulcers/Injuries Policy and 46 STNAs were educated on turning and repositioning and incontinence care. • Beginning on [DATE], the DON/designee will audit three random residents with high-risk Braden assessments weekly for four weeks. The DON/designee will audit all new admissions weekly for four weeks to ensure all preventative measures are all on the care plan. • On [DATE], interviews with LPN #401, STNA #402, STNA #403, LPN #404, LPN #405, and STNA #406 revealed the staff were knowledgeable on the education they had received on pressure ulcer in-regards to documentation, assessments, prevention and treatment of pressure ulcer, notification, and turning and repositioning. • Beginning on [DATE], weekly QAPI meetings will be completed so any discrepancies from the audits can be reviewed with the team. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: Review of the closed medical record for Resident #14, revealed an admission date of [DATE] and a discharge date of [DATE]. Resident #14 had diagnoses including transient cerebral ischemia, cerebral infarction, anxiety, altered mental status, occlusion and stenosis, and peripheral vascular disease. Review of the hospital after visit/Discharge summary dated [DATE] revealed Resident #14 had a transient ischemic attack (stroke). Speech and language pathology discharge recommendations included dysphagia (difficulty swallowing) treatment, one assist with meals, upright position for oral intake, diet tolerance monitoring, swallow function, and cognitive communication functioning. Resident #14 was to follow up with neurologist and heart and vascular specialists. Review of the nursing assessment dated [DATE] revealed the resident was admitted with no pressure areas. The resident was noted to have bunions to her bilateral feet. Review of the Braden scale assessment (assessment for risk factors for developing pressure ulcers) dated [DATE] revealed Resident #14 was at high risk for the development of pressure ulcers. Review of the plan of care (POC) dated [DATE] revealed Resident #14 had a potential for impairment to skin integrity with skin risk related to artery occlusions, peripheral artery disease (PAD), cardiac disease, cardiomegaly, high-density lipoprotein, hypertension, left ventricular hypertrophy, abnormal labs and blood sugars, nicotine use, fragile skin, muscle wasting, incontinence of bowel and bladder, decreased mobility, and history of wound to lower leg. Interventions on the [DATE] POC included to avoid scratching and keep hands and body parts from excessive moisture, keep fingernails short, encourage good nutrition and hydration in order to promote healthier skin, follow facility protocols for treatment of injury, keep skin clean and dry and use lotion on dry skin, monitor for side effects of the antibiotics and over-the-counter pain medications: gastric distress, rash or allergic reactions which could exacerbate skin injury, obtain blood work and culture and sensitivity of any open wounds as ordered by physician, use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface, wound and treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations, medications, treatments, labs, tests and consultations as ordered or needed, and see medication and treatment administration record, wound reports and skin assessments as appropriate. Review of the POC dated [DATE] revealed Resident #14 had an activities of daily living (ADL) self-care performance deficit related to aphasia, cardiomegaly, hypertension, impaired gait/balance, impaired vision, left ventricular hypertrophy, nicotine dependence, PAD, history of altered mental status, anxiety, cerebrovascular accident, left facial droop, left-sided weakness, shortness of breath, and stroke. Interventions included repositioning and toileting with a two-person assist. The POC did not specify any interventions related to the frequency of turning or repositioning for the resident. In addition, record review revealed no documented evidence staff provided turning and repositioning between [DATE] and [DATE]. The resident did not have any type of air mattress during this time. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #14 had impaired cognition. The assessment revealed the resident required extensive assistance from two staff for bed mobility and transfers, staff assistance for eating and was frequently incontinent of bowel and bladder. The assessment revealed Resident #14 had no skin concerns. A weekly skin assessment dated [DATE] revealed Resident #14 had no skin concerns. On [DATE] a physician order was obtained for zinc barrier cream to be applied to the resident's buttocks every shift for prevention and as needed. The treatment administration record (TAR) included documentation of the zinc barrier cream being applied as ordered beginning on [DATE]. Record review revealed no additional assessment of the resident's skin at this time or information to note why the zinc was ordered. A skin sweep/bathing sheet dated [DATE] revealed a red area was marked to Resident #14's right buttock. There was no evidence of new interventions initiated at that time. A weekly skin assessment dated [DATE] revealed Resident #14 had moisture associated skin damage (MASD) to her bilateral buttocks/sacrum area. The assessment indicated preventive measures (zinc barrier cream) were put in place. MASD is caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate, mucus, saliva, and their contents. MASD is characterized by inflammation of the skin, occurring with or without erosion or secondary cutaneous infection. A progress note dated [DATE] at 9:00 A.M. revealed a State Tested Nursing Assistant (STNA) #400 summoned the DON and the DON noted the resident had an unstageable pressure area to her coccyx that measured one cm long and 1.9 cm wide to the right buttocks. The note indicated the DON realized once Resident #14 started getting into a specialized Broda chair, Resident #14 started getting pressure from the chair. Orders were received on [DATE] for a cushion to be placed in the Broda chair and the note documented every two-hour turns were to continue. A Broda chair is a specialized type of wheelchair that provides tilt-in-space positioning, recline and leg rest adjustments. However, there was no documented evidence to support every two-hour turns were being provided for the resident. Review of the wound nurse practitioner (CNP #400), note dated [DATE] revealed Resident #14 was seen for an unstageable pressure wound to sacrum that measured 9.2 cm long by 10.4 cm wide. The wound base had 40-percent granulation tissue and 15-percent slough. There was a scant amount of serous (thin, watery, clear) drainage and no signs of infection. The CNP noted a new treatment order for Triad (a sterile coating that can be used on broken skin, keeping the wound covered and protected from incontinence). On [DATE] Resident #14's POC was updated to include interventions of an air mattress to assist in redistribution, every two hour turns, and use of a pillow/cushion when sitting in Broda chair. A skin sweep/bathing sheet dated [DATE] revealed Resident #14 had a new area to buttocks. An arrow drawn on the sheet appeared to be pointed to the left buttock/sacrum area. Review of a weekly skin assessment dated [DATE] revealed Resident #14 had an unstageable pressure ulcer to sacrum that measured 9.2 cm long and 10.4 cm wide. Review of a weekly wound assessment dated [DATE] revealed Resident #14's coccyx/sacrum pressure ulcer had worsened/deteriorated, and a new treatment order was received for the area to be cleansed with normal saline, packed with Dakin's solution (moist to dry dressing), and covered with bordered foam dressing twice a day and as needed. The unstageable pressure ulcer to Resident #14's coccyx measured 9.2 cm long by 10.4 cm wide. The peri-wound tissue appeared macerated. A corresponding note, from CNP #400 also dated [DATE] revealed Resident #14 had an unstageable pressure ulcer to the sacrum that measured 9.2 cm long by 10.4 cm wide. There was undermining between 12 o'clock for a maximum of 4.8 cm. The wound base had 20-percent granulation and 60-percent slough. The note revealed there had been a rapid decline of the wound. The treatment was changed on this date with a new order to pack wound with Dakin's solution (wound cleanser to treat and prevent infections) wet to moist dressing twice daily to help clean out remaining slough. There was a large amount of serosanguinous (blood and serous fluid). CNP #400 revealed there were no signs of infection and the peri wound appeared to be macerated. The overall wound condition had declined. CNP #400 documented Resident #14 was immobile and unable to offload pressure areas independently, had poor nutritional intake, dementia/confusion, incontinence, overall poor medical condition, and declining medical condition which she believed made the deterioration or presence of the wound unavoidable. However, record review revealed Resident #14 was dependent on staff for off-loading interventions and the resident's medical record contained no additional evidence of non-compliance from the resident. Review of a weekly skin assessment dated [DATE] revealed Resident #14 had an overall wound decline to the sacrum. The area measured 9.2 cm long by 10.4 cm wide. Review of a note by CNP #400 dated [DATE] revealed Resident #14 had an unstageable pressure ulcer to the sacrum that measured 9.6 cm long by 10.9 cm wide. There was now undermining between 8 o'clock and 4 o'clock for a maximum of 4.6 cm. There was 80-percent slough to the wound. The wound bed was filled with black necrotic tissue and the area was debrided. A new order was received to stop Dakin's solution and start Anasept (antimicrobial wound cleanser) gel and pack with normal saline wet to moist gauze. A progress note dated [DATE] at 10:30 A.M. revealed Resident #14 was cool to touch and non-responsive. The resident's blood pressure was 136/54 millimeter of mercury (mmHg), pulse was 113 beats per minute, oxygen saturation was 97-percent, and temperature was 94.7 degrees Fahrenheit (F). Resident #14 was sent to the hospital for evaluation. Review of the hospital Orthopedic Surgery Consultation Note from Physician #940 dated [DATE] revealed Resident #14 presented to the emergency room revealed the general surgery team had a concern for a necrotizing soft tissue infection arising from her full-thickness sacral decubitus ulcer. Review of the hospital Orthopedic Surgery consult dated [DATE] from Physician #958 revealed general surgery did recommend to debride the sacral decubitus ulcer. Review of the hospital nephrology consultation note dated [DATE] revealed Resident #14 was brought into the hospital with a large decubitus infected wound. Resident #14 was found to have severe necrotizing soft tissue infection on cat (CT) scan. Resident #14 was admitted to the intensive care unit for sepsis. On presentation the resident had lactic acidosis and acute kidney injury. On [DATE] at 1:21 P.M. interview with Wound Care Nurse Practitioner (CNP) #400 revealed Resident #14 had an unstageable pressure ulcer when the resident was seen on [DATE]. There was slough and the area appeared to be superficial, so barrier paste was ordered. Wound Care Nurse Practitioner #400 stated she thought it was possibly a Kennedy ulcer due to how quickly it deteriorated. The CNP indicated the wound never appeared red or had a foul odor to indicate it was infected. A Kennedy ulcer, also known as a Kennedy terminal ulcer (KTU), is a dark sore that develops rapidly during the final stages of a person's life. Kennedy ulcers grow as skin breaks down as part of the dying process. Record review from [DATE] to [DATE] revealed no evidence Resident #14 was terminal or actively dying. On [DATE] at 1:26 P.M. interview with the Director of Nursing (DON) revealed Resident #14 had only been up in the Broda chair once prior to the pressure ulcer developing. The DON indicated she believed Resident #14 was provided incontinence care and repositioned every two hours. However, the DON verified there was no documented evidence to support this care was provided. The DON indicated she had observed the area to Resident #14's sacrum on [DATE] and indicated the area was consistent with MASD. The DON verified on [DATE] the area to Resident #14's sacrum was consistent with an unstageable pressure ulcer and the wound nurse practitioner was asked to look at the area on [DATE]. On [DATE] at 11:29 A.M. interview with Resident #14's family, Family #700 revealed they were not aware Resident #14 had a pressure ulcer or that the resident had sustained a health decline. Family #700 revealed after being sent to the hospital, they were told Resident #14 had a bad infection that had to be removed surgically. Resident #14 was at the hospital from [DATE] to either [DATE] or [DATE] (unable to recall exact date). Family #700 stated Resident #14 was discharged from the hospital to another long-term care facility with Hospice services. Resident #14 passed away on [DATE]. Family #700 stated a vascular surgeon reported to them Resident #14 would not survive another surgery because everything was too weak. Family #700 stated they did not know if the surgeon meant she was weak from the stroke, infection, or just in general. Family #700 stated they were disappointed in the care Resident #14 received at the facility. Family #700 indicated they sought nursing home placement for the resident as they were unable to provide the necessary care for her in the home setting. On [DATE] at 2:04 P.M. an interview with DON revealed the standard of care was for all residents to be turned and repositioned every two hours. The standard of care also included incontinence care to be provided every two hours. The DON verified zinc barrier cream was not added until [DATE] as a preventative measure. The DON also verified there was not a POC implemented for the resident related to incontinence care. On [DATE] at 2:29 P.M. interview with State Tested Nursing Assistant (STNA) #850 revealed she had provided care for Resident #14 and had alerted the nurse that a dry area was noted to Resident #14's bottom (date not provided) but there were no open areas. STNA #850 revealed when she returned to work a few days later, the areas to Resident #14's bottom were significantly bigger. STNA #850 stated Resident #14 was unable to turn or reposition herself and was incontinent. On [DATE] at 3:26 P.M. interview with Regional Director of Clinical Services (RDO) #802 revealed it was automatic for each resident to be turned and repositioned and that this intervention was not care planned. The RDO revealed the area to Resident #14's sacrum appeared to be MASD but was actually necrotizing fasciitis. During the interview, RDO #802 revealed different interventions were not implemented for residents assessed to be at different risk for development of pressure ulcers. She stated interventions were resident specific and case by case. Regional Director of Clinical Services #802 was unable to provide any additional information to support effective and individualized interventions were implemented for Resident #14, who was assessed on admission to be at high risk for the development of pressure ulcers. On [DATE] at 1:02 P.M. interview with Medical Physician (MD) #600, the physician assigned to care for Resident #14 during her stay revealed the resident was seen on [DATE]. The resident was at baseline and alert to self but aphasic (a symptom of damage to parts of the brain that control language and make it difficult to read, write and say what the person wants to say). The physician indicated her main concern during the visit was Resident #14's elevated blood pressures. The resident had recently had a stroke and continued with elevated blood pressures. The blood pressures were within acceptable parameters but were being monitored. MD #600 stated the nursing staff were asked if Resident #14 had any skin concerns on her back or bottom to which they denied. MD #600 stated she visited Resident #14 again on [DATE]. Resident #14 was asleep but was easily awakened. MD #600 revealed the resident continued at her baseline; alert to self and aphasic. MD #600 revealed she collaborated with the nurse and STNA and was told there was nothing new. The nursing staff did not report Resident #14 any skin concerns at that time. MD #600 stated the documentation she reviewed on [DATE] did not show any skin impairment. MD #600 revealed in general she looked at wounds if the wound nurse practitioner had not recently looked at them or if there was concern. MD #600 again verified there was nothing documented in the notes that were reviewed on [DATE]. Review of Policy for Perineal Care revised [DATE] revealed the purposes of the procedure was to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. The procedure revealed the following information should be recorded in the resident's medical record: the date and time that perineal care was given, the name and title of the individual giving the perineal care, how the resident tolerated the procedure, and the signature and title of the person recording the data. Review of Policy for Prevention of Pressure Ulcers/Injuries revised [DATE] revealed to review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Risk Assessment: Assess the resident on admission for existing pressure ulcer/injury risk factors. Conduct a comprehensive skin assessment upon admission. Inspect the skin on a daily basis when performing or assisting with personal care and ADLs. Reposition resident as indicated on the care plan. Prevention included keeping the skin clean and free of exposure to urine or fecal matter. Choose a frequency for repositioning based on the resident's mobility, the support surface in use, skin condition and tolerance, and the resident's stated preferences. At least every hour, reposition residents who are chair-bound or bed-bound with the head of the bed elevated at 30-degress or more. At least every two hours, reposition residents who are reclining and dependent on staff for repositioning. Reposition more frequently as needed, based on the condition of the skin and the resident's comfort. Select appropriate support surfaces based on the residents' mobility, continence, skin moisture and perfusion, body size, weight, and overall risk factors. Review of the Centers for Disease Control and Prevention (CDC) guidance titled Necrotizing Fasciitis: All You Need to Know, last reviewed [DATE], revealed necrotizing fasciitis is a rare bacterial infection that spreads quickly in the body and can cause death. Accurate diagnosis, rapid antibiotics, and prompt surgery are important to stopping this infection. To prevent necrotizing fasciitis, wash your hands often and clean and care for wounds. Review of pubmed.ncbi.nlm.nih.gov revealed necrotizing soft tissue infections (STI) are serious complications that may arise from pressure ulcers. Necrotizing STIs developed primarily from pressure ulcers over the sacrum. Necrotizing STI's arising from pressure ulcers are generally caused by mixed pathogens and exhibit symptoms that are milder than those of necrotizing fasciitis caused by group A Streptococcus. Review of the information from the NPIAP at https://npiap.com/ revealed facilities should develop and implement a risk-based prevention plan for individuals identified being at risk for developing pressure injuries. Reposition all individuals with or at risk of pressure injuries on a individualized schedule, unless contraindicated. Reposition the individual in such a way that optimal offloading of all bony prominences and maximum redistribution of pressure is achieved. Promote seating out of bed in an appropriate chair or wheelchair for limited periods of time. Use a pressure redistribution cushion for preventing pressure injuries in people at high risk who are seated in a chair/wheelchair for prolonged periods, particularly if the individual is unable to perform pressure relieving maneuvers. Further review revealed an Unstageable Pressure injury was defined as full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. This deficiency represents non-compliance investigated under Complaint Number OH00141720.