**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of hospital records, interviews, and facility policy review, the facility failed to provide timely and necessary care and treatment to prevent complications following a fall with injury and changes in resident condition. This resulted in Immediate Jeopardy and serious life-threatening harm on [DATE] when Resident #2 sustained a fall with his left arm assessed to have an area that was raised, red, and warm to touch between his ulna and humerus bone without evidence of additional medical treatment. Between [DATE] and [DATE] Resident #2 continued to exhibit changes in condition including his arm being red, edematous, warm, and tender to touch, Resident #2 was lethargic and experienced episodes of decreased appetite, elevated body temperatures, and decreased oxygen saturation levels. The facility failed to seek medical treatment for Resident #2 until [DATE] (five days later), when Resident #2 was transported to the emergency room (ER). Resident #2 was admitted to the intensive care unit (ICU) with diagnoses of cellulitis and related septic shock. Resident #2 required Levophed (a potent vasoconstrictor used to treat hypotension) intravenous (IV) and IV antibiotics. Resident #2 was hospitalized for four days, returning to the facility on [DATE]. The Immediate Jeopardy and actual harm continued on [DATE] at 1:50 A.M. when Resident #2 was found to be foaming at the mouth with a decreased level of consciousness, and was cold and clammy, lethargic, and difficult to arouse, with a decreased oxygen saturation of 71% on room air, an elevated respiratory rate of 28 and a decreased blood glucose level of 23 milligrams per deciliter (mg/dl) (per the Centers for Disease Control, a blood glucose level below 70 mg/dl is considered hypoglycemia). Glucagon was administered via intramuscular (IM) injection. After 15 minutes, Resident #2's blood glucose level was 66. On [DATE] at 4:05 A.M., Resident #2's blood glucose level was 47 and a second dose of Glucagon IM was administered. After 15 minutes, his blood glucose level was 38 and a third dose of Glucagon was administered. Resident #2 was then administered half packet of oral glucose gel and given orange juice, which resulted in a glucose level of 68. Resident #2 was transferred to the ER by Emergency Medical Services (EMS) at 6:15 A.M. (over four hours after the change in condition was first identified). Resident #2 was admitted to the intensive care unit (ICU) with diagnoses of worsening (left upper extremity [LUE]) cellulitis and severe sepsis. Resident #2 did not return to the facility and expired on [DATE]. Additionally, a concern that did not rise to an Immediate Jeopardy occurred when facility staff failed to adequately monitor and report (to the physician) episodes of hyperglycemia for Resident #1 to properly manage the resident's diagnosis of diabetes mellitus. This affected two residents (#1 and #2) of three residents reviewed for change in condition. The facility census was 77. On [DATE] at 5:20 P.M., the Administrator and the Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] when facility staff failed to timely identify and obtain medical treatment for Resident #2 following an acute change in condition. The facility failed to seek adequate and necessary treatment until [DATE] when Resident #2 was transferred to the emergency room and admitted with cellulitis and related septic shock. Following Resident #2's return to the facility, on [DATE] at 1:50 A.M. the resident exhibited an acute change in condition but was not transferred to the emergency room until 6:15 A.M. (over four hours later) where he was admitted with worsening (LUE) cellulitis and severe sepsis. Resident #2 did not return to the facility and expired on [DATE]. The Immediate Jeopardy was removed on [DATE] when the facility completed the following corrective actions: • On [DATE] the facility initiated a Performance Improvement Plan (PIP)/Quality Assurance Performance Improvement (QAPI) for skin prevention. • On [DATE], the DON and Interdisciplinary Team (IDT) reviewed the skin care policy and no changes were made. • On [DATE], the DON conducted an investigation concerning physician response during Resident #2's change of condition on [DATE]. • On [DATE], the DON spoke with Resident #2's physician and voiced concern the on-call practitioner did not respond during a change of status for Resident #2. The practitioner stated that he would look into why no one responded. • On [DATE], the DON then contacted the [NAME] President of Nursing for the facility and the facility Medical Director via a conference call. • On [DATE], the DON devised a plan of correction (POC) for physician notification with a change of condition. • On [DATE], the staff nurse involved in the hypoglycemia incident was educated by the DON on the incident and facility POC. • On [DATE], the rolodex on each nurse's unit was updated by the DON with the medical director's name and phone number. • On [DATE], a secure conversation was sent out to all nurses' regarding physician notification by the DON, after the message was read, each nurse had to respond through PointClickCare (PCC) to the DON that the message was received and read. • On [DATE], the DON and wound nurse completed small huddles with nurses and State-Tested Nursing Assistant (STNA) staff regarding importance of preventable skin measures. • On [DATE], the facility wound nurse began tracking all skin issues such as, skin tears, abrasions, rashes, etc. The wound nurse would notify the practitioner of new wounds and change in wounds, weekly and as needed. She also would notify the resident power of attorney (POA) weekly of wound status and any changes, unless the POA did not want weekly updates, then it would be documented how often POA would like to be notified. • On [DATE] to [DATE], the DON reviewed one-on-one with all professional nurses, the facility skin care policy. • On [DATE] and [DATE] the DON conducted official meetings with all nurses addressing physician notification during resident change of status, skin integrity/wounds, falls/injuries, assessments and documentation. The meeting was mandatory with all nurses present on either [DATE] or [DATE]. • On [DATE], the IDT met for the first monthly meeting to discuss skin issues and concerns, as well as compare if skin issues improved or worsened for one year. • On [DATE] and [DATE], skin sweeps for all residents with the wound nurse and wound practitioner were conducted. Findings were documented in the resident's medical record. If any open areas or concerns, treatments were initiated and POA's were notified. • On [DATE], a plan for weekly skin sweeps to be completed by the staff nurse on duty for the shift and day the skin sweep was scheduled. • On [DATE], the facility performance improvement plan (PIP) was evaluated by the IDT and facility continued with the current interventions put in place. It was discussed that the IDT would review with the Medical Director compliance and barriers regarding skin assessments during quarterly Quality Assurance (QA) meetings, discussing standards in practice and utilizing any guidance. The facility wound nurse would present findings and initiate any PlP's according to QA discussion. • On [DATE], the DON developed a tracking tool to review resident charts to ensure physicians were being notified promptly and resident change of condition was being addressed promptly. • On [DATE], the facility implemented a plan for the DON and /or assigned designee to review the 24-hour report in PCC daily to review documentation for any change of status and ensure physician notification was being completed in a timely manner. • On [DATE], the facility implemented a plan for the DON and/or designee to address any concerns promptly with the staff, should a concern arise. • The IDT will review with the Medical Director compliance and barriers regarding change of condition and physician notification during quarterly QA meetings, discussing standards in practice and utilizing any guidance. The DON would present findings and initiate any PIP's according to QA discussion. • On [DATE], a facility Quality Assessment Performance Improvement (QAPI) plan was developed. • On [DATE], a tracking log was developed to track blood sugars (BS) of all diabetics to ensure that a practitioner had been properly notified (based on physician orders or facility policy parameters). • On [DATE], the facility implemented a plan for the DON and/or designee to audit BS results daily for one year then as needed to ensure physician was notified and policy and procedure followed. If any concerns were observed during the auditing process they would be addressed promptly by the DON and/or designee, as well as education to involved staff. • The IDT will review with the Medical Director compliance and barriers regarding Blood Sugar Policy and Procedure during quarterly QA meetings, discussing standards in practice and utilizing any guidance. The DON will present findings and initiate any PIP's according to QA discussion. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a 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 plan and monitoring to ensure on-going compliance. Findings include: 1. Review of the closed medical record for Resident #2 revealed an initial admission date of [DATE] with diagnoses including mild cognitive impairment, diabetes mellitus, chronic kidney disease, atherosclerotic heart disease, anxiety disorder, and muscle weakness. Review of the medical record revealed Resident #2's physician was Physician #400. Review of Resident #2's care plan, dated [DATE], revealed the resident had diabetes mellitus with interventions including to administer insulin per physician orders, monitor/document/report as needed any side effects and/or effectiveness; and to check all body for breaks in skin and treat promptly as ordered by the physician. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated [DATE], revealed Resident #2 had moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of nine. The assessment revealed Resident #2 required limited, one-person assistance from one staff for bed mobility, transfer, walking corridor, toileting, and personal hygiene. The assessment further indicated the resident sustained one fall since admission/re-entry or prior assessment with no major injury. The resident had no pressure ulcers or other ulcers, wounds, or skin problems. The resident was continent of bowel and bladder. Review of the nursing progress note, dated [DATE] at 9:30 P.M., revealed Resident #2 was found sitting on the floor with his back against his bathroom door. Vital signs were not within normal limits (WNL) with an oxygen (O2) saturation bouncing around in the 70's, blood pressure (BP) 80/62 (hypotensive), and temperature 98.9 degrees F. The resident's left arm was observed to be raised, red, and warm to touch between his ulna and humerus bone. The resident was noted to be incontinent of bowel movement (BM) at the time of the fall. The physician was notified, and an x-ray was ordered for the left arm. The physician instructed the nurse to continue to monitor the resident closely. Review of the nursing progress note, dated [DATE] at 12:32 P.M., revealed Resident #2 was very lethargic during the shift. His O2 saturation was 86% on room air and oxygen was applied at 2 liters (L) per nasal cannula. The resident was very non-compliant with leaving the nasal cannula on. The resident complained of pain to the LUE and Tylenol was administered. There was no documented evidence that the resident's physician was notified of the low oxygen saturation and complaint of LUE pain. Review of the Medication Administration Record (MAR), dated [DATE], revealed Tylenol 650 milligram (mg) suppository was administered on [DATE] at 1:14 A.M. for a temperature of 100.6 degrees F. Review of the post-fall 72 Hour Neurological assessment dated [DATE] at 1:00 A.M. revealed Resident #2 was hypotensive with a blood pressure (BP) of 89/63. At 5:00 A.M. the resident's BP was 86/58 (hypotensive). There was no documented evidence the resident's physician was notified of the resident's hypotension or that the resident was transferred to the emergency room for evaluation/treatment. Review of the nursing progress note, dated [DATE] at 10:29 A.M., revealed Resident #2's left forearm was red, warm, swollen, and painful to the touch. The nurse's note revealed the resident's physician was updated at that time. A physician's order, dated [DATE], revealed an order for the antibiotic, Clindamycin HCL 300 milligrams (mg) one capsule, three times per day, for cellulitis of the left arm. The physician also provided an order, on [DATE] to cleanse left wrist laceration with normal saline and apply a Vaseline gauze and foam patch each day shift. Review of the Treatment Administration Record (TAR), dated [DATE], revealed the order (obtained [DATE]) to cleanse left wrist laceration with normal saline and apply a Vaseline gauze and foam patch was not initiated until [DATE]. Review of the nursing progress notes revealed Resident #2 sustained two additional falls without injury on [DATE] and [DATE]. Review of the Medication Administration Record, dated [DATE], revealed on [DATE] at 5:00 P.M., Resident #2's blood glucose was 315 and on [DATE] at 8:00 A.M., the blood glucose was 361. There was no documented evidence of the physician being notified of the resident's blood glucose levels greater than 300 per the facility's policy (for hyperglycemia). Review of the nursing progress note, dated [DATE] at 12:54 P.M., revealed Resident #2's left arm remained edematous, red, and warm to touch. The resident required two-person assistance with activities of daily living (ADL) and was incontinent of bowel and bladder. There was no documented evidence that the resident's physician was notified of the continued edema, redness, and warmth of the left arm, continued bowel incontinence, or of the resident's decline in ADL status. There was no evidence the resident was transferred to the emergency room for evaluation/treatment at this time. Review of the nursing progress note, dated [DATE] at 6:10 P.M., revealed Resident #2's left arm continued to be edematous and tight, red, and warm to touch. Inside elbow skin is sloughed off and red, moist skin under. The resident was lethargic. There was no documented evidence that the resident's physician was notified of the continued edema, tightness, redness, warmth, and skin sloughing of the left arm or that the resident was transferred to the emergency room for evaluation/treatment at this time. Review of the nursing progress note, dated [DATE] at 10:07 A.M., revealed Resident #2 refused breakfast and his left arm remained red, warm, edematous, and tender to touch. The dressing was changed to the left wrist wound. There was no documented evidence that the resident's physician was notified of the continued edema, redness, and warmth of the left arm or that the resident was transferred to the emergency room for evaluation/treatment at this time. Review of the nursing progress note, dated [DATE] at 7:28 P.M., revealed Resident #2 was lethargic and difficult to arouse. Cellulitis to the left arm was worsening and he was unable to take oral medication. Resident #2's BP was 72/42 (hypotensive), pulse 62, respirations 24, temperature 99.9 F, and O2 saturation was 65% (low). The resident's fingers were cold with poor circulation noted. At 4:00 P.M., the resident's blood glucose level was elevated at 232 and his insulin held because the resident had not eaten anything all day and drank very little. The physician was notified at that time and the note indicated the nurse was awaiting a return call. Review of the nursing progress note, dated [DATE] at 7:47 P.M., revealed Resident #2 was transported to the ER by EMS. Review of hospital records, dated [DATE], revealed Resident #2 presented with hypotension and a swollen left arm and forearm and was diagnosed with cellulitis and septic shock. IV fluids and antibiotics per sepsis protocol were initiated in the emergency department (ED). The resident required Levophed IV, a potent vasoconstrictor used to treat hypotension and was admitted to the intensive care unit (ICU) until [DATE]. Review of the nursing progress note, dated [DATE] at 4:30 P.M., revealed Resident #2 returned from the hospital and was re-admitted to the skilled nursing facility. Review of the physician order, dated [DATE], revealed the order for the antibiotic, Augmentin oral tablet 875-125 mg, one tablet every 12 hours for seven days, for cellulitis. Review of a nursing progress note, dated [DATE] at 7:42 P.M., revealed Resident #2 refused his antibiotic Augmentin. There was no documented evidence of the physician being notified of the resident's medication refusal. Review of the Medication Administration Record, dated [DATE], revealed on [DATE] at 5:00 P.M. the resident's blood glucose was 332. There was no documented evidence of the physician being notified of the resident's blood glucose levels greater than 300 per the facility's policy. Review of a nursing progress note, dated [DATE] at 1:50 A.M., revealed Resident #2 was found to be foaming at the mouth with a decreased level of consciousness, and was cold and clammy, lethargic, and hard to arouse. His O2 saturation was 71% on room air and his respiratory rate was 28. An attempt to notify the physician was unsuccessful. Resident #2's blood glucose level was 23 mg/dl (per the Centers for Disease Control, a blood glucose level below 70 mg/dl is considered hypoglycemia) and Glucagon was administered via IM injection. After 15 minutes, at 2:10 A.M. the resident's blood glucose level was 66. At 2:45 A.M., the blood glucose level was 68. Review of a nursing progress note, dated [DATE] at 4:05 A.M., revealed Resident #2's blood glucose level was 47 and a second dose of Glucagon IM was administered. After 15 minutes, his blood glucose level was 38 and a third dose of Glucagon was administered. The resident was then administered half packet of oral glucose gel and given orange juice, which resulted in a glucose level of 68. Further attempts to notify the physician were unsuccessful. The POA was called at 6:15 A.M. and Resident #2 was transferred to the ED by EMS at 6:30 A.M. Review of the hospital history and physical, dated [DATE], revealed Resident #2's chief complaint was worsening shortness of breath and low blood sugar. The resident's white blood cell count was 13.9 (elevated). The LUE had cellulitis from the distal forearm to the proximal humerus with ulcerations noted in the area. The assessment revealed LUE cellulitis, dementia, septic shock, and bilateral pneumonia. The resident did not return to the facility following this hospitalization and expired on [DATE]. Interview on [DATE] at 2:40 P.M., with Registered Nurse (RN) #124 confirmed she authored the nursing progress note, dated [DATE] at 11:46 A.M., which revealed Resident #2 had a left wrist laceration with thick, yellow drainage in the wound bed and redness and warmth was noted in the peri-wound. RN #124 confirmed she did not obtain wound measurements or notify the physician of the thick, yellow drainage to obtain adequate and necessary medical treatment. Interview on [DATE] at 11:15 A.M. with the DON confirmed a thorough skin/wound assessment, including wound measurements, was not completed for Resident #2's left, open wrist wound, nor was there a comprehensive assessment of the LUE cellulitis. The DON confirmed the physician should have been updated regarding any changes of condition or worsening of Resident #2's cellulitis. The DON further confirmed the facility had identified an issue related to Resident #2's incidents of hypoglycemia on [DATE] and the lack of physician response when notification was attempted. The DON stated the nurse should have contacted the resident's POA and sent Resident #2 to the hospital sooner for evaluation when she could not reach the physician. Interview on [DATE] at 12:39 P.M. with Physician #400 revealed he was not notified of Resident #2's continued LUE redness, swelling, edema, and pain following the initiation of the antibiotic Clindamycin. Physician #400 stated that without proper skin assessments, the nursing staff would have been unable to determine if the infection was spreading despite the treatment plan. Physician #400 further stated while he was not sure if anything additional could of have been done in the outpatient setting, he would have sent the resident to the hospital (sooner) and properly adjusted the treatment plan. Physician #400 stated the resident's cellulitis contributed to septic shock because the antibiotic Clindamycin was not strong enough and the patient was not responding and needed IV antibiotics and IV fluids to get out of harm's way. Review of the facility policy titled, Non-Pressure Related Skin Assessment Policy and Procedure, dated [DATE], revealed document any non-pressure skin impairments, notify the physician, initiate treatment and document on the Treatment Administration Record (TAR), notify the family, and evaluate the treatment and effectiveness of treatment, update the physician as needed. Review of the facility policy titled, Blood Sugar Policy, revision date [DATE], revealed the following protocol would be followed concerning blood sugar results by an outside lab, assisted living, or nursing home monitoring system. Hypoglycemia: Administer 15 grams of carbohydrates for a blood sugar below 60 mg/ml and the resident is still alert. Recheck the blood sugar. If hypoglycemic symptoms continue, treat again with carbohydrates. If the hypoglycemia episode was unresolved within one hour, notify the attending or on-call physician. If the resident was unresponsive due to hypoglycemia, administer Glucagon one mg IM per standing order. If hypoglycemia episode was unresolved within one hour, notify the attending or on-call physician. Hyperglycemia: Notify the attending or on-call physician for a blood sugar reading of 300 mg/ml or higher unless physician has given specific blood sugar parameters. Examples of 15 grams of carbohydrates: four ounces of a sugar free supplement, four ounces of orange juice, or one dose of Glutose 45 (a fast-acting glucose gel). 2. Review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia, Alzheimer's disease, diabetes mellitus, anxiety, dysphagia, and chronic kidney disease. Review of the annual Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 99 which indicated the resident could not be interviewed. The assessment revealed Resident #1 was dependent on staff with assistance for eating, toileting, and personal hygiene. The assessment further revealed the resident was always incontinent of bowel and bladder. Review of Resident #1's care plan, dated [DATE], revealed an intervention for fingerstick blood glucose monitoring per physician order/facility policy and as needed and to notify the physician of blood sugar reading below or above specified physician order/facility policy values. Review of the Medication Administration Record, dated [DATE] and [DATE], revealed on [DATE] at 5:00 P.M., Resident #1's blood glucose was 341, on [DATE] at 5:00 P.M., Resident #2's blood glucose was 355, on [DATE] at 5:00 P.M., the blood glucose was 385, on [DATE] at 5:00 P.M., the blood glucose was 305, on [DATE] at 5:00 P.M. the blood glucose was 312, and on [DATE] at 5:00 P.M. at the blood glucose was 420. There was no documented evidence of the physician being notified of Resident #1's blood glucose levels greater than 300 per the facility's policy. Interview on [DATE] at 3:40 P.M. with the Director of Nursing (DON) confirmed Resident #1's physician was not notified of blood glucose levels greater than 300 on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] as indicated in the facility's policy resulting in the resident's diabetes mellitus not being properly managed and monitored. Review of the facility policy titled, Blood Sugar Policy, revision date [DATE], revealed the following protocol would be followed concerning blood sugar results by an outside lab, assisted living, or nursing home monitoring system. Hypoglycemia: Administer 15 grams of carbohydrates for a blood sugar below 60 mg/ml and the resident is still alert. Recheck the blood sugar. If hypoglycemic symptoms continue, treat again with carbohydrates. If the hypoglycemia episode was unresolved within one hour, notify the attending or on-call physician. If the resident was unresponsive due to hypoglycemia, administer Glucagon one mg IM per standing order. If hypoglycemia episode was unresolved within one hour, notify the attending or on-call physician. Hyperglycemia: Notify the attending or on-call physician for a blood sugar reading of 300 mg/ml or higher unless physician has given specific blood sugar parameters. Examples of 15 grams of carbohydrates: four ounces of a sugar free supplement, four ounces of orange juice, or one dose of Glutose 45. This deficiency represents non-compliance investigated under Complaint Number OH00148970.