**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, family and staff interviews, observations, review of hospital records and review of the facility policy, the facility failed to ensure Resident #35 was properly monitored and interventions were applied to address constipation. This resulted in actual harm when Resident #35 went multiple days with no recorded bowel movements, went to the local hospital emergency room (ER) and was subsequently admitted to the hospital for a small bowel obstruction. This affected one resident (#35) of three residents reviewed for constipation. The facility also failed to ensure an order for a wound dressing treatment was in place prior to the application of wound dressing. This affected one resident (#11) of four residents reviewed for skin conditions. The Facility census was 39. Findings Include: 1. Review of Resident #35's medical record revealed an admission date of 01/26/23. Diagnoses included, but not limited to, epilepsy, dysphagia, cerebral palsy, mild intellectual disabilities, and autistic disorder. Review of Resident #35's Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was not assessed. A Staff Assessment for Mental Status revealed Resident #35 had short and long-term memory problems. Resident #35 was totally dependent on staff for eating and toileting, and required extensive or limited assistance with other activities of daily living (ADLs). Review of Resident #35's physician's orders dated 01/26/23, revealed the resident was ordered to receive Bisacodyl rectal suppository insert 10 milligrams (mg) rectally every 24 hours as needed (PRN) for constipation. Physician orders dated 01/26/23 and discontinued 03/23/23, revealed the resident was ordered to receive Senna S Oral tablet 8.6 -50 mg give two tablets via peg (gastric) tube every twelve hours as needed (PRN) for constipation. The physician's orders dated 01/31/23 and discontinued on 03/18/23, revealed the resident was ordered to receive routine Senna oral tablet one tablet via peg tube two times a day for constipation and the corresponding MAR for the month of March 2023 revealed the routine medication was administered as ordered. Review of Resident #35's care plan revised 04/17/23, revealed the resident had tube for feeding, was at risk for falls, had a seizure disorder, self-care deficit, impaired cognitive function, mild intellectual disabilities, and a risk for constipation. Interventions for constipation included the staff were to follow the facility bowel protocol for bowel management, monitor/document and report to the physician as needed signs and symptoms of complications related to constipation, record bowel movements pattern each day and describe the amount, color, and consistency. Review of a facility document titled ADL Flow Record for Resident #35 revealed the resident had no documented bowel movements from 03/03/23 through 03/11/23 (eight days). On 03/11/23 a 1 was recorded on the ADL Flow Record and through interviews with staff, this indicated the resident had a bowel movement; however, there was no description for the bowel movement. Resident #35 then went from 03/12/23 to 03/14/23 with no recorded bowel movements. Review of Resident #35's handwritten progress notes dated 03/07/23 at 5:00 P.M., revealed Resident #35 was not eating meals well and had an emesis. Review of Resident #35's handwritten progress notes dated 03/08/23, revealed the resident was having increased seizure activity. Review of Resident #35's handwritten progress notes dated 03/12/23, revealed the resident had two episodes of emesis. Review of Resident #35's handwritten progress notes dated 03/13/23, revealed the resident's abdomen was flat, soft and non-tender with hypoactive bowel sounds. Review of Resident #35's handwritten progress notes dated 03/14/23, revealed the resident vomited large brown emesis with small seizure activity. Resident #35's mother was present in the room and Resident #35 was transferred to the hospital. Review of Resident #35's hospital documentation dated 03/14/23 through 03/18/23, revealed Resident #35 presented to hospital ER with a several days history of constipation, hiccoughing (spasms of the diaphragm) which was noted to be worsening over the last several weeks and the resident was vomiting a dark/brown material. Resident #35 had a Computed Tomography (CT) scan of his abdomen and pelvis with contrast due to five days of constipation and vomiting. There was marked distension of bowel throughout the abdomen with multiple air-fluid levels which affected Resident #35's small bowel. A generous amount of stool was in the resident's rectosigmoid colon and findings were consistent with distal small bowel obstruction. After the ER's interventions, the resident had recorded bowel movements on 03/14/23 and the resident's vomiting improved. Resident #35 was admitted to the hospital for a small bowel obstruction with a planned surgical intervention to eliminate the small bowel obstruction. The hospital notes indicated on 03/17/23, the resident had a general surgery consult. The consult information revealed the resident had another large bowel movement in the afternoon on 03/16/23, the resident ate food and did not seem to be having belly pain per his mother and no surgical interventions were noted. Resident #35 returned to the facility on [DATE]. Review of Resident #35's progress notes dated 03/18/23, revealed a staff member from a local hospital called the facility to give a report for Resident #35. The hospital staff reported Resident #35 had three bowel movements after arriving at the ER. Resident #35 was placed on Osmolite tube feeding nutrition at 45 milliliters (ml) per hour from 9:00 P.M. to 6:00 A.M. to increase fiber nutrition. Resident #35 was to continue a regular diet during the day. It was noted eating had been difficult for Resident #35. No signs of seizure activity were noted, and the residents Dilantin (anti-seizure) medication was changed to three times a day with no change in dosage. Review of the March 2023 medication administration record (MAR) dated 03/07/23 through 03/15/23 for Resident #35, revealed there was no evidence of the PRN Bisacodyl documented as being administered and one dose of the PRN Senna documented as being administered on 03/13/23. Interview on 04/18/23 at 10:05 A.M. with Resident #35's responsible party/mother, revealed Resident #35 was hospitalized approximately three weeks ago due to being backed up. Resident #35's mother reported Resident #35 had not had a bowel movement in five or more days and ended up being hospitalized . She stated Resident #35 had since returned to the facility and things had improved but she continued to make sure to ask every day about his bowel movements. Interview on 04/18/23 at 2:20 P.M. with State Tested Nursing Assistant (STNA) #352, revealed Resident #35 was not able to make his needs known so he was checked and changed every couple hours. STNA #352 reported Resident #35 received a tube feeding at night which the nurses connected and disconnected, and staff assisted the resident with eating during the day. STNA #352 reported Resident #35 was dependent on staff for toileting and all his bowel movements were to be documented in his medical record. Interview on 04/19/23 at 2:55 P.M. with STNA #355, verified Resident #35 had no bowel movements (BM) documented from 03/03/23 through 03/11/23 (eight days). STNA #352 stated the handwritten bowel movement tracking dated 03/11/23, indicated Resident #35 had one BM. STNA #352 verified Resident #35 went from 03/12/23 to 03/14/23 with no documented bowel movements. Interview on 04/19/23 at 3:42 P.M. with the Director of Nursing (DON) verified Resident #35 was admitted to the hospital on [DATE] for a small bowel obstruction. The DON indicated she was not familiar with how the STNAs tracked the bowel movements on the handwritten documentation and was not able to decipher what was written. The DON provided a handwritten MAR documentation which showed Resident #35 received one dose of his PRN Senna on 03/13/23 and also verified there no other PRN constipation interventions provided to address the resident's lack of bowel movements from 03/03/23 through 03/11/23 and 3/12/23 through 03/14/23. Review of the facility policy titled, Bowel Elimination Policy and Procedure, revised August of 2022 revealed it was the standard of practice for residents to achieve or maintain their own patterns of elimination and be free from complications. The bowel activity of each resident was to be monitored and assessed by the nursing staff every shift. If a resident was without a BM for 48 hours, 120 milliliters (ml) of prune juice or bran mixture would be offered. Continued monitoring was to occur. If a resident was without a BM for 72 hours the nurse would consider administering osmotic laxative such as milk of magnesia per physician orders. If a resident was without a BM for eight hours after milk of magnesia the nurse would follow established PRN order for a stimulant laxative such as a suppository. If a resident is without a BM eight hours after the suppository was given the nurse would administer an enema as ordered by the physician. Should no result occur, resident assessment and interventions would be reported to the primary care provider for further measures to be taken until bowel elimination occurs and the resident had no acute symptoms of constipation. 2. Review of Resident #11's medical record revealed an admission date of 06/02/20. Diagnoses included, but not limited to, type II diabetes, urinary incontinence, uterine cancer, dysphagia, major depressive disorder, anxiety disorder, epilepsy, and obesity. Review of Resident #11's MDS assessment dated [DATE], revealed a BIMS score of 15 indicating Resident #11 was cognitively intact. Resident #11 had moisture associated skin damage (MASD) at the time of the review. Assessment revealed the resident had a pressure reducing device for her chair and bed, nutrition interventions to manage skin problems, and applications ointments/medications. Review of the physician's orders dated 07/01/21 for Resident #11, revealed the resident was ordered to receive Nystatin powder applied to skin folds topically every shift for skin care. Review of the physician's orders dated 07/09/21 for Resident #11, revealed the resident was ordered to receive Zinc Oxide Cream 10 percent (%) applied to buttocks topically every eight hours PRN for bilateral buttock skin protectant. Review of the physician's orders dated 01/06/23 for Resident #11, revealed the resident was ordered to receive peri-guard to buttocks, labia, and posterior thighs twice a day for skin care. Review of Resident #11's care plan revised on 02/09/23, revealed the resident had a self-care deficit, bladder incontinence, presence of a colostomy, and potential/actual impairment to skin integrity. Interventions for impaired skin integrity included to administer medications as order, turn and reposition every two hours, administer treatments as ordered, apply peri-guard to buttocks, labia, posterior thighs as ordered, avoid scratching, and keep hands and body parts from excessive moisture, keep fingernails short, keep skin clean and dry. Review of active April 2023 physician's orders for Resident #11, revealed no orders for the current dressing being completed on Resident #11's skin impairment. Review of the April 2023 nurses progress notes for Resident #11, revealed no documented evidence of any physician orders for the dressings being utilized or any documentation related to the staff completing the dressing changes. Review of April 2023 treatment administration records (TARs) for Resident #11, revealed no documented evidence of any wound dressings being ordered and/or completed. Interview on 04/17/23 at 7:10 P.M. with Resident #11 found her to be alert and aware. Resident #11 reported she had an open area on the back of her left leg that the facility changed dressings on. Resident #11 reported it was an open area that really hurt her. The resident reported the dressing was last changed a couple of nights ago. Interview on 04/17/23 at 8:53 P.M. with the Assistant Director of Nursing (ADON) #500 verified there was no active order for a dressing change for Resident #11 and she was not aware of any current open areas or wounds. ADON #500 reported she was the wound nurse at the facility. Interview on 04/18/23 at 2:27 P.M. with State Tested Nursing Assistant (STNA) #352 verified she had observed Resident #11 to have skin issues on the back of her legs, under her chest and under her arms. STNA #352 reported the aide applied powder to Resident #11 when the areas were not open and a cream when the areas were open. STNA #352 reported Resident #11 had cream applied because the areas were open. STNA #352 reported the aides only applied the powders and creams and the nurses applied any dressings. STNA #352 stated she had reported Resident #11's skin changes to the nurse. Observation on 04/18/23 at 3:17 P.M. of Resident #11, revealed ADON #500 assisted Resident #11 to roll to her right side to expose her left, posterior, upper thigh and buttock. Observation revealed a bordered foam dressing dated 04/16/23. ADON #500 removed the dressing to reveal an area five centimeters (cm) by eight cm. The area was covered with a white, dry paste. ADON #500 gently removed the paste with toilet tissue paper and no bleeding was noted. The area was assessed ADON #500 as being MASD. Resident #11 stated the area was very painful. The areas of skin folds at the lateral side of the left breast, below the right breast, at the right medial thigh, and abdominal folds were reddened appearing to be consistent with yeast. Resident #11 had been heavily incontinent of urine. The incontinence brief and the cloth incontinence pad were both wet. ADON #500 verified Resident #11 had MASD and had a dressing in place with no physician's order. Review of the facility policy titled, Wound Care, revised August 2022 revealed the staff was to verify there was a physician's order for the procedure and document the treatment was completed in the electronic medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on observation, medical record review, staff interview, review of a facility investigation, review of an employee personnel file, and review of facility in-services, the facility failed to ensure staff members utilized proper safety devices when assisting a resident with ambulation resulting in a fall. This resulted in actual harm when Resident #41 was walking with a nurse aide without the use of a walker or gait belt, and subsequently fell, hitting her head and causing excessive bleeding which required hospitalization. This deficient practice affected one (#41) of three residents reviewed for falls. The facility census was 40. Findings include: Review of Resident #41's medical record revealed an admission date of 02/18/23 and a discharged dated of 02/19/23. Diagnoses included dementia and repeated falls. Review of the Minimum Data Set (MDS) assessment, dated 02/18/22, revealed Resident #41 was identified with moderate cognitive impairment. The resident was assessed to require limited assistance of a one person physical assistance for toileting, her walking was not steady, and was only able to stabilize with staff assistance and used a walker. Resident #41 had a fall with fracture prior to admission and a fall with major injury since admission. Review of a baseline care plan dated 02/18/23 for Resident #41 revealed, for safety, the resident had a history of a fall and she had a subdural hematoma as history of a fall related injury. Interventions included to assist with ambulation and rounding; and for transfers and walking, Resident #41 was to be assisted with one person and equipment used were a wheelchair and a walker. Review of a fall risk assessment dated [DATE] revealed Resident #41 was assessed at high risk for falls with a score of 10. Further review of the assessment revealed a score of 10 or greater indicated the resident should be considered at high risk for falls. Review of a progress note dated 02/19/23 at 12:00 P.M., which was the late entry admission note, revealed Resident #41 arrived at the facility at approximately 4:45 P.M. on 02/18/23 with no family present. Resident #41 was alert but confused and had 13 staples present to the left side of the back of her head from an injury related to a previous fall. Per the hospital, Resident #41 was assisted by one person with a walker and all staff on the shift were notified of the need for assistive devices. Review of a nursing progress note dated 02/19/23 at 5:04 P.M. revealed at approximately 8:45 A.M., an aide alerted the nurse that Resident #41 fell and was bleeding badly from her head. The nurse was in assisted living for medication pass, and the nurse aide indicated another nurse on shift was with Resident #41 while she came to notify this nurse. The nurse asked the nurse aide if anyone called for emergency services and the nurse aide denied anyone called. The nurse and nurse aide ran to the area where Resident #41 fell. Upon arrival, the other nurse on the shift was kneeled down next to Resident #41 with a large amount of blood noted on the floor, and the nurse immediately called emergency services. Resident #41 was lying on the floor on her stomach in front of the nurse station. A nurse aide and another nurse used a blanket to help control the bleeding and were unable to determine the exact location of the bleeding due to amount of blood present. The bleeding appeared to be coming from the right side front of Resident #41's head. Resident #41 was crying saying she wanted to get up and her head hurt. The staff advised Resident #41 not to move and emergency services were on the way to the facility. Another nurse attempted to obtain vital signs, but was unable due to Resident #41 crying and attempting to move around. The nurse asked the nurse aide who was assisting Resident #41 and what happened. The nurse aide indicated she was walking with Resident #41 to the bathroom. The nurse asked the nurse aide if Resident #41 was using a walker, and the nurse aide replied Resident #41 did not have a walker and did not know she needed one. This nurse recalled telling the nurse aide who assisted Resident #41 and other staff several times that Resident #41 required a one staff member assist with a walker. The nurse aide indicated Resident #41 tripped over her own feet and fell. The nurse aide stated she attempted to catch Resident #41 as she fell, but was unable to. Resident #41 did have her own shoes on. The nurse aide stayed with Resident #41 while the nurse and another nurse on shift made phone calls to notify necessary persons of the incident and getting paperwork for the hospital. At approximately 8:53 A.M., Resident #41's granddaughter was notified and indicated she wanted Resident #41 transferred back to the hospital. At approximately 8:55 A.M., report was called to the hospital, and at approximately 8:56 A.M., emergency services arrived and assumed care. Emergency services applied a head wrap bandage around the area of bleeding to Resident #41's head and applied a cervical collar around her neck. Once Resident #41 was on the back board she complained of pain to there right side. Resident #41 left the facility at approximately 9:03 A.M. with emergency services. Review of the investigation form dated 02/19/23 at 8:45 A.M. revealed State Tested Nurse Aide (STNA) #264 was walking Resident #41 from the dining room to the bathroom, and Resident #41 tripped over her feet and fell. STNA #264 was unable to catch Resident #41 and she fell and hit her head which began to bleed. Resident #41 was wearing her own shoes. The facility contacted emergency services and notified Resident #41's emergency contact, the physician, the director of nursing, and the administrator. Resident #41 was sent to the hospital and staff were educated. Review of a witnessed fall document, dated 02/19/23 at 8:45 A.M., revealed at approximately 8:45 A.M. a nurse aide alerted a nurse that Resident #41 fell and was bleeding badly from her head. The nurse aide indicated she was walking Resident #41 to the bathroom at the time of the fall. The nurse and nurse aide ran to the area where Resident #41 fell, and upon arrival, large amounts of blood were noted on the floor. Resident #41 was laying on her stomach in front of the nurses' station and blood appeared to be coming from the right side of her head. The nurse immediately called emergency services. Resident #41 was crying and indicated she she wanted to get up and her head hurt. Resident #41 also indicated she was in pain and was noted to have occasional labored breathing with a short period of hyperventilation. A nurse attempted to obtain vital signs, but was unable due to Resident #41 crying and attempting to move around. Resident #41 was not able to be consoled, distracted, or reassured. Further review of the document revealed predisposing physiological factors included confusion, recent illness, gait imbalance, and impaired memory; and predisposing situational factors included ambulating with assistance and admission to the facility in the last 72 hours. Review of an investigation interview with STNA #264, related to Resident #41's fall on 02/19/23, revealed she was walking with Resident #41 from the dining room to the toilet. The resident tripped over her own feet and fell. STNA #264 grabbed four blankets and helped the nurse place them under Resident #41's head by the right temporal area. After emergency services arrived, the nurse informed them Resident #41 was bleeding, and they were not able to stop it. Review of the investigation interview with Licensed Practical Nurse (LPN) #224 on 02/19/23 revealed she was alerted by STNA #264 that Resident #41 had fallen. Upon arrival to the nurses station, the other nurse was next to Resident #41 and there was a large amount of blood noted on the floor. LPN #224 asked the nurse aide who was assisting Resident #41 when the fall occurred, and the nurse aide indicated she was walking Resident #41 to the bathroom. LPN #224 asked the nurse aide if Resident #41 was using a walker and the nurse aide indicated Resident #41 did not have a walker and was not aware she needed one. LPN #224 recalled telling the nurse aide assisting Resident #41 that the resident required a one person assistance and a walker when ambulating. During an interview on 03/14/23 at 2:15 P.M., the Administrator stated Resident #41's fall was found to be a problem when it was discovered STNA #264 was walking Resident #41 without a gait belt or a walker. Resident #41 did not come to the facility with a walker from her previous nursing home, but the Administrator stated they were available in the facility. The Administrator verified physical therapy did not have the chance to evaluate Resident #41 for an appropriate walker. The Administrator stated the staff member who was with Resident #41 when she fell was disciplined with a consultation. The Administrator also stated the facility educated all the nursing staff for using gait belts and to always have one on their person. The Administrator also verified the facility did not have enough gait belts and immediately ordered more. Interview on 03/14/23 at 2:24 P.M. with the Director of Nursing (DON) verified the staff members were to be using gait belts for ambulation and transfers as a standard practice. The DON stated when Resident #41 fell and STNA #264 was not using a gait belt or walker, the facility put a gait belt policy into place and educated all the nursing staff. Review of education provided to nursing staff on 02/21/23 revealed a gait belt was part of the staff member's uniform and also a safety device used to help someone move. The gait belt helps provide support and helps prevent a fall. There was a note included with the education for staff to remember to use each resident's assistive device such as a walker, cane, or wheelchair. As a result of the incident, the facility implemented the following corrective actions to correct the deficient practice on 03/13/23: • On 02/19/23, Resident #41 was sent to the hospital and did not return to the facility. • Review of STNA #264's employee personnel file revealed on 02/20/23, STNA #264 was disciplined with a consultation for ambulating a resident without a gait belt and the resident fell. The violation was not using necessary equipment needed to increase resident safety. The education included using equipment needed to increase resident safety. • Review of a Quality Assurance and Performance Improvement (QAPI) plan dated 02/20/23 revealed Resident #41 had a fall with injury. The root cause of the fall was staff did not use a gait belt, there were not enough gait belts available, and there was no access to a walker. The facility took corrective action steps to include educating the nursing staff, ordering more gait belts, auditing staff randomly for three weeks, auditing staff for three transfers and/or ambulation for use of gait belts, and each nurse will have treatment keys to access assisted devices after hours and weekends. • All staff members were educated on the use of gait belts on 02/21/23. Review of education provided to nursing staff on 02/21/23 revealed a gait belt was part of the staff member's uniform and also a safety device used to help someone move. The gait belt helps provide support and helps prevent a fall. There was a note included with the education for staff to remember to use each resident's assistive device such as a walker, cane, or wheelchair. • On 02/24/23, the DON or designee completed audits three times a week for using gait belts with transfers and ambulation to ensure the gait belts were with the staff member. The audits were completed through 03/13/23, with three aides being given gait belts and provided additional education. • On 03/14/23, observations and interviews with four (#224, #244, #282, and #284) STNAs, during transfer activities with residents, revealed appropriate safety devices were utilized while providing transfers and ambulation. All four STNAs had gait belts in their possession and all four verified they received education and provided knowledge on use of gait belts and assistive devices. This deficiency represents non-compliance investigated under Complaint Number OH00140493.