**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview it has been determined that the facility failed to provide treatment and care in accordance with professional standards of practice and failed to promptly identify and intervene during acute changes in condition for 2 of 2 residents reviewed, Resident ID #s 1 and 2. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 5/28/2024, alleged concerns regarding Resident ID #1's wound care and ascites (a buildup of fluid in the abdomen) management as the resident was admitted to the hospital and needed 5 Liters of fluid drained from his/her abdomen. 1a. According to Nursing Health Assessment: A clinical Judgement Approach 4th edition, 2023 published by Wolters Kluwer, it has been revealed that characteristics of a deep vein thrombosis, (DVT) also known as a blood clot, include, but are not limited to, pain and swelling at the site. Record review revealed that Resident ID #1 was readmitted to the facility in May of 2024 with diagnoses including, but not limited to, chronic pain and pancreatic cancer. Review of the resident's admission assessment dated [DATE], revealed that the resident presented with 3+ pitting edema (swelling that occurs in your feet, ankles, or legs, but may also occur in the face, hands, or arms. When the edema is pressed it leaves a dimple this is called pitting edema. A 3+ pitting edema this indicates severe edema and can take up to 30 seconds or more to rebound) to his/her bilateral lower extremities. Record review revealed the following: 5/17/2024 at 6:13 AM- The resident presented with 2+ pitting edema (2+ pitting edema indicates slight swelling that can take up to 15 seconds to rebound) to his/her bilateral lower extremities. 5/17/2024 at 12:25 PM- The Nurse Practitioner assessed the resident and indicated that s/he has 4+ edema (4+ pitting edema indicates a very deep pit that takes approximately 2-5 minutes to rebound) to his/her bilateral lower extremities. Record review revealed that although the Nurse Practitioner assessed the 4+ pitting edema on 5/17/2024 no interventions or orders were implemented. 5/18/2024 at 1:41 PM- The resident presented with 2+ pitting edema noted in all extremities. Record review failed to reveal evidence that the provider was notified of the documented edemas that was in all extremities and failed to reveal any new interventions or orders that were implemented for the edema noted to all extremities. 5/18/2024 at 5:28 PM - The provider completed an examination on the resident and no indication of edema was present (despite the previous assessments on 5/15, 5/16, 5/17 and 5/18/2024 that indicate varying fluctuations and locations of the resident's edema). 5/19/2024 at 7:12 PM - The resident presented with 3-4+ pitting edema. Record review failed to reveal evidence that the provider was notified of the increased edema or that any new interventions or orders were implemented from 5/18/2024 to 5/19/2024. 5/20/2024 at 10:29 AM- The resident presented with 4+ pitting edema to his/her bilateral lower extremities. The resident also has a blister to his/her right foot due to the edema. Further record review revealed the resident requested to go to the hospital on 5/20/2024 as s/he was experiencing discomfort. Review of the hospital's emergency department [ED] documentation revealed, the resident presented to the hospital and that the Patient started to have pain in [his/her] R [right] leg 3 days ago which has been getting worse. R leg is more swollen as well. It is 10/10, constant, sharp pain at the back of [the] R leg with no radiation. [S/he] was able to walk with a walker but has been lying in bed more recently in [the] nursing home. Since the pain started, [s/he] hasn't been able to bear weight as it makes the pain even worse. [S/he] also has abdominal distention and pain as well. [S/he] had paracentesis [removal of fluid from the abdomen] 3 weeks ago during previous hospitalization. [His/Her] abdomen has been getting more and more distended since then. Denies [nausea /vomiting/diarrhea /constipation]. In ED, [s/he] was found to have [an] acute DVT [Deep Vein Thrombosis, blood clot] in [his/her] R leg. During a surveyor interview on 5/29/2024 at 10:48 AM with the facility's wound nurse, he revealed that he saw the resident for the first and only time on 5/20/2024. He indicated that the resident's legs were very swollen and that it was very painful for him/her when his/her wounds were assessed. He revealed that if the resident was not on hospice, he would have assessed him/her for a DVT due to the amount of pain s/he was in. Furthermore, he was unaware that the resident was diagnosed with a DVT while hospitalized . During a surveyor interview on 6/3/2024 at approximately 10:00 AM with the Nurse Practitioner she acknowledged that she assessed the resident on 5/17/2024 as having 4+ pitting edema to his/her bilateral lower extremities but did not implement any new orders or interventions. During a surveyor interview on 5/29/2024 at 11:12 AM with the Director of Nursing Services (DNS), she revealed that the resident was on hospice services, but that she would have expected the staff to notify the provider or hospice of the resident's increasing edema and pain. She further revealed she would have expected an ultrasound (a procedure used to assess a vein for a blood flow and identification of a DVT) to have been obtained to rule out a DVT due to the resident's increased edema. 1b. Record review revealed that the resident complained of abdominal pain on 5/18/2024 and required an as needed dose of morphine (an opiate medication) for pain management. Record review revealed a physician's order dated 5/18/2024 to measure the resident's abdominal girth every morning related to ascites. Record review of the May 2024 Medication and Treatment Administration Record notes revealed, on 5/19/2024 and 5/20/2024 the abdominal girth was not measured due to the facility not having a measuring tape available. Further record review revealed on 5/20/2024, the resident complained of abdominal discomfort and requested to go to the hospital for a paracentesis [a procedure to remove fluid from the abdomen] and was admitted to the hospital. Review of the hospital's emergency department [ED] documentation dated 5/20/2024 revealed, the resident presented to the hospital and a paracentesis was scheduled. Review of a hospital provided procedure document revealed a paracentesis procedure was completed on 5/21/2024 and the resident had a Large volume of ascites and that 4800 milliliters of clear yellow fluid was removed from his/her abdominal cavity. During a surveyor interview with the DNS on 5/29/2024 at 11:10 AM, she revealed she would have expected the resident's abdomen to have been measured on 5/19/2024 and 5/20/2024 and that she would have expected someone to notify management staff that a measuring tape was unavailable. 1c. Record review of a progress note authored by Registered Nurse, Staff A, dated 5/16/2024 revealed, the resident bumped the back of his/her right lower extremity on the bed frame and a small open area was noted. The note indicates that the wound nurse was notified and saw resident. The note further indicates that an abdominal pad was placed over night. Record review failed to reveal evidence that the provider was notified of the open area to his/her right lower extremity and or that any new interventions or orders were implemented by the provider. Record review reveals that on 5/17/2024 at 12:25 PM the Nurse Practitioner assessed the resident and indicated that s/he has 4+ edema to his/her bilateral lower extremities but there was no assessment of the open area to his/her lower extremity that occurred on 5/16/2024. Review of a progress note dated 5/19/2024 revealed, the resident had visitors present and there were complaints that his/her right leg was weeping (oozing fluid). The resident's Tubi-grip (compression wrap) on his/her right leg was removed and two wounds were identified one on the top of his/her right foot and another on the back of his/her right lower leg, both were weeping. The note further states, .cleansed and bacitracin with dry dressing applied .Hospice called and informed of above. Hospice team will follow up tomorrow .Visitors took pictures of wounds . Record review failed to reveal evidence that the provider was notified of the open areas to his/her right foot or lower leg and or that any new interventions or orders were implemented by the provider. Further record review failed to reveal evidence of an assessment completed by the wound nurse on 5/16, 5/17, 5/18 or 5/19/2024. Review of the May 2024 Medication and Treatment Administration Records failed to reveal evidence that any treatment orders were implemented between 5/16/2024 through 5/20/2024 for the wounds that were identified on 5/16/2024 and 5/19/2024. Review of a progress note dated 5/20/2024 revealed, the resident was seen regarding a broken saline blister to his/her right dorsal foot. The blister measured 5 x 4 centimeters (cm) with an opening of 1 x 1 cm and a dressing was applied. Further review of the 5/20/2024 progress notes revealed, the resident and his/her friend .had concerns about wound care pertaining to a blister that popped . During a surveyor interview on 5/29/2024 at 10:48 AM with the wound nurse, he revealed that he initially assessed the resident's wounds on 5/20/2024 and that the resident was in a lot of pain during the dressing change. He indicated that he was unaware that a new wound was identified to the resident's right lower extremity on 5/16/2024. Additionally, he revealed that it was not until 5/20/2024, 5 days after the wound had been observed by nursing staff that he was made aware the resident had any new wounds. During a surveyor interview on 5/29/2024 at 11:08 AM with the DNS, she revealed that she would have expected an order to have been obtained on 5/16/2024 when the new wound was identified to the resident's right lower extremity was first identified. She was unable to explain why the nurse implemented treatments on 5/16/2024 and 5/19/2024 without contacting the provider. 1d. Record review of a progress note dated 5/17/2024 at 5:58 PM revealed the resident was found kneeling on the floor on the side of his/her bed. The progress note further indicated, the resident stated they had tried to lay on the bed but rolled over onto the floor. Record review failed to reveal evidence that the resident was assessed after the fall, that the physician was notified, or any interventions were put in place to prevent future falls from occurring. During a surveyor interview on 5/31/2024 at 1:07 PM with Licensed Practical Nurse, Staff B, she indicated that the Nurse Practitioner was in the facility and went to the room to assess the resident. During a surveyor interview on 6/2/2024 at approximately 10:00 AM with the Nurse Practitioner she was unaware that the resident experienced a fall on 5/17/2024 and did not assess him/her specifically for a fall on 5/17/2024. She indicated she saw him/her for the first time earlier in the day for an admission assessment and was never called back to assess him/her for a fall. 1e. Record review revealed a physician's order dated 5/16/2024 to obtain an admission weight. Record review failed to reveal evidence of an admission weight. Further record review revealed a physician's order dated 5/16/2024 to weigh the resident on the second day after admission. Record review failed to reveal evidence of a weight on the second day after admission. Further record review failed to review that a weight was ever obtained on this resident. During an interview on 5/31/2024 at approximately 1:00 PM with Registered Nurse, Staff A, she indicated she completed the admission for the resident but did not get an admission weight. 2a. Record review revealed that Resident ID #2 was admitted to the facility in December of 2018 with diagnoses including, but not limited to, dementia and type two diabetes mellitus. Record review revealed a nursing note dated 4/30/2024 at 2:59 PM, authored by, LPN, Staff C, that she responded to the activity room as the resident was not responding at baseline. Resident was noted to be awake in the wheelchair but was not speaking. The resident seemed weak and his/her limbs were somewhat floppy. The note indicates that a call was placed to the Nurse Practitioner and a message was left on her voicemail. Further record review reveals a second nursing note written on 4/30/2024 at 10:01 PM that the Nurse Practitioner did not return the call. Record review failed to reveal evidence that the provider was notified of the incident on 4/30/2024 or that any interventions were put in place for his/her unresponsive incident on 4/30/2024. 2b. Record review revealed a nursing note dated 5/4/2024 at 2:06 PM, authored by Staff C that indicates the resident became pale and unresponsive and was incontinent of stool. Record review failed to reveal evidence that the provider was notified of the incident on 5/4/2024 or that any interventions were put in place for his/her unresponsive incident on 5/4/2024. During a surveyor interview on 6/4/2024 at approximately 2:30 PM with the Nurse Practitioner she indicated that she was not aware of the unresponsive incidents that Resident ID #2 experienced on 4/30/2024 and 5/4/2024. She indicated that if she was aware she would have conducted an assessment and ordered labs. She also indicated that staff should be calling the on-call provider if they were unable to reach her. During a surveyor interview on 6/4/2024 at 2:45 PM with the Administrator and Director of Nursing they were unable to explain why staff did not alert the provider of the resident's change in condition on 4/30/2024 and 5/4/2024.